SECTION 42.165. Carrier On-Site Audit of Hospital Bills

(a) The carrier may request an on-site audit of a hospital bill.

(b) The request shall:

(1) be made in writing;

(2) be made no later than 40 days after receipt of the bill; and

(3) be accompanied by payment of either 75% of the bill as submitted, or a $50 audit fee.

(c) The audit shall be conducted according to the Instructions for On-Site Audit of Hospital Charges by Workers' Compensation Carrier, hereby adopted by reference. Copies of this document will be made available upon written request to the Administrator, Medical Cost Evaluation Division, Industrial Accident Board, 200 East Riverside, First Floor, Austin, Texas 78704-1287.

(d) Every audit shall be documented on the medical audit summary sheet, which shall include the following information:

(1) claimant's name;

(2) IAB claim number;

(3) provider's name, address, and federal tax identification number;

(4) health care provider-reviewer's report; and

(5) for each audited item, the following: applicable code; code description; amount billed; amount paid; and, if appropriate, amount reduced or denied, accompanied by a sufficient explanation for each reduction or denial.

Source Note: The provisions of this §42.165 adopted to be effective October 20, 1988, 13 TexReg 4994.