Medical and Facility Fee Guidelines and Information
In the Texas workers compensation system, reimbursement of medical services and treatments for non-network care is determined by fee guideline rules. These fee guideline rules are based on the Texas Workers Compensation Act and are adopted through the administrative rule making process. Understanding the fee guideline rules and related resources is crucial to successful reimbursement for workers' compensation claims.
Medical Fee Guidelines | Hospital Fee Guidelines | Ambulatory Surgical Center Fee Guideline | Pharmacy | Dental Fee Guideline | Fee Guidelines History | Training and Related Resources
Medical Fee Guidelines
On December 28, 2007, TDI-DWC adopted rules to update the Medical Fee Guidelines for professional services. These guidelines are applicable for dates of service on and after March 1, 2008.
- Rules: Chapter 134 - Benefits - Guidelines for Medical Services, Charges, and Payments
SUBCHAPTER A. Medical Reimbursement Policies - Sections 134.1 and 134.2
SUBCHAPTER C. Medical Fee Guidelines - Sections 134.203 and 134.204 (Word, PDF) [rule text begins on page 141]
- Conversion Factors for Workers’ Compensation Medical Fee Guidelines
- Commissioner's Bulletin No. B-0030-12 - Changes to calendar year 2013 Conversion Factors for Workers’ Compensation Medical Fee Guidelines 28 TAC §134.203 Medical Fee Guideline for Professional Services Chapter 134 – Benefits – Guidelines for Medical Services, Charges and Payments Subchapter C. Medical Fee Guidelines
- Conversion Factors (PDF)
- General Information for Medical Fee Guidelines 28 TAC §§134.2, 134.203, and 134.204 (PDF)
- Medical Fee Guidelines Frequently Asked Questions 2/7/13
- Medical Fee Guideline Training Module (PDF)
Hospital Fee Guidelines
On December 28, 2007, TDI-DWC adopted rules to establish a hospital outpatient fee guideline and to update the hospital inpatient fee guideline. These guidelines are applicable for dates of service on and after March 1, 2008.
- Rules: Chapter 134 - Benefits - Guidelines for Medical Services, Charges, and Payments
SUBSCHAPTER E. Health Facility Fees
Section 134.403 - Hospital Facility Fee Guideline - Outpatient (PDF - rule text begins on page 125.)
Section 134.404 - Hospital Facility Fee Guideline - Inpatient (PDF - rule text begins on page 132.) - Reports Used in HFG Rule Development
- THA Survey (zip)
- TMIC - RPC (zip)
- Renaissance (zip)
- Milliman (zip)
Ambulatory Surgical Center Fee Guideline
On August 8, 2008, TDI-DWC adopted the amended Ambulatory Surgical Center (ASC) Fee Guideline, §134.402. This guideline is applicable for dates of service on and after September 1, 2008.
- Rules: Chapter 134 - Benefits - Guidelines for Medical Services, Charges, and Payments
SUBCHAPTER E. Health Facility Fees
Section 134.402 - Ambulatory Surgical Center Fee Guideline - ASC Frequently Asked Questions (FAQs) (for calendar year 2010)
- Calculations Examples for Ambulatory Surgical Center Fee Guidelines
- Reports Used in ASC Rule Development
Pharmacy Fee Guideline
- Rules: Chapter 134 Benefits-Guidelines for Medical Services, Charges, and Payments Subsection F Pharmaceutical Benefits
Section 134.503 Pharmacy Fee Guideline. - Pharmacy homepage - includes information concerning the Closed Formulary and all other pharmacy rules
Dental Fee Guideline
- Rules: Chapter 134 Benefits--Guidelines for Medical Services, Charges, and Payments
Subchapter C Medical Fee Guidelines
Section 134.303 - 2005 Dental Fee Guideline
Training and Related Resources
- Basic Workers’ Compensation for Health Care Providers - Check the events calendar for a seminar in your area.
- Preauthorization Rule: §134.600 Preauthorization, Concurrent Review, and Voluntary Certification of Health Care
- eBill - Electronic Medical Billing
- Medical Fee Dispute Resolution
For more information contact:
Last updated: 02/07/2013
