In the Texas workers compensation system, fee guidelines determine reimbursement of medical services and treatments for non-network care. 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.
Fee guidelines are in 28 Texas Administrative Code, Chapter 134 - Benefits - Guidelines for Medical Services, Charges, and Payments.
In most cases, the Division of Workers’ Compensation (DWC) fee guidelines do not apply to health care services provided through a certified workers’ compensation health care network.
- Chapter 134 - Benefits - Guidelines for Medical Services, Charges, and Payments. Subchapter A. Medical Reimbursement Policies – §134.1
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
- Medical Fee Guidelines apply to professional medical services and workers' compensation specific codes, services, and programs, other than health care facilities services, prescription drugs, and dental services. These guidelines are applicable for dates of service specified in the rules.
- Rules: Chapter 134 - Benefits - Guidelines for Medical Services, Charges, and Payments. Subchapter C. Medical Fee Guidelines - §134.203 and §134.209 to §134.250
- Conversion Factors for Workers' Compensation Medical Fee Guidelines
- Medical Fee Guidelines Frequently Asked Questions
Hospital fee guidelines
On December 28, 2007, 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. Subchapter E. Health Facility Fees - §134.403 - Hospital Facility Fee Guideline - Outpatient and §134.404 - Hospital Facility Fee Guideline - Inpatient
Ambulatory surgical center fee guideline
On August 8, 2008, 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 - §134.402 - Ambulatory Surgical Center Fee Guideline
- ASC Frequently Asked Questions (FAQs)
- Calculations Examples for Ambulatory Surgical Center Fee Guidelines
Pharmacy fee guideline
- Rules: Chapter 134 Benefits - Guidelines for Medical Services, Charges, and Payments. Subchapter F. Pharmaceutical Benefits - §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 - §134.303 - 2005 Dental Fee Guideline
Training and related resources
- Medical Billing, Processing and Payment pre-recorded webinar.
- Live health care provider webinars - Check the events calendar for webinar schedule.
- eBill - electronic medical billing
- Medical state reporting EDI
- Prospective and concurrent review of health care
- Medical fee dispute resolution
- Reimbursement of services provided by a federal military treatment facility
- Federal military treatment facility disputes
- Workers' Compensation Insurance Coverage for Certain Government Employees. Labor Code, Title 5. Workers' Compensation, Subtitle C.
For more information, contact us at 800-252-7031, option 3 or CompConnection@tdi.texas.gov.