Texas Claims Dispute & Statutory Guide
The Texas workers' compensation system is administered by the Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC). Medical billing fee disputes are handled through the Medical Fee Dispute Resolution (MFDR) process under 28 Texas Administrative Code § 133.307.
Statutory Framework & Jurisdiction
Texas is an elective workers' compensation state (employers may opt out as 'non-subscribers'). For covered employers, certified workers' comp healthcare networks (HCNs) operate under Chapter 1305 of the Texas Insurance Code.
Official Medical Fee Schedule & Reimbursement Standards
name
Texas Medical Fee Guidelines (28 TAC Chapter 134)
structure
Medicare-based methodology with state-specific conversion factors for professional medical services, inpatient hospital services, and ambulatory surgical centers.
electronic Billing
Mandatory electronic medical billing under 28 TAC §§ 133.500 - 133.501
Preauthorization & Decision Point Review
protocol
Governed by 28 TAC § 134.600. Certain non-emergency outpatient surgeries, physical medicine beyond guideline limits, and repeat diagnostics require prospective preauthorization.
deadlines
Carrier must respond within 3 working days of receipt of complete preauthorization request.
dispute Mechanism
Independent Review Organization (IRO) process for medical necessity determinations under Texas Insurance Code Chapter 4202.
Medical Billing & Appeals Procedure
timely Filing
95 days from date of service (Texas Labor Code § 408.0272)
reconsideration
Mandatory prerequisite. Provider must request reconsideration within 10 months of the date of service or 60 days from initial EOB.
medical Fee Dispute Resolution
TDI-DWC MFDR filed on DWC Form-027 within one year of the date of service under 28 TAC § 133.307.
soah Hearings
Appeals of MFDR decisions proceed to the State Office of Administrative Hearings (SOAH) for formal contested case adjudication.
Critical Statutory & Dispute Deadlines
| Dispute Phase / Trigger Event | Statutory Timeline / Deadline |
|---|---|
| Initial Medical Bill Submission | 95 calendar days from date of service |
| Carrier Explanation of Benefits (EOB) | 45 days from receipt of clean medical bill |
| Request for Medical Bill Reconsideration | 10 months from date of service |
| Carrier Reconsideration Response | 30 days from receipt of request |
| MFDR Application (DWC Form-027) | Strictly within 1 year from the date of service |
Required Evidentiary Filing Checklist
- ✓DWC Form-027 (Medical Fee Dispute Resolution Request)
- ✓Complete CMS-1500 / UB-04 billing form with applicable CPT codes and modifiers
- ✓Medical records, daily progress notes, and diagnostic test findings for contested dates of service
- ✓Copy of original medical bill, initial EOB, written request for reconsideration, and second EOB
- ✓Detailed position statement calculating allowable amounts under Texas Medical Fee Guidelines
Official Primary Sources & Legislative Authorities
Official Forms & Downloads for Texas
TX DWC Form 027 Medical Fee Dispute Resolution
Dispute Forms reference for Texas Workers' Compensation. Available for download.
Governing Regulatory Authorities
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