Texas Labor Code Title 5, Chapter 413 - Medical Review
SUBCHAPTER A GENERAL PROVISIONS
- Texas Section 413.002 - Medical Review
(a) The division shall monitor health care providers, insurance carriers, independent review organizations, and workers' compensation claimants who receive medical services to ensure the compliance...
- Texas Section 413.003 - Authority To Contract
The division may contract with a private or public entity to perform a duty or function of the division. Acts 1993, 73rd Leg., ch. 269,...
- Texas Section 413.004 - Coordination With Providers
The division shall coordinate its activities with health care providers as necessary to perform its duties under this chapter. The coordination may include: (1) conducting...
- Texas Section 413.006 - Advisory Committees
The commissioner may appoint advisory committees as the commissioner considers necessary. Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993. Amended by:...
- Texas Section 413.007 - Information Maintained By Division
(a) The division shall maintain a statewide data base of medical charges, actual payments, and treatment protocols that may be used by: (1) the commissioner...
SUBCHAPTER B MEDICAL SERVICES AND FEES
- Texas Section 413.008 - Information From Insurance Carriers; Administrative Violation
(a) On request from the division for specific information, an insurance carrier shall provide to the division any information in the carrier's possession, custody, or...
- Texas Section 413.011 - Reimbursement Policies And Guidelines; Treatment Guidelines And Protocols
(a) The commissioner shall adopt health care reimbursement policies and guidelines that reflect the standardized reimbursement structures found in other health care delivery systems with...
- Texas Section 413.0111 - Processing Agents
The rules adopted by the commissioner for the reimbursement of prescription medications and services must authorize pharmacies to use agents or assignees to process claims...
- Texas Section 413.0115 - Requirements For Certain Voluntary Or Informal Networks
(a) In this section: (1) "Informal network" means a health care provider network described by Section 413.011(d-1) that: (A) is established under a contract between...
- Texas Section 413.012 - Medical Policy And Guideline Updates Required
The medical policies and fee guidelines shall be reviewed and revised at least every two years to reflect fair and reasonable fees and to reflect...
- Texas Section 413.013 - Programs
The commissioner by rule shall establish: (1) a program for prospective, concurrent, and retrospective review and resolution of a dispute regarding health care treatments and...
- Texas Section 413.014 - Preauthorization Requirements; Concurrent Review And Certification Of Health Care
(a) In this section, "investigational or experimental service or device" means a health care treatment, service, or device for which there is early, developing scientific...
- Texas Section 413.0141 - Initial Pharmaceutical Coverage
The commissioner may by rule provide that an insurance carrier shall provide for payment of specified pharmaceutical services sufficient for the first seven days following...
- Texas Section 413.015 - Payment By Insurance Carriers; Audit And Review
(a) Insurance carriers shall make appropriate payment of charges for medical services provided under this subtitle. An insurance carrier may contract with a separate entity...
- Texas Section 413.016 - Payments In Violation Of Medical Policies And Fee Guidelines
(a) The division shall order a refund of charges paid to a health care provider in excess of those allowed by the medical policies or...
- Texas Section 413.017 - Presumption Of Reasonableness
The following medical services are presumed reasonable: (1) medical services consistent with the medical policies and fee guidelines adopted by the commissioner; and (2) medical...
- Texas Section 413.018 - Review Of Medical Care If Guidelines Exceeded
(a) The commissioner by rule shall provide for the periodic review of medical care provided in claims in which guidelines for expected or average return...
- Texas Section 413.019 - Interest Earned For Delayed Payment, Refund, Or Overpayment
(a) Interest on an unpaid fee or charge that is consistent with the fee guidelines accrues at the rate provided by Section 401.023 beginning on...
- Texas Section 413.020 - Division Charges
The commissioner by rule shall establish procedures to enable the division to charge: (1) an insurance carrier a reasonable fee for access to or evaluation...
- Texas Section 413.021 - Return-to-work Coordination Services
(a) An insurance carrier shall, with the agreement of a participating employer, provide the employer with return-to-work coordination services on an ongoing basis as necessary...
- Texas Section 413.022 - Return-to-work Reimbursement Program For Employers; Fund
(a) In this section: (1) "Account" means the workers' compensation return-to-work account. (2) "Eligible employer" means any employer, other than this state or a political...
- Texas Section 413.023 - Information To Employers
(a) The division shall provide employers with information on methods to enhance the ability of an injured employee to return to work. The information may...
- Texas Section 413.024 - Information To Employees
The division shall provide injured employees with information regarding the benefits of early return to work. The information must include information on how to receive...
SUBCHAPTER C DISPUTE RESOLUTION
- Texas Section 413.025 - Return-to-work Goals And Assistance
(a) The division shall assist recipients of income benefits to return to the workforce. The division shall develop improved data sharing, within the standards of...
- Texas Section 413.031 - Medical Dispute Resolution
(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...
- Texas Section 413.0311 - Review Of Medical Necessity Disputes; Contested Case Hearing
(a) This section applies only to an appeal of an independent review organization decision regarding determination of the medical necessity for a health care service....
- Texas Section 413.0312 - Review Of Medical Fee Disputes; Benefit Review Conference
(a) This section applies only to a medical fee dispute that remains unresolved after any applicable review under Sections 413.031(b) through (i). (b) Subject to...
SUBCHAPTER D HEALTH CARE PROVIDERS
- Texas Section 413.032 - Independent Review Organization Decision; Appeal
(a) An independent review organization that conducts a review under this chapter shall specify the elements on which the decision of the organization is based....
- Texas Section 413.041 - Disclosure
(a) Each health care practitioner shall disclose to the division the identity of any health care provider in which the health care practitioner, or the...
- Texas Section 413.042 - Private Claims; Administrative Violation
(a) A health care provider may not pursue a private claim against a workers' compensation claimant for all or part of the cost of a...
- Texas Section 413.043 - Overcharging Prohibited; Offense
(a) A health care provider commits an offense if the person knowingly charges an insurance carrier an amount greater than that normally charged for similar...
SUBCHAPTER E IMPLEMENTATION OF COMMISSION POWERS AND DUTIES
- Texas Section 413.044 - Sanctions On Designated Doctor
(a) In addition to or in lieu of an administrative penalty under Section 415.021 or a sanction imposed under Section 415.023, the commissioner may impose...
- Texas Section 413.051 - Contracts With Review Organizations And Health Care Providers
(a) In this section, "health care provider professional review organization" includes an independent review organization. (b) The division may contract with a health care provider,...
- Texas Section 413.0511 - Medical Advisor
(a) The division shall employ or contract with a medical advisor, who must be a doctor as that term is defined by Section 401.011. (b)...
- Texas Section 413.05115 - Medical Quality Review Process
(a) The division shall develop, and the commissioner shall adopt, criteria concerning the medical case review process under this subchapter. In developing the criteria, and...
- Texas Section 413.0512 - Medical Quality Review Panel
(a) The medical advisor shall establish a medical quality review panel of health care providers to assist the medical advisor in performing the duties required...
- Texas Section 413.05121 - Quality Assurance Panel
(a) The medical advisor shall establish the quality assurance panel within the medical quality review panel to: (1) provide an additional level of evaluation in...
- Texas Section 413.05122 - Medical Quality Review Panel: Rules; Training
(a) The commissioner, after consultation with the medical advisor, shall adopt rules concerning the operation of the medical quality review panel, including rules that establish:...
- Texas Section 413.0513 - Confidentiality Requirements
(a) Information collected, assembled, or maintained by or on behalf of the division under Section 413.0511 or 413.0512 constitutes an investigation file for purposes of...
- Texas Section 413.0514 - Information Sharing With Occupational Licensing Boards
(a) This section applies only to information held by or for the division, the Texas State Board of Medical Examiners, and Texas Board of Chiropractic...
- Texas Section 413.0515 - Reports Of Physician And Chiropractor Violations
(a) If the division or the Texas State Board of Medical Examiners discovers an act or omission by a physician that may constitute a felony,...
- Texas Section 413.052 - Production Of Documents
The commissioner by rule shall establish procedures to enable the division to compel the production of documents. Acts 1993, 73rd Leg., ch. 269, Sec. 1,...
- Texas Section 413.053 - Standards Of Reporting And Billing
The commissioner by rule shall establish standards of reporting and billing governing both form and content. Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff....
- Texas Section 413.054 - Immunity From Liability
(a) A person who performs services for the division as a designated doctor, an independent medical examiner, a doctor performing a medical case review, or...
- Texas Section 413.055 - Interlocutory Orders; Reimbursement
(a) The commissioner may enter an interlocutory order for the payment of all or part of medical benefits. The order may address accrued benefits, future...
Last modified: September 28, 2016