Texas Department of Insurance

Fee Guidelines Information

In the Texas workers compensation system, reimbursement of medical services and treatments for non-network care is determined by fee guideline rules.  These fee guideline rules are based on the Texas Workers Compensation Act and are adopted through the administrative rule making process.  Understanding the fee guideline rules and related resources is crucial to successful reimbursement for workers compensation claims.

Medical Fee Guidelines | Hospital Fee Guidelines | Ambulatory Surgical Center Fee Guideline | Pharmacy | Dental Fee Guideline | Training and Related Resources

   Medical Fee Guidelines

On December 28, 2007, TDI-DWC adopted rules to update the Medical Fee Guidelines for professional services. These guidelines are applicable for dates of service on and after March 1, 2008.

• Rules: Chapter 134 - Benefits - Guidelines for Medical Services, Charges, and Payments
  SUBCHAPTER A. Medical Reimbursement Policies - Sections 134.1 and 134.2
  SUBCHAPTER C. Medical Fee Guidelines - Sections 134.203 and 134.204 (Word, PDF) [rule text begins on page 141]
  
  
• Commissioner's Bulletin #B-0075-08 - Changes to Conversion Factors for Workers’ Compensation Medical Fee Guidelines, 28 TAC §134.203 11/20/08
• Conversion Factors
• Medical Fee Guidelines Training Module (PDF)
• General Information for Medical Fee Guidelines 28 TAC §§134.2, 134.203, and 134.204 (PDF)
• Medical Fee Guidelines Frequently Asked Questions (Word)

   Hospital Fee Guidelines

On December 28, 2007, TDI-DWC adopted rules to establish a hospital outpatient fee guideline and to update the hospital inpatient fee guideline. These guidelines are applicable for dates of service on and after March 1, 2008.

• Rules: Chapter 134 - Benefits - Guidelines for Medical Services, Charges, and Payments
  SUBSCHAPTER E. Health Facility Fees 
  Section 134.403 - Hospital Facility Fee Guideline - Outpatient (PDF - rule text begins on page 125.)
  Section 134.404 - Hospital Facility Fee Guideline - Inpatient (PDF - rule text begins on page 132.) 
  
  
• Hospital Facility Fee Guidelines Frequently Asked Questions (FAQs) (PDF)
• Reports Used in HFG Rule Development
  • THA Survey (zip)
  • TMIC - RPC (zip)
  • Renaissance (zip)
  • Milliman (zip)

   Ambulatory Surgical Center Fee Guideline 

On August 8, 2008, TDI-DWC adopted the amended Ambulatory Surgical Center (ASC) Fee Guideline, §134.402. This guideline is applicable for dates of service on and after September 1, 2008.

• Rules: Chapter 134 - Benefits - Guidelines for Medical Services, Charges, and Payments
  SUBCHAPTER E.  Health Facility Fees
  Section 134.402 - Ambulatory Surgical Center Fee Guideline
  
  
• Calculation of Ambulatory Surgical Center (ASC) Fully Implemented Facility Reimbursement Rates for 2009 2/2/09 (PDF)
• ASC Frequently Asked Questions (FAQs)
• Calculations Examples for Ambulatory Surgical Center Fee Guidelines
• Reports Used in ASC Rule Development
  • Deloitte Indexing DWC to Medicare
  • Deloitte Indexing Commercial to Medicare
• Texas Ambulatory Surgical Center Localities

   Dental Fee Guideline

• Rules: Chapter 134 Benefits--Guidelines for Medical Services, Charges, And Payments
  Subchapter C Medical Fee Guidelines 
  Section 134.303 - 2005 Dental Fee Guideline

   Pharmacy

• Rules:  Rules: Chapter 134 - Benefits - Guidelines for Medical Services, Charges, and Payments
  SUBCHAPTER F. Pharmaceutical Benefits
  
• Pharmacy Closed Formulary Rule Development
  • August 20, 2009 Stakeholder Meeting (announcement, slides, archived audio)
  • March 5, 2009 Stakeholder Meeting (announcement, slides, archived audio)
  • Memo: Use of Pharmaceuticals in the Texas Workers' Compensation System
  • August 25, 2008 Stakeholder Meeting (announcement, archived audio)

   Training and Related Resources

• Basic Workers’ Compensation for Health Care Providers -  New dates for this seminar will be scheduled beginning in March 2009.  Check the events calendar for a seminar in your area.
• Disability Management
• Preauthorization Rule: §134.600 Preauthorization, Concurrent Review, and Voluntary Certification of Health Care
• eBill - Electronic Medical Billing
• Medical Fee Dispute Resolution
• Return to Work / Stay at Work

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