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“Worker’s Compensation doesn’t follow the insurance code.”
While that’s true that worker’s compensation follows the Texas Labor Code, the Texas Insurance Code does prevail when there is a conflict between the two codes over “time frames for payment of medical bills” or “disputes regarding medical benefits.” Under the Texas Workers Compensation Act, you have 45 days to pay or deny, and if the claim goes into audit you must advance 85% of either fee guidelines or the contracted amount.
Texas Insurance Code § 1305.003
“In the event of a conflict between Title 5, Labor Code, and this chapter as to the provision of medical benefits for injured employees, the establishment and regulation of fees for medical treatments and services, the time frames for payment of medical bills, the operation and regulation of workers’ compensation health care networks, the regulation of health care providers who contract with those networks, or the resolution of disputes regarding medical benefits provided through those networks, this chapter prevails.”
Texas Labor Code § 408.027
The insurance carrier must pay, reduce, deny, or determine to audit the health care provider’s claim not later than the 45th day after the date of receipt by the carrier of the provider’s claim. … If the insurance carrier chooses to audit the claim, the insurance carrier must pay to the health care provider not later than the 45th day after the date of receipt by the carrier of the provider’s claim 85 percent of:
(1) the amount for the health care service established under the fee guidelines authorized under this subtitle if the health care service is not provided through a workers’ compensation health care network under Chapter 1305, Insurance Code; or
(2) the amount of the contracted rate for that health care service if the health care service is provided through a workers’ compensation health care network under Chapter 1305, Insurance Code.
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