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ADVISORY 2003-08

SUBJECT: Workers' Compensation Medical Dispute Resolution

If a health care provider or an insurance carrier has a dispute over a medical fee or a dispute on whether medical services are medically necessary in the workers' compensation system, they may file a form TWCC-60, "Medical Dispute Resolution, Request/Response" with the Commission within the time deadlines specified in Commission rules 133.307(d) and 133.308(e) and after documenting attempts to obtain resolution as required in Commission Rule 133.304.

The health care provider or the insurance carrier should not seek to resolve such a dispute in a court without first exhausting the administrative dispute resolution process specified in Texas Labor Code section 413.031 and Commission rules 133.305 - 133.308.

The Commission has and will assert its primary jurisdiction over these medical disputes and will seek injunctive and declaratory relief, as well as reimbursement of its costs and attorneys' fees, against any system participant who attempts to bypass the administrative dispute resolution process. A Travis County District Court judge, on May 28, 2003, issued a final judgment in Cause No. GN-200976, Robert S. Howell, D.C. and First Rio Valley Medical, P.A. v. Texas Workers' Compensation Commission et al. requiring certain system participants to exhaust their administrative medical dispute remedies, enjoining them from filing court cases to initially resolve their disputes, and requiring them to pay costs and reasonable and necessary attorneys' fees. The Commission has asserted its primary jurisdiction on all medical dispute issues except for the issue of what is a "usual and customary charge for the same or similar service" for pharmacy prescriptions.

Signed on this 3rd day of July, 2003

Richard F. Reynolds, Executive Director

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