Texas Labor Codes 413.031 pre 1/1/02
From Wcc
§ 413.031 pre 1/1/02 Medical Dispute Resolution - pre 1/1/02
| (a) A party, including a health care provider, is entitled to a review of a medical service provided or for which authorization of payment is sought if a health care provider is:
(1) denied payment or paid a reduced amount for the medical service rendered; (2) denied authorization for the payment for the service requested or performed if authorization is required by the medical policies of the commission; or (3) ordered by the division to refund a payment received for a medical service rendered. (b) A health care provider who submits a charge in excess of the fee guidelines or treatment policies is entitled to a review of the medical service to determine if reasonable medical justification exists for the deviation. (c) A review of a medical service under this section shall be provided by a health care provider professional review organization if requested by the health care practitioner or if ordered by the commission. (d) [effective for a hearing held before or pending on January 1, 1996.] A party to a medical dispute that remains unresolved after a review of the medical service under this section is entitled to a hearing. The hearing shall be conducted in the manner provided for a contested case under Chapter 2001, Government Code. (d) [effective for a hearing beginning on or after January 1, 1996.] A party to a medical dispute that remains unresolved after a review of the medical service under this section is entitled to a hearing. The hearing shall be conducted by the State Office of Administrative Hearings within 90 days of receipt of a request for a hearing in the manner provided for a contested case under Chapter 2001, Government Code (the administrative procedure law). Acts 1993, 73rd Leg., ch. 269, section 1, eff. Sept. 1, 1993. Amended by Acts 1995, 74th Leg., ch. 76, section 5.95(49), eff. Sept. 1, 1995; Acts 1995, 74th Leg., ch. 980, section 1.43, eff. Sept. 1, 1995. |
