SECTION 42.155. Carrier Review of Bills

(a) General. The carrier shall promptly date stamp each health care provider bill with the date the same was received by the carrier. Failure on the carrier's part to comply with this rule shall create a rebuttable presumption that such health care provider bill was received by the carrier within five business days of the date of such bill.

(b) Time for review.

(1) General. The carrier shall complete its review of a bill within 30 days of receipt. The review may include an audit, as described by §42.160 of this title (relating to Carrier Desk Audit of Bills). A bill may not be reduced unless the carrier conducts an audit.

(2) Pharmaceutical bills. The carrier shall complete its review of a pharmaceutical bill within 10 days of receipt.

(3) Hospital bills; on-site audit. If the carrier decides to conduct an on-site audit of a hospital bill, the carrier shall proceed according to the provisions of §42.165 of this title (relating to Carrier On-Site Audit of Hospital Bills). The time for review shall be extended until completion of the on-site audit.

(c) Completion of review. Within 10 days of completion of the review, or, if a pharmaceutical bill, within five days of completion of the review, the carrier shall:

(1) remit to the provider full payment of the bill as submitted; or

(2) remit to the provider the amount of payment the carrier has determined to be appropriate. If the carrier remits to the provider an amount less than the amount billed, or remits no payment, the carrier shall immediately send the provider and the claimant or claimant's representative copies of the appropriate medical audit summary sheet, as described in §42.160 and §42.165 of this title (relating to Carrier Desk Audit of Bills and Carrier On-Site Audit of Hospital Bills). The copies sent to the provider and the claimant or claimant's representative shall contain the following statement. "The insurance carrier and not the claimant/patient or employer, is solely liable for all reasonable and necessary medical treatment rendered in connection with the injury, and no billing for any unpaid amounts should be directed to the claimant/patient or employer, nor should any attempt be made to collect any unpaid amount from the claimant/patient or employer, unless the claim has been denied by the board or the court."

(d) Suspension of medical benefits. The carrier's failure to comply with the requirements of subsection (c) of this section within the time indicated constitutes suspension of medical benefits, pursuant to Texas Civil Statutes, Article 8306, §18a(b).

(e) Bill reduction. Forty days after posting, the health care provider may request assistance from the board in compelling the carrier to file reasons for reducing a bill.

Source Note: The provisions of this §42.155 adopted to be effective October 20, 1988, 13 TexReg 4994; amended to be effective May 31, 1990, 15 TexReg 2803.