Sample Letter: Workers' Comp Claim or Claims in Process over 45 days

RE: Request for Claim Resolution

Patient: _________________________

Member ID: ______________________

Insured: _________________________

Date of Service: ___________________

Amount: _________________________

Dear Payor:

Please be advised that this letter is to request a final resolution of the claim/ or claims for the services in question.

It appears your organization has had the attached completed claim(s) pending in your system for 45 or more calendar days. All data elements required by The Texas Workers' Compensation Commission Rules were present on the claim(s) when submitted to your organization of processing.

We believe that failure to release payment is a violation of the Texas Workers' Compensation Commission Rules. Chapter 133, Subchapter D, Rule 133.300 and 133.304 specifically prohibits insurers from unnecessarily delaying the processing of a claim or claims. An insurance carrier or self insurer has 45 days to (1) pay the fair and reasonable reimbursement of a completed claim in accordance with the Medical Fee Guideline or, (2) deny care reported on the medical bill with sufficient explanation to clarify the reason for the full or partial denial. The rules further state that a health care provider's failure to provide an insurance carrier with additional documentation, no later than the 14 th day after the receipt of a request, does not extend the amount of time the insurance carrier has to make payment or deny payment on a claim We also understand from TWCC Advisory 98-03 that if insurance carriers and self insured plans fail to meet these requirements they are in violation of the rules and can be subject to an administrative penalty not to exceed $10,000 if they commit repeated administrative violations, or as a business practice allow repeated administrative violations to continue.

In addition, Rule 133.304 provides that all payments of medical bills that an insurance carrier makes on or after the 60 th day after the date the carrier originally received the bill shall include interest calculated in accordance with Rule 134.803. Interest shall be paid from the 60 th day to the date of payment, without order of the Commission.

Since the claim(s) in question were received by your organization over 45 days ago, we are requesting the following actions be taken:

  1. Immediate payment for the covered services according to the maximum allowable reimbursement in the Commission Medical Fee Guidelines and,
  2. Interest of those treatments and services not reimbursed on or after the 60 th day that your organization received the completed claim.

Thank you for your prompt attention to this matter. If we do not hear from you within 10 days, this matter will be referred to the TWCC Compliance and Practice Division for their review and resolution. Should you have any questions, please contact our office at __________________________. 

Sincerely, 

Cc: Employer


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