Appeal of a Medical Fee Dispute Decision
An injured employee may appeal a medical fee dispute decision by requesting a BRC no later than 20 days from the date the medical fee dispute decision is received by the party. At a BRC, the parties may not resolve the dispute by negotiating fees that are inconsistent with any applicable fee guidelines adopted by the Commissioner of Workers' Compensation. A first responder's request to schedule a benefit review conference must be accelerated by the Texas Department of Insurance, Division of Workers' Compensation (DWC) and given priority.
DWC Forms
DWC Form-045M, Request to Schedule, Reschedule, or Cancel a Benefit Review Conference to Appeal a Medical Fee Dispute Decision (BRC-MFD)
Additional Information
For a medical fee dispute the injured employee should:
- include copy of the medical fee dispute decision with the request to schedule a BRC (DWC Form-045M) to satisfy the documentation requirements in 28 Texas Administrative Code (TAC) §141.1(d);
- provide a copy of any applicable section of the fee guidelines adopted by the Commissioner of Workers' Compensation; and
- attach any receipts to show individual out-of-pocket medical expenses incurred.
Exchange of Information
Pertinent information must be exchanged in accordance with 28 TAC §141.4.
- Disputing party must exchange all documents in their possession with the other party before requesting a BRC.
- Opposing party must exchange documents within 10 working days after receiving the request to schedule a BRC (DWC Form-045M).
- Any additional documents that come into a party's possession after the initial time frames must be exchanged no later than 14 days before the BRC (5 days if the BRC is expedited).
- All documents must be submitted to the DWC no later than 14 days before the BRC (5 days if the BRC is expedited).
- Any documents obtained after the exchange deadline should be brought to the BRC with sufficient copies for both the other party and DWC.
Definition of Terms
- "Benefit" means a medical benefit, an income benefit, a death benefit, or a burial benefit based on a compensable injury. See Texas Labor Code §401.011(5).
- "Agreement" means the resolution by the parties to a dispute under this subtitle of one or more issues regarding an injury, death, coverage, compensability, or compensation. The term does not include a settlement. See Texas Labor Code §401.011(3).
- "Health care facility" means a hospital, emergency clinic, outpatient clinic, or other facility providing health care. See Texas Labor Code §401.011(20).
- "Health care practitioner" means:
- (A) an individual who is licensed to provide or render and provides or renders health care; or
- (B) a nonlicensed individual who provides or renders health care under the direction or supervision of a doctor. See Texas Labor Code §401.011(21).
- "Health care provider" means a health care facility or health care practitioner. See Texas Labor Code §401.011(22).