SECTION 42.307. Procedure for Requesting Dispute Review

(a) A request for dispute review shall be made in writing, and filed with the administrator of the Medical Cost Evaluation Division.

(b) The request shall be made no later than 365 days after the date the disputed bill was submitted to the carrier.

(c) The request shall include the following:

(1) all identifying information required by §42.30(d) of this title (relating to Written Communications);

(2) the bill as originally submitted to the carrier;

(3) copies of all written communications relating to the dispute; and

(4) written documentation that all reasonable efforts to resolve the dispute have been exhausted.

(d) The board may request additional information, and may compel production of documents, if necessary.

(e) A carrier requesting review shall:

(1) file the original request in person with the Medical Cost Evaluation Division;

(2) tender the review fee to the board at the time of filing, unless the provider is responsible for the fee, as provided in §42.309 of this title (relating to Payment for the Review); and

(3) send simultaneously, by certified mail, a copy of the request to the provider.

(f) A health care provider requesting review shall:

(1) file the original and one copy of the request by mail or in person with the Medical Cost Evaluation Division; and

(2) tender the review fee to the board, if responsible, as provided in §42. 309 of this title (relating to Payment for the Review).

(g) When a health care provider requests review, the board will notify the carrier's Austin board representative to appear in person to accept the carrier's copy of the request and tender the review fee, unless the provider is responsible for the fee, as provided in §42.309 of this title (relating to Payment for the Review).

Source Note: The provisions of this §42.307 adopted to be effective February 17, 1989, 14 TexReg 694.