Texas Regulations 133.2
From Wcc
§ 133.2 Definitions.
| History:
(1) Bill review -- Review of any aspect of a medical bill, including retrospective review, in accordance with the Labor Code, the Insurance Code, Division or Department rules, and the appropriate fee and treatment guidelines. (2) Complete medical bill -- A medical bill that contains all required fields as set forth in the billing instructions for the appropriate form specified in § 133.10 of this chapter (relating to Required Billing Forms/Formats), or as specified for electronic medical bills in § 133.500 of this chapter (relating to Electronic Formats for Electronic Medical Bill Processing). (3) Emergency -- Either a medical or mental health emergency as follows: (A) a medical emergency is the sudden onset of a medical condition manifested by acute symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected to result in: (i) placing the patient's health or bodily functions in serious jeopardy, or (ii) serious dysfunction of any body organ or part; (B) a mental health emergency is a condition that could reasonably be expected to present danger to the person experiencing the mental health condition or another person. (4) Final action on a medical bill -- (A) sending a payment that makes the total reimbursement for that bill a fair and reasonable reimbursement in accordance with § 134.1 of this title (relating to Medical Reimbursement); and/or (B) denying a charge on the medical bill. (5) Health care provider agent -- A person or entity that the health care provider contracts with or utilizes for the purpose of fulfilling the health care provider's obligations for medical bill processing under the Labor Code or Division rules. (6) Insurance carrier agent -- A person or entity that the insurance carrier contracts with or utilizes for the purpose of providing claims services, including fulfilling the insurance carrier's obligations for medical bill processing under the Labor Code, the Insurance Code, Division or Department rules. (7) Pharmacy processing agent -- A person or entity that contracts with a pharmacy in accordance with Labor Code § 413.0111, establishing an agent or assignee relationship, to process claims and act on behalf of the pharmacy under the terms and conditions of a contract related to services being billed. Such contracts may permit the agent or assignee to submit billings, request reconsideration, receive reimbursement, and seek medical dispute resolution for the pharmacy services billed. (8) Retrospective review -- The process of reviewing the medical necessity and reasonableness of health care that has been provided to an injured employee. (9) In this chapter, the following terms have the meanings assigned by Labor Code § 413.0115: (A) Voluntary networks; and (B) Informal networks. |
