What dispute deadlines should providers track in Texas?

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. Verify the trigger date, current agency notices, and any extension before acting.

Which agencies administer these rules in Texas?

The guide identifies Texas Department of Insurance - Division of Workers' Compensation (TDI-DWC), State Office of Administrative Hearings (SOAH). The correct agency depends on the plan and claim jurisdiction.

Workers' Compensation Medical Billing State Guides

Texas Workers' Compensation Medical Billing 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.

Accountability & Review

Reviewed by Millennova Legal Operational Integrity Team, Senior Audit and Arbitration Analysts

Last Reviewed

2026-03-01

Plain-language overview

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.

Medical fee schedule and reimbursement rules

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 and utilization 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.

Billing and appeal 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.

Claim and dispute deadlines

Deadlines can depend on the trigger event and may be affected by agency relief notices. Confirm the live rule before filing.

Event	Timeframe
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

Documentation 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

Responsible agencies

Texas Department of Insurance - Division of Workers' Compensation (TDI-DWC)Statewide Workers' Compensation Administration & MFDR
State Office of Administrative Hearings (SOAH)Administrative law hearings for contested MFDR decisions

Primary legal and regulatory sources

Texas Labor Code Title 5 (Workers' Compensation)Texas Legislature · 2024
Texas Administrative Code Title 28, Part 2 (Division of Workers' Compensation)Texas Secretary of State · 2025

This operational reference is educational, is not legal advice, and does not create an attorney-client relationship.

Common questions

What rules govern workers' compensation medical billing state guides in Texas?: 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.
What dispute deadlines should providers track in Texas?: 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. Verify the trigger date, current agency notices, and any extension before acting.
Which agencies administer these rules in Texas?: The guide identifies Texas Department of Insurance - Division of Workers' Compensation (TDI-DWC), State Office of Administrative Hearings (SOAH). The correct agency depends on the plan and claim jurisdiction.