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Advisory 2002-03B

Medical Fee Dispute Resolution - Identification of Health Care Provider

This Advisory repeals and replaces Advisory 2002-03, SUBJECT: Medical Fee Dispute Resolution-Medical Signatures.

The Texas Workers' Compensation Commission provides the following clarification regarding identification of licensed health care providers on medical reports, SOAP (Subjective/Objective Assessment Plan/Procedure) notes, interdisciplinary program notes, office notes, physical or occupational therapy notes, or any medical documentation of service(s)/treatment(s) rendered for which a licensed health care provider is seeking medical fee dispute resolution.

If the insurance carrier (carrier) disputes reimbursement for medical services based on the failure of the licensed health care provider to identify himself/herself on the medical documentation, the carrier may use the denial code "N," which means "Not appropriately documented," on the TWCC-62 (Explanation of Benefits), with the explanation of "Unable to determine provider of services due to lack of identifying information on the medical documents." The Medical Review Division will review the file based on that denial code in addition to any other denial codes the carrier has used prior to filing the request for dispute resolution.

The lack of identification on the medical documentation may result in an adverse decision if the services are disputed, particularly when reimbursement is based on the type of provider who provides the service(s)/treatment(s). Therefore, any medical documentation submitted to the Medical Review Division or to an Independent Review Organization to support reimbursement, should identify the person who actually performed the service(s) or treatment(s). An original signature is not the only acceptable method of identification. A typed name or stamped signature is also acceptable if the person has authorized its use on the documentation. Alternatively, the person who performed the service(s) or treatment(s) may submit a signed statement, attached to the pertinent documentation, in which the person affirms that they rendered the service(s)/treatment(s) documented. The signed statement should be dated, include the printed name of the person signing, and be provided with the dispute resolution request or response. Interdisciplinary team members shall also identify themselves on their medical documentation for the service(s)/treatment(s) they rendered.

This Advisory provides guidance for medical disputes filed on or after the date this Advisory is signed.

Signed this 14 th day of March, 2002

Richard F. Reynolds, Executive Director

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