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Advisory 95-08

CHARGES FOR MEDICAL DISPUTE RESOLUTION

TEX.LAB.CODE Sections 413.015 and 413.020 provide the TWCC with statutory authority to assess fees for the review of health care treatment, fees, or charges. This authority is interpreted to include, but not limited to, assessing charges when the following situations occur:

  • The Commission shall charge a health care provider a fee if:
    • The dispute involves a health care provider who has exceeded a fee or treatment guideline and who has not provided adequate documentation of the procedure to support and justify the disputed level of service, or
    • The dispute involves a health care provider who has billed for a service not covered by a fee or treatment guideline or is DOP (documentation of procedure) in a guideline and has not provided adequate documentation of the procedure to support the disputed level of service.
  • The Commission shall charge an insurance carrier a fee if:
    • The dispute involves and insurance carrier who has, absent an agreement with the health care provider, incorrectly applied fee or treatment guidelines and as a result, has denied or reduced payment for health care services provided, or
    • The dispute involves an insurance carrier who has denied or reduced payment for a health care service provided which is not covered by a fee or treatment guideline or is DOP in a guideline but which has been adequately supported by the health care provider's documentation of procedure.

The Commission shall commence assessing charges for dispute resolution cases on November 1, 1995. In assessing charges, the Commission shall use the following fee schedule:

  • $25 per hour for disputes received between June 1, 1992 and February 28, 1993.
  • $33 per hour for disputes received between March 1, 1993 and August 31, 1993.
  • $34 per hour for disputes received between September 1, 1993 and August 31, 1994.
  • $35 per hour for disputes received between September 1, 1994 and August 31, 1995
  • $41 per hour for disputes received on or after September 1, 1995.

Signed September 14, 1995.

Todd K. Brown, Executive Director



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Last updated: 09/06/2014

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Translation by WorldLingo


Translation by WorldLingo