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Apollo Enterprises, Inc. v. ScripNet, Inc.

Under Texas Labor Code �413.031, one type of review of a medical service concerns "disputes over the amount of payment due for services determined to be medically necessary and appropriate for treatment of a compensable injury," commonly termed "medical fee disputes." Two of appellant's four claims present medical fee disputes and therefore implicate the Texas Department of Insurance's exclusive jurisdiction. Austin Court of Appeals, No. 03-07-00551-CV, 12-04-2009

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OPINION

This appeal requires us to consider the breadth of the exclusive jurisdiction that the legislature has vested in the Division of Workers’ Compensation, Texas Department of Insurance (the Division)*fn1 to determine “disputes over the amount of payment due” from workers’ compensation insurance carriers to reimburse pharmacies for health care provided to workers’ compensation claimants. See Tex. Lab. Code Ann. § 413.031(c) (West Supp. 2009);*fn2 Texas Mut. Ins. Co. v. Eckerd Corp., 162 S.W.3d 261, 263-67 (Tex. App.–Austin 2005, pet. denied); Howell v. Texas Workers’ Comp. Comm’n, 143 S.W.3d 416, 428-29, 434-38 (Tex. App.–Austin 2004, pet. denied). Specifically, we must consider whether this jurisdiction extends to certain tort claims asserted against a pharmacy benefits manager by a pair of competitive rivals that contract with pharmacies to purchase assignments of workers’ compensation reimbursement claims. In response to a plea to the jurisdiction based on exclusive jurisdiction and exhaustion-of-remedies grounds, the district court dismissed all of these tort claims. While we agree that some of the tort claims fall within the Division’s exclusive jurisdiction and affirm the district court’s judgment to that extent, we conclude that others do not, and reverse and remand the judgment as to those claims.

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