CHAPTER 413. MEDICAL REVIEW - Texas Statutes

LABOR CODE

TITLE 5. WORKERS' COMPENSATION

SUBTITLE A. TEXAS WORKERS' COMPENSATION ACT

CHAPTER 413. MEDICAL REVIEW

SUBCHAPTER A. GENERAL PROVISIONS

Sec. 413.002. MEDICAL REVIEW. (a) The division shall monitor

health care providers, insurance carriers, independent review

organizations, and workers' compensation claimants who receive

medical services to ensure the compliance of those persons with

rules adopted by the commissioner relating to health care,

including medical policies and fee guidelines.

(b) In monitoring health care providers who serve as designated

doctors under Chapter 408 and independent review organizations

who provide services described by this chapter, the division

shall evaluate:

(1) compliance with this subtitle and with rules adopted by the

commissioner relating to medical policies, fee guidelines,

treatment guidelines, return-to-work guidelines, and impairment

ratings; and

(2) the quality and timeliness of decisions made under Section

408.0041, 408.122, 408.151, or 413.031.

(c) The division shall report the results of the monitoring of

independent review organizations under Subsection (b) to the

department on at least a quarterly basis.

(d) If the commissioner determines that an independent review

organization is in violation of this chapter, rules adopted by

the commissioner under this chapter, applicable provisions of

this code or rules adopted under this code, or applicable

provisions of the Insurance Code or rules adopted under that

code, the commissioner or a designated representative shall

notify the independent review organization of the alleged

violation and may compel the production of any documents or other

information as necessary to determine whether the violation

occurred.

Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.

Amended by Acts 1995, 74th Leg., ch. 980, Sec. 1.42, eff. Sept.

1, 1995.

Amended by:

Acts 2005, 79th Leg., Ch.

265, Sec. 3.227, eff. September 1, 2005.

Sec. 413.003. AUTHORITY TO CONTRACT. The division may contract

with a private or public entity to perform a duty or function of

the division.

Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.

Amended by:

Acts 2005, 79th Leg., Ch.

265, Sec. 3.228, eff. September 1, 2005.

Sec. 413.004. COORDINATION WITH PROVIDERS. The division shall

coordinate its activities with health care providers as necessary

to perform its duties under this chapter. The coordination may

include:

(1) conducting educational seminars on commissioner rules and

procedures; or

(2) providing information to and requesting assistance from

professional peer review organizations.

Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.

Amended by:

Acts 2005, 79th Leg., Ch.

265, Sec. 3.229, eff. September 1, 2005.

Sec. 413.006. ADVISORY COMMITTEES. The commissioner may appoint

advisory committees as the commissioner considers necessary.

Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.

Amended by:

Acts 2005, 79th Leg., Ch.

265, Sec. 3.230, eff. September 1, 2005.

Sec. 413.007. INFORMATION MAINTAINED BY DIVISION. (a) The

division shall maintain a statewide data base of medical charges,

actual payments, and treatment protocols that may be used by:

(1) the commissioner in adopting the medical policies and fee

guidelines; and

(2) the division in administering the medical policies, fee

guidelines, or rules.

(b) The division shall ensure that the data base:

(1) contains information necessary to detect practices and

patterns in medical charges, actual payments, and treatment

protocols; and

(2) can be used in a meaningful way to allow the commission to

control medical costs as provided by this subtitle.

(c) The division shall ensure that the data base is available

for public access for a reasonable fee established by the

commissioner. The identities of injured workers and

beneficiaries may not be disclosed.

(d) The division shall take appropriate action to be aware of

and to maintain the most current information on developments in

the treatment and cure of injuries and diseases common in

workers' compensation cases.

Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.

Amended by:

Acts 2005, 79th Leg., Ch.

265, Sec. 3.231, eff. September 1, 2005.

Sec. 413.008. INFORMATION FROM INSURANCE CARRIERS;

ADMINISTRATIVE VIOLATION. (a) On request from the division for

specific information, an insurance carrier shall provide to the

division any information in the carrier's possession, custody, or

control that reasonably relates to the division's duties under

this subtitle and to health care:

(1) treatment;

(2) services;

(3) fees; and

(4) charges.

(b) The division shall keep confidential information that is

confidential by law.

(c) An insurance carrier commits an administrative violation if

the insurance carrier fails or refuses to comply with a request

or violates a rule adopted to implement this section.

Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.

Amended by:

Acts 2005, 79th Leg., Ch.

265, Sec. 3.232, eff. September 1, 2005.

SUBCHAPTER B. MEDICAL SERVICES AND FEES

For expiration of Subsections (d-1), (d-2), (d-3),and (d-6), see

Subsection (d-6)

Sec. 413.011. REIMBURSEMENT POLICIES AND GUIDELINES; TREATMENT

GUIDELINES AND PROTOCOLS. (a) The commissioner shall adopt

health care reimbursement policies and guidelines that reflect

the standardized reimbursement structures found in other health

care delivery systems with minimal modifications to those

reimbursement methodologies as necessary to meet occupational

injury requirements. To achieve standardization, the

commissioner shall adopt the most current reimbursement

methodologies, models, and values or weights used by the federal

Centers for Medicare and Medicaid Services, including applicable

payment policies relating to coding, billing, and reporting, and

may modify documentation requirements as necessary to meet the

requirements of Section 413.053.

(b) In determining the appropriate fees, the commissioner shall

also develop one or more conversion factors or other payment

adjustment factors taking into account economic indicators in

health care and the requirements of Subsection (d). The

commissioner shall also provide for reasonable fees for the

evaluation and management of care as required by Section

408.025(c) and commissioner rules. This section does not adopt

the Medicare fee schedule, and the commissioner may not adopt

conversion factors or other payment adjustment factors based

solely on those factors as developed by the federal Centers for

Medicare and Medicaid Services.

(c) This section may not be interpreted in a manner that would

discriminate in the amount or method of payment or reimbursement

for services in a manner prohibited by Section 1451.104,

Insurance Code, or as restricting the ability of chiropractors to

serve as treating doctors as authorized by this subtitle. The

commissioner shall also develop guidelines relating to fees

charged or paid for providing expert testimony relating to an

issue arising under this subtitle.

(d) Fee guidelines must be fair and reasonable and designed to

ensure the quality of medical care and to achieve effective

medical cost control. The guidelines may not provide for payment

of a fee in excess of the fee charged for similar treatment of an

injured individual of an equivalent standard of living and paid

by that individual or by someone acting on that individual's

behalf. The commissioner shall consider the increased security

of payment afforded by this subtitle in establishing the fee

guidelines.

(d-1) Notwithstanding Subsections (b) through (d) and Section

413.016, an insurance carrier may pay fees to a health care

provider that are inconsistent with the fee guidelines adopted by

the division if the insurance carrier, or a network under Chapter

1305, Insurance Code, arranging out-of-network services under

Section 1305.006, Insurance Code, has a contract with the health

care provider and that contract includes a specific fee schedule.

An insurance carrier or the carrier's authorized agent may use

an informal or voluntary network, as those terms are defined by

Section 413.0115, to obtain a contractual agreement that provides

for fees different from the fees authorized under the division's

fee guidelines. If a carrier or the carrier's authorized agent

chooses to use an informal or voluntary network to obtain a

contractual fee arrangement, there must be a contractual

arrangement between:

(1) the carrier or authorized agent and the informal or

voluntary network that authorizes the network to contract with

health care providers on the carrier's behalf; and

(2) the informal or voluntary network and the health care

provider that includes a specific fee schedule and complies with

the notice requirements established under Subsection (d-2).

(d-2) An informal or voluntary network, or the carrier or the

carrier's authorized agent, as appropriate, shall notify each

health care provider of any person that is given access to the

network's fee arrangements with that health care provider within

the time and according to the manner provided by commissioner

rule.

(d-3) An insurance carrier shall provide copies of each contract

described by Subsection (d-1) to the division on the request of

the division. Information included in a contract under

Subsection (d-1) is confidential and is not subject to disclosure

under Chapter 552, Government Code. For medical fee disputes

that arise regarding non-network and out-of-network care, the

division may request that copies of each contract under which

fees are being paid be submitted to the division for review.

Notwithstanding Subsection (d-1) or Section 1305.153, Insurance

Code, the insurance carrier may be required to pay fees in

accordance with the division's fee guidelines if the contract:

(1) is not provided in a timely manner to the division on the

division's request;

(2) does not include a specific fee schedule consistent with

Subsection (d-1); and

(3) does not:

(A) clearly state that the contractual fee arrangement is

between the health care provider and the named insurance carrier

or the named insurance carrier's authorized agent; or

(B) comply with the notice requirements under Subsection (d-2).

Text of subsection effective on January 01, 2011

(d-4) Notwithstanding this section or any other provision of

this title, an insurance carrier, an insurance carrier's

authorized agent, or a network certified under Chapter 1305,

Insurance Code, arranging for non-network services or

out-of-network services under Section 1305.006, Insurance Code,

may continue to contract with a health care provider to secure

health care for an injured employee for fees that exceed the fees

adopted by the division under this section.

(d-5) The commissioner and the commissioner of insurance may

adopt rules as necessary to implement this section.

(d-6) Subsections (d-1) through (d-3) and this subsection expire

January 1, 2011.

(e) The commissioner by rule shall adopt treatment guidelines

and return-to-work guidelines and may adopt individual treatment

protocols. Treatment guidelines and protocols must be

evidence-based, scientifically valid, and outcome-focused and

designed to reduce excessive or inappropriate medical care while

safeguarding necessary medical care. Treatment may not be denied

solely on the basis that the treatment for the compensable injury

in question is not specifically addressed by the treatment

guidelines.

(f) In addition to complying with the requirements of Subsection

(e), medical policies or guidelines adopted by the commissioner

must be:

(1) designed to ensure the quality of medical care and to

achieve effective medical cost control;

(2) designed to enhance a timely and appropriate return to work;

and

(3) consistent with Sections 413.013, 413.020, 413.052, and

413.053.

(g) The commissioner may adopt rules relating to disability

management that are designed to promote appropriate health care

at the earliest opportunity after the injury to maximize injury

healing and improve stay-at-work and return-to-work outcomes

through appropriate management of work-related injuries or

conditions. The commissioner by rule may identify claims in

which application of disability management activities is required

and prescribe at what point in the claim process a treatment plan

is required. The determination may be based on any factor

considered relevant by the commissioner. Rules adopted under

this subsection do not apply to claims subject to workers'

compensation health care networks under Chapter 1305, Insurance

Code.

(h) A dispute involving a treatment plan required under

Subsection (g) may be appealed to an independent review

organization in the manner described by Section 413.031.

(i) The division shall examine whether injured employees have

reasonable access to surgically implanted, inserted, or otherwise

applied devices or tissues and investigate whether reimbursement

rates or any other barriers exist that reduce the ability of an

injured employee to access those medical needs. The division

shall recommend to the legislature any statutory changes

necessary to ensure appropriate access to those medical needs.

Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.

Amended by Acts 2001, 77th Leg., ch. 1456, Sec. 6.02, eff. June

17, 2001; Acts 2003, 78th Leg., ch. 962, Sec. 1, 2, eff. June 20,

2003.

Amended by:

Acts 2005, 79th Leg., Ch.

265, Sec. 3.233, eff. September 1, 2005.

Acts 2007, 80th Leg., R.S., Ch.

1177, Sec. 2, eff. September 1, 2007.

Acts 2007, 80th Leg., R.S., Ch.

1177, Sec. 2, eff. January 1, 2011.

Sec. 413.0111. PROCESSING AGENTS. The rules adopted by the

commissioner for the reimbursement of prescription medications

and services must authorize pharmacies to use agents or assignees

to process claims and act on the behalf of the pharmacies under

terms and conditions agreed on by the pharmacies.

Added by Acts 2005, 79th Leg., Ch.

265, Sec. 3.234, eff. September 1, 2005.

Sec. 413.0115. REQUIREMENTS FOR CERTAIN VOLUNTARY OR INFORMAL

NETWORKS. (a) In this section:

(1) "Informal network" means a health care provider network

described by Section 413.011(d-1) that:

(A) is established under a contract between an insurance carrier

and health care providers; and

(B) includes a specific fee schedule.

(2) "Voluntary network" means a voluntary workers' compensation

health care delivery network established by an insurance carrier

under former Section 408.0223, as that section existed before

repeal by Chapter 265, Acts of the 79th Legislature, Regular

Session, 2005.

(b) Not later than January 1, 2011, each informal network or

voluntary network must be certified as a workers' compensation

health care network under Chapter 1305, Insurance Code.

(c) Effective September 1, 2007, each informal network and

voluntary network must provide the following information to the

division:

(1) an executive contact for official correspondence for the

network;

(2) a toll-free telephone number by which a health care provider

may contact the informal network or voluntary network;

(3) a list of each insurance carrier with whom the network

contracts; and

(4) a list of each entity associated with the network working on

behalf of the insurance carrier, including contact information

for each entity.

(d) Each informal network and voluntary network shall report any

changes to the information provided under Subsection (c) to the

division not later than the 30th day after the effective date of

the change.

Added by Acts 2007, 80th Leg., R.S., Ch.

1177, Sec. 3, eff. September 1, 2007.

Sec. 413.012. MEDICAL POLICY AND GUIDELINE UPDATES REQUIRED.

The medical policies and fee guidelines shall be reviewed and

revised at least every two years to reflect fair and reasonable

fees and to reflect medical treatment or ranges of treatment that

are reasonable or necessary at the time the review and revision

is conducted.

Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.

Sec. 413.013. PROGRAMS. The commissioner by rule shall

establish:

(1) a program for prospective, concurrent, and retrospective

review and resolution of a dispute regarding health care

treatments and services;

(2) a program for the systematic monitoring of the necessity of

treatments administered and fees charged and paid for medical

treatments or services, including the authorization of

prospective, concurrent, or retrospective review under the

medical policies of the division to ensure that the medical

policies or guidelines are not exceeded;

(3) a program to detect practices and patterns by insurance

carriers in unreasonably denying authorization of payment for

medical services requested or performed if authorization is

required by the medical policies of the division; and

(4) a program to increase the intensity of review for compliance

with the medical policies or fee guidelines for any health care

provider that has established a practice or pattern in charges

and treatments inconsistent with the medical policies and fee

guidelines.

Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.

Amended by:

Acts 2005, 79th Leg., Ch.

265, Sec. 3.235, eff. September 1, 2005.

Sec. 413.014. PREAUTHORIZATION REQUIREMENTS; CONCURRENT REVIEW

AND CERTIFICATION OF HEALTH CARE. (a) In this section,

"investigational or experimental service or device" means a

health care treatment, service, or device for which there is

early, developing scientific or clinical evidence demonstrating

the potential efficacy of the treatment, service, or device but

that is not yet broadly accepted as the prevailing standard of

care.

(b) The commissioner by rule shall specify which health care

treatments and services require express preauthorization or

concurrent review by the insurance carrier. Treatments and

services for a medical emergency do not require express

preauthorization.

(c) The commissioner's rules adopted under this section must

provide that preauthorization and concurrent review are required

at a minimum for:

(1) spinal surgery, as provided by Section 408.026;

(2) work-hardening or work-conditioning services provided by a

health care facility that is not credentialed by an organization

recognized by commissioner rules;

(3) inpatient hospitalization, including any procedure and

length of stay;

(4) physical and occupational therapy;

(5) outpatient or ambulatory surgical services, as defined by

commissioner rule; and

(6) any investigational or experimental services or devices.

(d) The insurance carrier is not liable for those specified

treatments and services requiring preauthorization unless

preauthorization is sought by the claimant or health care

provider and either obtained from the insurance carrier or

ordered by the commissioner.

(e) If a specified health care treatment or service is

preauthorized as provided by this section, that treatment or

service is not subject to retrospective review of the medical

necessity of the treatment or service.

(f) The division may not prohibit an insurance carrier and a

health care provider from voluntarily discussing health care

treatment and treatment plans and pharmaceutical services, either

prospectively or concurrently, and may not prohibit an insurance

carrier from certifying or agreeing to pay for health care

consistent with those agreements. The insurance carrier is

liable for health care treatment and treatment plans and

pharmaceutical services that are voluntarily preauthorized and

may not dispute the certified or agreed-on preauthorized health

care treatment and treatment plans and pharmaceutical services at

a later date.

Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.

Amended by Acts 2001, 77th Leg., ch. 1456, Sec. 4.02, eff. June

17, 2001; Acts 2003, 78th Leg., ch. 980, Sec. 1, eff. Sept. 1,

2003.

Amended by:

Acts 2005, 79th Leg., Ch.

265, Sec. 3.236, eff. September 1, 2005.

Sec. 413.0141. INITIAL PHARMACEUTICAL COVERAGE. The

commissioner may by rule provide that an insurance carrier shall

provide for payment of specified pharmaceutical services

sufficient for the first seven days following the date of injury

if the health care provider requests and receives verification of

insurance coverage and a verbal confirmation of an injury from

the employer or from the insurance carrier as provided by Section

413.014. The rules adopted by the commissioner shall provide

that an insurance carrier is eligible for reimbursement for

pharmaceutical services paid under this section from the

subsequent injury fund in the event the injury is determined not

to be compensable.

Added by Acts 2001, 77th Leg., ch. 1456, Sec. 4.03, eff. June 17,

2001.

Amended by:

Acts 2005, 79th Leg., Ch.

265, Sec. 3.237, eff. September 1, 2005.

Sec. 413.015. PAYMENT BY INSURANCE CARRIERS; AUDIT AND REVIEW.

(a) Insurance carriers shall make appropriate payment of charges

for medical services provided under this subtitle. An insurance

carrier may contract with a separate entity to forward payments

for medical services. Any payment due the insurance carrier from

the separate entity must be made in accordance with the contract.

The separate entity is subject to the direction of the insurance

carrier, and the insurance carrier is responsible for the actions

of the separate entity under this subsection.

(b) The commissioner shall provide by rule for the review and

audit of the payment by insurance carriers of charges for medical

services provided under this subtitle to ensure compliance of

health care providers and insurance carriers with the medical

policies and fee guidelines adopted by the commissioner.

(c) The rules must require the insurance carrier to pay the

expenses of the review and audit.

Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.

Amended by Acts 2001, 77th Leg., ch. 1456, Sec. 6.03, eff. June

17, 2001.

Amended by:

Acts 2005, 79th Leg., Ch.

265, Sec. 3.238, eff. September 1, 2005.

Sec. 413.016. PAYMENTS IN VIOLATION OF MEDICAL POLICIES AND FEE

GUIDELINES. (a) The division shall order a refund of charges

paid to a health care provider in excess of those allowed by the

medical policies or fee guidelines. The division shall also refer

the health care provider alleged to have violated this subtitle

to the division of compliance and practices.

(b) If the division determines that an insurance carrier has

paid medical charges that are inconsistent with the medical

policies or fee guidelines adopted by the commissioner, the

division shall investigate the potential violation. If the

insurance carrier reduced a charge of a health care provider that

was within the guidelines, the insurance carrier shall be

directed to submit the difference to the provider unless the

reduction is in accordance with an agreement between the health

care provider and the insurance carrier.

Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.

Amended by:

Acts 2005, 79th Leg., Ch.

265, Sec. 3.239, eff. September 1, 2005.

Sec. 413.017. PRESUMPTION OF REASONABLENESS. The following

medical services are presumed reasonable:

(1) medical services consistent with the medical policies and

fee guidelines adopted by the commissioner; and

(2) medical services that are provided subject to prospective,

concurrent, or retrospective review as required by the medical

policies of the division and that are authorized by an insurance

carrier.

Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.

Amended by:

Acts 2005, 79th Leg., Ch.

265, Sec. 3.240, eff. September 1, 2005.

Sec. 413.018. REVIEW OF MEDICAL CARE IF GUIDELINES EXCEEDED.

(a) The commissioner by rule shall provide for the periodic

review of medical care provided in claims in which guidelines for

expected or average return to work time frames are exceeded.

(b) The division shall review the medical treatment provided in

a claim that exceeds the guidelines and may take appropriate

action to ensure that necessary and reasonable care is provided.

(c) The division shall implement a program to encourage

employers and treating doctors to discuss the availability of

modified duty to encourage the safe and more timely return to

work of injured employees. The division may require a treating

or examining doctor, on the request of the employer, insurance

carrier, or division, to provide a functional capacity evaluation

of an injured employee and to determine the employee's ability to

engage in physical activities found in the workplace or in

activities that are required in a modified duty setting.

(d) The division shall provide through the division's health and

safety information and medical review outreach programs

information to employers regarding effective return to work

programs. This section does not require an employer to provide

modified duty or an employee to accept a modified duty

assignment. An employee who does not accept an employer's offer

of modified duty determined by the division to be a bona fide job

offer is subject to Section 408.103(e).

(e) The commissioner may adopt rules and forms as necessary to

implement this section.

Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.

Amended by Acts 1999, 76th Leg., ch. 956, Sec. 3, eff. Sept. 1,

1999.

Amended by:

Acts 2005, 79th Leg., Ch.

265, Sec. 3.241, eff. September 1, 2005.

Sec. 413.019. INTEREST EARNED FOR DELAYED PAYMENT, REFUND, OR

OVERPAYMENT. (a) Interest on an unpaid fee or charge that is

consistent with the fee guidelines accrues at the rate provided

by Section 401.023 beginning on the 60th day after the date the

health care provider submits the bill to an insurance carrier

until the date the bill is paid.

(b) Interest on a refund from a health care provider accrues at

the rate provided by Section 401.023 beginning on the 60th day

after the date the provider receives notice of alleged

overpayment from the insurance carrier until the date the refund

is paid.

Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.

Sec. 413.020. DIVISION CHARGES. The commissioner by rule shall

establish procedures to enable the division to charge:

(1) an insurance carrier a reasonable fee for access to or

evaluation of health care treatment, fees, or charges under this

subtitle; and

(2) a health care provider who exceeds a fee or utilization

guideline established under this subtitle or an insurance carrier

who unreasonably disputes charges that are consistent with a fee

or utilization guideline established under this subtitle a

reasonable fee for review of health care treatment, fees, or

charges under this subtitle.

Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.

Amended by:

Acts 2005, 79th Leg., Ch.

265, Sec. 3.242, eff. September 1, 2005.

Sec. 413.021. RETURN-TO-WORK COORDINATION SERVICES. (a) An

insurance carrier shall, with the agreement of a participating

employer, provide the employer with return-to-work coordination

services on an ongoing basis as necessary to facilitate an

employee's return to employment, including on receipt of a notice

that an injured employee is eligible to receive temporary income

benefits. The insurance carrier shall notify the employer of the

availability of the return-to-work reimbursement program under

Section 413.022. The insurance carrier shall evaluate a

compensable injury in which the injured employee sustains an

injury that could potentially result in lost time from employment

as early as practicable to determine if skilled case management

is necessary for the injured employee's case. As necessary, case

managers who are appropriately certified shall be used to perform

these evaluations. A claims adjuster may not be used as a case

manager. These services may be offered by insurance carriers in

conjunction with the accident prevention services provided under

Section 411.061. Nothing in this section supersedes the

provisions of a collective bargaining agreement between an

employer and the employer's employees, and nothing in this

section authorizes or requires an employer to engage in conduct

that would otherwise be a violation of the employer's obligations

under the National Labor Relations Act (29 U.S.C. Section 151 et

seq.).

(b) Return-to-work coordination services under this section may

include:

(1) job analysis to identify the physical demands of a job;

(2) job modification and restructuring assessments as necessary

to match job requirements with the functional capacity of an

employee; and

(3) medical or vocational case management to coordinate the

efforts of the employer, the treating doctor, and the injured

employee to achieve timely return to work.

(c) An insurance carrier is not required to provide physical

workplace modifications under this section and is not liable for

the cost of modifications made under this section to facilitate

an employee's return to employment.

(d) The division shall use certified rehabilitation counselors

or other appropriately trained or credentialed specialists to

provide training to division staff regarding the coordination of

return-to-work services under this section.

(e) The commissioner shall adopt rules necessary to collect data

on return-to-work outcomes to allow full evaluations of successes

and of barriers to achieving timely return to work after an

injury.

(f) Repealed by Acts 2003, 78th Leg., 3rd C.S., ch. 10, Sec.

1.02(a).

Added by Acts 2001, 77th Leg., ch. 1456, Sec. 3.02, eff. June 17,

2001. Amended by Acts 2003, 78th Leg., 3rd C.S., ch. 10, Sec.

1.02(a), eff. Oct. 20, 2003.

Amended by:

Acts 2005, 79th Leg., Ch.

265, Sec. 3.243, eff. September 1, 2005.

Acts 2009, 81st Leg., R.S., Ch.

1388, Sec. 1, eff. June 19, 2009.

Sec. 413.022. RETURN-TO-WORK REIMBURSEMENT PROGRAM FOR

EMPLOYERS; FUND. (a) In this section:

(1) "Account" means the workers' compensation return-to-work

account.

(2) "Eligible employer" means any employer, other than this

state or a political subdivision subject to Subtitle C, who has

workers' compensation insurance coverage and who:

(A) employed at least two but not more than 50 employees on each

business day during the preceding calendar year; or

(B) is a type of employer designated as eligible to participate

in the program by the commissioner.

(3) "Program" means the return-to-work reimbursement program

established under this section.

(b) The commissioner shall establish by rule a return-to-work

reimbursement program designed to promote the early and sustained

return to work of an injured employee who sustains a compensable

injury. The commissioner, by rule, may expand eligibility to

participate in the program to types of employers who are not

described by Subsection (a)(2)(A).

(c) The program shall reimburse from the account an eligible

employer for expenses incurred by the employer to make workplace

modifications necessary to accommodate an injured employee's

return to modified or alternative work. Reimbursement under this

section to an eligible employer may not exceed $5,000. The

expenses must be incurred to allow the employee to perform

modified or alternative work within doctor-imposed work

restrictions. Allowable expenses may include:

(1) physical modifications to the worksite;

(2) equipment, devices, furniture, or tools; and

(3) other costs necessary for reasonable accommodation of the

employee's restrictions.

(c-1) The commissioner by rule shall establish an optional

preauthorization plan for eligible employers who participate in

the program. To participate in the preauthorization plan, an

employer must submit a proposal to the division, in the manner

prescribed by the division, that describes the workplace

modifications and other changes that the employer proposes to

make to accommodate an injured employee's return to work. If the

division approves the employer's proposal, the division shall

guarantee reimbursement of the expenses incurred by the employer

in implementing the modifications and changes from the account

unless the division determines that the modifications and changes

differ materially from the employer's proposal. If determined to

be a public purpose by the commissioner, and in accordance with

rules adopted by the commissioner, the division may provide the

employer an advance of funds under this subsection. Reimbursement

or an advance of funds under this subsection is subject to the

limit imposed under Subsection (c).

(d) The account is established as a special account in the

general revenue fund. From administrative penalties received by

the division under this subtitle, the commissioner shall deposit

in the account an amount not to exceed $100,000 annually. Money

in the account may be spent by the division, on appropriation by

the legislature, only for the purposes of implementing this

section.

(e) An employer who wilfully applies for or receives

reimbursement from the account under this section knowing that

the employer is not an eligible employer commits a violation.

(f) Notwithstanding Subsections (a)-(e), this section may be

implemented only to the extent funds are available.

(g) The commissioner shall adopt rules as necessary to implement

this section.

Added by Acts 2005, 79th Leg., Ch.

265, Sec. 3.244, eff. September 1, 2005.

Amended by:

Acts 2007, 80th Leg., R.S., Ch.

106, Sec. 1, eff. May 17, 2007.

Acts 2009, 81st Leg., R.S., Ch.

1388, Sec. 2, eff. June 19, 2009.

Acts 2009, 81st Leg., R.S., Ch.

1388, Sec. 3, eff. June 19, 2009.

Acts 2009, 81st Leg., R.S., Ch.

1388, Sec. 4, eff. June 19, 2009.

Sec. 413.023. INFORMATION TO EMPLOYERS. (a) The division shall

provide employers with information on methods to enhance the

ability of an injured employee to return to work. The

information may include access to available research and best

practice information regarding return-to-work programs for

employers.

(b) The division shall augment return-to-work program

information provided to employers to include information

regarding methods for an employer to appropriately assist an

injured employee to obtain access to doctors who:

(1) provide high-quality care; and

(2) use effective occupational medicine treatment practices that

lead to returning employees to productive work.

(c) The information provided to employers under this section

must help to foster:

(1) effective working relationships with local doctors and with

insurance carriers or workers' compensation health care networks

certified under Chapter 1305, Insurance Code, to improve

return-to-work communication; and

(2) access to return-to-work coordination services provided by

insurance carriers.

(d) The division shall develop and make available the

information described by this section.

Added by Acts 2005, 79th Leg., Ch.

265, Sec. 3.244, eff. September 1, 2005.

Sec. 413.024. INFORMATION TO EMPLOYEES. The division shall

provide injured employees with information regarding the benefits

of early return to work. The information must include

information on how to receive assistance in accessing

high-quality medical care through the workers' compensation

system.

Added by Acts 2005, 79th Leg., Ch.

265, Sec. 3.244, eff. September 1, 2005.

Sec. 413.025. RETURN-TO-WORK GOALS AND ASSISTANCE. (a) The

division shall assist recipients of income benefits to return to

the workforce. The division shall develop improved data sharing,

within the standards of federal privacy requirements, with all

appropriate state agencies and workforce programs to inform the

division of changes needed to assist income benefit recipients to

successfully reenter the workforce.

(b) The division shall train staff dealing with income benefits

to respond to questions and assist injured employees in their

effort to return to the workforce. If the division determines

that an injured employee is unable to ever return to the

workforce, the division shall inform the employee of possible

eligibility for other forms of benefits, such as social security

disability income benefits.

(c) As necessary to implement the requirements of this section,

the division shall:

(1) attempt to remove any barriers to successful employment that

are identified at the division, the Texas Workforce Commission,

the Department of Assistive and Rehabilitative Services, and

private vocational rehabilitation programs;

(2) ensure that data is tracked among the division, the Texas

Workforce Commission, the Department of Assistive and

Rehabilitative Services, and insurance carriers, including

outcome data;

(3) establish a mechanism to refer income benefit recipients to

the Texas Workforce Commission and local workforce development

centers for employment opportunities; and

(4) develop a mechanism to promote employment success that

includes post-referral contacts by the division with income

benefit recipients.

Added by Acts 2005, 79th Leg., Ch.

265, Sec. 3.244, eff. September 1, 2005.

SUBCHAPTER C. DISPUTE RESOLUTION

Sec. 413.031. MEDICAL DISPUTE RESOLUTION. (a) A party,

including a health care provider, is entitled to a review of a

medical service provided or for which authorization of payment is

sought if a health care provider is:

(1) denied payment or paid a reduced amount for the medical

service rendered;

(2) denied authorization for the payment for the service

requested or performed if authorization is required or allowed by

this subtitle or commissioner rules;

(3) ordered by the commissioner to refund a payment received; or

(4) ordered to make a payment that was refused or reduced for a

medical service rendered.

(b) A health care provider who submits a charge in excess of the

fee guidelines or treatment policies is entitled to a review of

the medical service to determine if reasonable medical

justification exists for the deviation. A claimant is entitled

to a review of a medical service for which preauthorization is

sought by the health care provider and denied by the insurance

carrier. The commissioner shall adopt rules to notify claimants

of their rights under this subsection.

(c) In resolving disputes over the amount of payment due for

services determined to be medically necessary and appropriate for

treatment of a compensable injury, the role of the division is to

adjudicate the payment given the relevant statutory provisions

and commissioner rules. The division shall publish on its

Internet website the division's medical dispute decisions,

including decisions of independent review organizations, and any

subsequent decisions by the State Office of Administrative

Hearings. Before publication, the division shall redact only

that information necessary to prevent identification of the

injured worker.

(d) A review of the medical necessity of a health care service

requiring preauthorization under Section 413.014 or commissioner

rules under that section or Section 413.011(g) shall be conducted

by an independent review organization under Chapter 4202,

Insurance Code, in the same manner as reviews of utilization

review decisions by health maintenance organizations. It is a

defense for the insurance carrier if the carrier timely complies

with the decision of the independent review organization.

(e) Except as provided by Subsections (d), (f), and (m), a

review of the medical necessity of a health care service provided

under this chapter or Chapter 408 shall be conducted by an

independent review organization under Chapter 4202, Insurance

Code, in the same manner as reviews of utilization review

decisions by health maintenance organizations. It is a defense

for the insurance carrier if the carrier timely complies with the

decision of the independent review organization.

(e-1) In performing a review of medical necessity under

Subsection (d) or (e), the independent review organization shall

consider the division's health care reimbursement policies and

guidelines adopted under Section 413.011. If the independent

review organization's decision is contrary to the division's

policies or guidelines adopted under Section 413.011, the

independent review organization must indicate in the decision the

specific basis for its divergence in the review of medical

necessity.

(e-2) Notwithstanding Section 4202.002, Insurance Code, an

independent review organization that uses doctors to perform

reviews of health care services provided under this title may

only use doctors licensed to practice in this state.

(e-3) Notwithstanding Subsections (d) and (e) of this section or

Chapters 4201 and 4202, Insurance Code, a doctor, other than a

dentist or a chiropractor, who performs a utilization review or

an independent review of a health care service provided to an

injured employee is subject to Section 408.0043. A dentist who

performs a utilization review or an independent review of a

dental service provided to an injured employee is subject to

Section 408.0044. A chiropractor who performs a utilization

review or an independent review of a chiropractic service

provided to an injured employee is subject to Section 408.0045.

(f) The commissioner by rule shall specify the appropriate

dispute resolution process for disputes in which a claimant has

paid for medical services and seeks reimbursement.

(g) In performing a review of medical necessity under Subsection

(d) or (e), an independent review organization may request that

the commissioner order an examination by a designated doctor

under Chapter 408.

(h) The insurance carrier shall pay the cost of the review if

the dispute arises in connection with:

(1) a request for health care services that require

preauthorization under Section 413.014 or commissioner rules

under that section; or

(2) a treatment plan under Section 413.011(g) or commissioner

rules under that section.

(i) Except as provided by Subsection (h), the cost of the review

shall be paid by the nonprevailing party.

(j) Notwithstanding Subsections (h) and (i), an employee may not

be required to pay any portion of the cost of a review.

(k) A party to a medical dispute, other than a medical dispute

regarding spinal surgery subject to Subsection (l) and a dispute

subject to Section 413.0311, that remains unresolved after a

review of the medical service under this section is entitled to a

hearing. A hearing under this subsection shall be conducted by

the State Office of Administrative Hearings not later than the

60th day after the date on which the party notifies the division

of the request for a hearing. The hearing shall be conducted in

the manner provided for a contested case under Chapter 2001,

Government Code.

(k-1) A party who has exhausted all administrative remedies

under Subsection (k) and who is aggrieved by a final decision of

the State Office of Administrative Hearings may seek judicial

review of the decision. Judicial review under this subsection

shall be conducted in the manner provided for judicial review of

a contested case under Subchapter G, Chapter 2001, Government

Code.

(k-2) The division and the department are not considered to be

parties to the medical dispute for purposes of Subsections (k)

and (k-1).

(l) A party to a medical dispute regarding spinal surgery that

remains unresolved after a review by an independent review

organization as provided by Subsections (d) and (e) is entitled

to dispute resolution as provided by Chapter 410.

(m) The decision of an independent review organization under

Subsection (d) is binding during the pendency of a dispute.

(n) The commissioner by rule may prescribe an alternate dispute

resolution process to resolve disputes regarding medical services

costing less than the cost of a review of the medical necessity

of a health care service by an independent review organization.

The cost of a review under the alternate dispute resolution

process shall be paid by the nonprevailing party.

Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.

Amended by Acts 1995, 74th Leg., ch. 76, Sec. 5.95(49), eff.

Sept. 1, 1995; Acts 1995, 74th Leg., ch. 980, Sec. 1.43, eff.

Sept. 1, 1995; Acts 2001, 77th Leg., ch. 1456, Sec. 6.04, eff.

June 17, 2001; Acts 2003, 78th Leg., ch. 980, Sec. 2, eff. Sept.

1, 2003; Acts 2003, 78th Leg., ch. 1323, Sec. 1, eff. June 21,

2003.

Amended by:

Acts 2005, 79th Leg., Ch.

265, Sec. 3.245, eff. September 1, 2005.

Acts 2007, 80th Leg., R.S., Ch.

133, Sec. 2, eff. September 1, 2007.

Acts 2007, 80th Leg., R.S., Ch.

1007, Sec. 1, eff. September 1, 2007.

Acts 2007, 80th Leg., R.S., Ch.

1218, Sec. 6, eff. September 1, 2007.

Acts 2009, 81st Leg., R.S., Ch.

1330, Sec. 18, eff. September 1, 2009.

Sec. 413.0311. REVIEW OF CERTAIN MEDICAL DISPUTES; CONTESTED

CASE HEARING. (a) This section applies only to the following

medical disputes that remain unresolved after any applicable

review under Sections 413.031(b) through (i):

(1) a medical fee dispute in which the amount of reimbursement

sought by the requestor in its request for medical dispute

resolution does not exceed $2,000;

(2) an appeal of an independent review organization decision

regarding determination of the retrospective medical necessity

for a health care service for which the amount billed does not

exceed $3,000; and

(3) an appeal of an independent review organization decision

regarding determination of the concurrent or prospective medical

necessity for a health care service.

(b) A party to a medical dispute described by Subsection (a) is

entitled to a contested case hearing. A contested case hearing

under this section shall be conducted by a hearings officer in

the manner provided for contested case hearings under Subchapter

D, Chapter 410. Notwithstanding Section 410.024, a benefit

review conference is not a prerequisite to a contested case

hearing under this section.

(c) The decision of a hearings officer under this section is

final in the absence of a timely appeal by a party for judicial

review under Subsection (d).

(d) A party who has exhausted all administrative remedies under

Section 413.031 and this section and who is aggrieved by a final

decision of the hearings officer under Subsection (c) may seek

judicial review of the decision. Judicial review under this

subsection shall be conducted in the manner provided for judicial

review of a contested case under Subchapter G, Chapter 2001,

Government Code.

(e) The division and the department are not considered to be

parties to the medical dispute for purposes of this section.

Added by Acts 2007, 80th Leg., R.S., Ch.

1007, Sec. 2, eff. September 1, 2007.

Sec. 413.032. INDEPENDENT REVIEW ORGANIZATION DECISION; APPEAL.

(a) An independent review organization that conducts a review

under this chapter shall specify the elements on which the

decision of the organization is based. At a minimum, the

decision must include:

(1) a list of all medical records and other documents reviewed

by the organization;

(2) a description and the source of the screening criteria or

clinical basis used in making the decision;

(3) an analysis of and explanation for the decision, including

the findings and conclusions used to support the decision; and

(4) a description of the qualifications of each physician or

other health care provider who reviews the decision.

(b) The independent review organization shall certify that each

physician or other health care provider who reviews the decision

certifies that no known conflicts of interest exist between that

provider and the injured employee, the injured employee's

employer, the injured employee's insurance carrier, the

utilization review agent, or any of the treating doctors or

insurance carrier health care providers who reviewed the case for

decision before referral to the independent review organization.

Added by Acts 2005, 79th Leg., Ch.

265, Sec. 3.247, eff. September 1, 2005.

SUBCHAPTER D. HEALTH CARE PROVIDERS

Sec. 413.041. DISCLOSURE. (a) Each health care practitioner

shall disclose to the division the identity of any health care

provider in which the health care practitioner, or the health

care provider that employs the health care practitioner, has a

financial interest. The health care practitioner shall make the

disclosure in the manner provided by commissioner rule.

(b) The commissioner shall require by rule that a doctor

disclose financial interests in other health care providers as a

condition of registration for the approved doctor list

established under Section 408.023 and shall define "financial

interest" for purposes of this section as provided by analogous

federal regulations. The commissioner by rule shall adopt the

federal standards that prohibit the payment or acceptance of

payment in exchange for health care referrals relating to fraud,

abuse, and antikickbacks.

(c) A health care provider that fails to comply with this

section is subject to penalties and sanctions as provided by this

subtitle, including forfeiture of the right to reimbursement for

services rendered during the period of noncompliance.

(d) The division shall publish all final disclosure enforcement

orders issued under this section on the division's Internet

website.

Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.

Amended by Acts 2001, 77th Leg., ch. 1456, Sec. 6.05, eff. June

17, 2001.

Amended by:

Acts 2005, 79th Leg., Ch.

265, Sec. 3.246, eff. September 1, 2005.

Sec. 413.042. PRIVATE CLAIMS; ADMINISTRATIVE VIOLATION. (a) A

health care provider may not pursue a private claim against a

workers' compensation claimant for all or part of the cost of a

health care service provided to the claimant by the provider

unless:

(1) the injury is finally adjudicated not compensable under this

subtitle; or

(2) the employee violates Section 408.022 relating to the

selection of a doctor and the doctor did not know of the

violation at the time the services were rendered.

(b) A health care provider commits an administrative violation

if the provider violates Subsection (a).

Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.

Amended by:

Acts 2005, 79th Leg., Ch.

265, Sec. 3.248, eff. September 1, 2005.

Sec. 413.043. OVERCHARGING PROHIBITED; OFFENSE. (a) A health

care provider commits an offense if the person knowingly charges

an insurance carrier an amount greater than that normally charged

for similar treatment to a payor outside the workers'

compensation system, except for mandated or negotiated charges.

(b) An offense under this section is a Class A misdemeanor.

Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.

Sec. 413.044. SANCTIONS ON DESIGNATED DOCTOR. (a) In addition

to or in lieu of an administrative penalty under Section 415.021

or a sanction imposed under Section 415.023, the commissioner may

impose sanctions against a person who serves as a designated

doctor under Chapter 408 who, after an evaluation conducted under

Section 413.002(b), is determined by the division to be out of

compliance with this subtitle or with rules adopted by the

commissioner relating to:

(1) medical policies, fee guidelines, and impairment ratings; or

(2) the quality of decisions made under Section 408.0041 or

Section 408.122.

(b) Sanctions imposed under Subsection (a) may include:

(1) removal or suspension from the division list of designated

doctors; or

(2) restrictions on the reviews made by the person as a

designated doctor.

Added by Acts 1995, 74th Leg., ch. 980, Sec. 1.44, eff. Sept. 1,

1995.

Amended by:

Acts 2005, 79th Leg., Ch.

265, Sec. 3.249, eff. September 1, 2005.

SUBCHAPTER E. IMPLEMENTATION OF COMMISSION POWERS AND DUTIES

Sec. 413.051. CONTRACTS WITH REVIEW ORGANIZATIONS AND HEALTH

CARE PROVIDERS. (a) In this section, "health care provider

professional review organization" includes an independent review

organization.

(b) The division may contract with a health care provider,

health care provider professional review organization, or other

entity to develop, maintain, or review medical policies or fee

guidelines or to review compliance with the medical policies or

fee guidelines.

(c) For purposes of review or resolution of a dispute as to

compliance with the medical policies or fee guidelines, the

division may contract with a health care provider, health care

provider professional review organization, or other entity that

includes in the review process health care practitioners who are

licensed in the category under review and are of the same field

or specialty as the category under review.

(d) The division may contract with a health care provider,

health care provider professional review organization, or other

entity for medical consultant services, including:

(1) independent medical examinations;

(2) medical case reviews; or

(3) establishment of medical policies and fee guidelines.

(e) The commissioner shall establish standards for contracts

under this section.

Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.

Amended by Acts 2001, 77th Leg., ch. 1456, Sec. 1.02, eff. June

17, 2001.

Amended by:

Acts 2005, 79th Leg., Ch.

265, Sec. 3.250, eff. September 1, 2005.

Sec. 413.0511. MEDICAL ADVISOR. (a) The division shall employ

or contract with a medical advisor, who must be a doctor as that

term is defined by Section 401.011.

(b) The medical advisor shall make recommendations regarding the

adoption of rules and policies to:

(1) develop, maintain, and review guidelines as provided by

Section 413.011, including rules regarding impairment ratings;

(2) review compliance with those guidelines;

(3) regulate or perform other acts related to medical benefits

as required by the commissioner;

(4) impose sanctions or delete doctors from the division's list

of approved doctors under Section 408.023 for:

(A) any reason described by Section 408.0231; or

(B) noncompliance with commissioner rules;

(5) impose conditions or restrictions as authorized by Section

408.0231(f);

(6) receive, and share with the medical quality review panel

established under Section 413.0512, confidential information, and

other information to which access is otherwise restricted by law,

as provided by Sections 413.0512, 413.0513, and 413.0514 from the

Texas State Board of Medical Examiners, the Texas Board of

Chiropractic Examiners, or other occupational licensing boards

regarding a physician, chiropractor, or other type of doctor who

applies for registration or is registered with the division on

the list of approved doctors;

(7) determine minimal modifications to the reimbursement

methodology and model used by the Medicare system as necessary to

meet occupational injury requirements; and

(8) monitor the quality and timeliness of decisions made by

designated doctors and independent review organizations, and the

imposition of sanctions regarding those decisions.

Added by Acts 2001, 77th Leg., ch. 1456, Sec. 1.02, eff. June 17,

2001. Amended by Acts 2003, 78th Leg., ch. 963, Sec. 1, eff. June

20, 2003.

Amended by:

Acts 2005, 79th Leg., Ch.

265, Sec. 3.251, eff. September 1, 2005.

Sec. 413.0512. MEDICAL QUALITY REVIEW PANEL. (a) The medical

advisor shall establish a medical quality review panel of health

care providers to assist the medical advisor in performing the

duties required under Section 413.0511. The panel is not subject

to Chapter 2110, Government Code.

(b) The Texas State Board of Medical Examiners and the Texas

Board of Chiropractic Examiners, with input from their respective

professional associations, shall develop lists of physicians and

chiropractors licensed by those agencies who have demonstrated

experience in workers' compensation or utilization review. The

medical advisor shall consider appointing some of the members of

the medical quality review panel from the names on those lists.

The medical advisor shall also consider nominations for the panel

made by labor, business, and insurance organizations.

(c) The medical quality review panel shall recommend to the

medical advisor:

(1) appropriate action regarding doctors, other health care

providers, insurance carriers, utilization review agents, and

independent review organizations; and

(2) the addition or deletion of doctors from the list of

approved doctors under Section 408.023 or the list of designated

doctors established under Section 408.1225.

(d) A person who serves on the medical quality review panel is

immune from suit and from civil liability for an act performed,

or a recommendation made, within the scope of the person's

functions as a member of the panel if the person acts without

malice and in the reasonable belief that the action or

recommendation is warranted by the facts known to that person. In

the event of a civil action brought against a member of the panel

that arises from the person's participation on the panel, the

person is entitled to the same protections afforded a commission

member under Section 402.010.

(e) The actions of a person serving on the medical quality

review panel do not constitute utilization review and are not

subject to Article 21.58A, Insurance Code.

(f) A member of the medical quality review panel, other than a

chiropractor, who reviews a specific workers' compensation case

is subject to Section 408.0043. A chiropractor who reviews a

specific workers' compensation case is subject to Section

408.0045.

Added by Acts 2001, 77th Leg., ch. 1456, Sec. 1.02, eff. June 17,

2001. Amended by Acts 2003, 78th Leg., ch. 963, Sec. 2, eff. June

20, 2003.

Amended by:

Acts 2005, 79th Leg., Ch.

265, Sec. 3.252, eff. September 1, 2005.

Acts 2007, 80th Leg., R.S., Ch.

1218, Sec. 7, eff. September 1, 2007.

Sec. 413.0513. CONFIDENTIALITY REQUIREMENTS. (a) Information

collected, assembled, or maintained by or on behalf of the

division under Section 413.0511 or 413.0512 constitutes an

investigation file for purposes of Section 402.092 and may not be

disclosed under Section 413.0511 or 413.0512 except as provided

by that section.

(b) Confidential information, and other information to which

access is restricted by law, developed by or on behalf of the

division under Section 413.0511 or 413.0512 is not subject to

discovery or court subpoena in any action other than:

(1) an action to enforce this subtitle brought by the division,

an appropriate licensing or regulatory agency, or an appropriate

enforcement authority; or

(2) a criminal proceeding.

Added by Acts 2001, 77th Leg., ch. 1456, Sec. 1.02, eff. June 17,

2001. Amended by Acts 2003, 78th Leg., ch. 963, Sec. 3, eff. June

20, 2003.

Amended by:

Acts 2005, 79th Leg., Ch.

265, Sec. 3.253, eff. September 1, 2005.

Sec. 413.0514. INFORMATION SHARING WITH OCCUPATIONAL LICENSING

BOARDS. (a) This section applies only to information held by or

for the division, the Texas State Board of Medical Examiners, and

Texas Board of Chiropractic Examiners that relates to a person

who is licensed or otherwise regulated by any of those state

agencies.

(b) The division and the Texas State Board of Medical Examiners

on requ