reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 124 - INSURANCE CARRIERS: NOTICES, PAYMENTS, AND REPORTING › Subchapter B - INSURANCE CARRIER CLAIM ELECTRONIC DATA INTERCHANGE REPORTING TO THE DIVISION › Section 124.102 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms when used in this subchapter
					 will have the following meanings, unless the context clearly indicates
					 otherwise:
(1) Application
				  acknowledgment code--A code used to identify the accepted or rejected status of
				  the transaction being acknowledged.
(2) Claim EDI record--The accurate data
				  associated with a single claim reported in a claim EDI transaction (first
				  report of injury or subsequent report of injury) obtained from all sources,
				  including the report of incident or injury and the insurance carrier's claim
				  file.
(3) Claim EDI
				  transmission--The data that is contained within the interchange
				  envelope.
(4) Division--The Texas
				  Department of Insurance, Division of Workers' Compensation or its data
				  collection agent.
(5)
				  EDI--Electronic data interchange.
(6) Edit Matrix--A table containing the edits
				  applied to Texas' first report of injury and subsequent report of injury
				  records.
(7) Element requirement
				  table--A table containing data elements used in Texas' first report of injury
				  and subsequent report of injury record layouts defining required and
				  conditional data elements and how data edits apply to the elements.
(8) Event table--A table containing the
				  reportable claim events for Texas' first report of injury and subsequent report
				  of injury records and timeframes for reporting the information.
(9) Insurance carrier claim number--An
				  identifier that distinguishes a specific claim within an insurance carrier's
				  claim processing system and is used throughout the life of the claim.
(10) IAIABC--The International Association of
				  Industrial Accident Boards and Commissions.
(11) Person--A person, partnership,
				  corporation, hospital district, insurance carrier, organization, business
				  trust, estate trust, association, limited liability company, limited liability
				  partnership, or other entity. This term does not include an injured
				  employee.
(12) Trading partner--A
				  person entering into an agreement with the insurance carrier to format
				  electronic data for transmission to the division, transmit electronic data to
				  the division, and respond to any technical issues related to the contents or
				  structure of an EDI file.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 124 - INSURANCE CARRIERS: NOTICES, PAYMENTS, AND REPORTING › Subchapter B - INSURANCE CARRIER CLAIM ELECTRONIC DATA INTERCHANGE REPORTING TO THE DIVISION › Section 124.103 - Reporting Standards

Current through Reg. 49, No. 28; July 12, 2024
(a) Except as
				  provided in this subchapter, the commissioner adopts by reference the IAIABC
				  EDI Implementation Guide for Claims, Release 3.1.4, dated January 1, 2021,
				  published by the IAIABC.
(b) The
				  commissioner adopts by reference the:
(1)
				  Texas Claim EDI Release 3.1.4 Implementation Guide, Version 1.0;
(2) Texas Claim EDI Release 3.1.4 Element
				  Requirement Table, Version 1.0;
(3)
				  Texas Claim EDI Release 3.1.4 Edit Matrix, Version 1.0, dated June 30, 2023;
				  and
(4) Texas Claim EDI Release
				  3.1.4 Event Table, Version 1.0. The Texas Claim EDI Release 3.1.4
				  Implementation Guide, tables, and the matrix are published by the
				  division.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 124 - INSURANCE CARRIERS: NOTICES, PAYMENTS, AND REPORTING › Subchapter B - INSURANCE CARRIER CLAIM ELECTRONIC DATA INTERCHANGE REPORTING TO THE DIVISION › Section 124.104 - Reporting Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) Insurance
				  carriers must submit timely and accurate claim EDI records to the division. For
				  the purpose of this section, a claim EDI record is considered accurately
				  submitted when the record:
(1) receives an
				  accepted application acknowledgment code;
(2) contains accurate claim EDI data, which
				  may be obtained from all sources, including the report of incident or injury
				  and the insurance carrier's claim file; and
(3) to the extent supported by the format,
				  contains all data elements necessary to identify activity on a claim.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 124 - INSURANCE CARRIERS: NOTICES, PAYMENTS, AND REPORTING › Subchapter B - INSURANCE CARRIER CLAIM ELECTRONIC DATA INTERCHANGE REPORTING TO THE DIVISION › Section 124.105 - Records Required to be Reported

Current through Reg. 49, No. 28; July 12, 2024
(a) Insurance
				  carriers must submit claim EDI records when the insurance carrier:
(1) takes action on or events occur in a
				  claim as described in §
											124.2
				  of this title (concerning Insurance Carrier Notification
				  Requirements);
(2) corrects
				  division-identified errors in a previously accepted electronic record as
				  provided in § 124.104(b) of this title (concerning Reporting
				  Requirements);
(3) corrects
				  insurance carrier-identified errors in a previously accepted electronic record
				  as provided in §
											124.2(b)(4)
				  of this title;
(4) discovers that a
				  claim EDI record should not have been submitted to the division, and the
				  division had previously accepted the claim EDI record; or
(5) receives a request from the division for
				  claim EDI records.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 124 - INSURANCE CARRIERS: NOTICES, PAYMENTS, AND REPORTING › Subchapter B - INSURANCE CARRIER CLAIM ELECTRONIC DATA INTERCHANGE REPORTING TO THE DIVISION › Section 124.106 - Records Excluded from Reporting

Current through Reg. 49, No. 28; July 12, 2024
Insurance carriers must not report claim EDI records
					 for:
(1) claims where the jurisdiction
				  state is not Texas;
(2) claims that
				  do not meet the requirements of §
										124.2(b)
				  of this title (concerning Insurance Carrier Notification
				  Requirements);
(3) claims involving
				  benefits payable under federal workers' compensation laws; and
(4) claims with dates of injury before
				  January 1, 1991.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 124 - INSURANCE CARRIERS: NOTICES, PAYMENTS, AND REPORTING › Subchapter B - INSURANCE CARRIER CLAIM ELECTRONIC DATA INTERCHANGE REPORTING TO THE DIVISION › Section 124.107 - State Specific Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) Insurance
				  carriers must submit claim EDI transactions according to the:
(1) IAIABC EDI Implementation Guide for
				  Claims, Release 3.1.4;
(2) Texas
				  Claim EDI Release 3.1.4 Implementation Guide, Version 1.0;
(3) Texas Claim EDI Release 3.1.4 Element
				  Requirement Table, Version 1.0;
(4)
				  Texas Claim EDI Release 3.1.4 Edit Matrix, Version 1.0, dated June 30, 2023;
				  and
(5) Texas Claim EDI Release
				  3.1.4 Event Table, Version 1.0.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 124 - INSURANCE CARRIERS: NOTICES, PAYMENTS, AND REPORTING › Subchapter B - INSURANCE CARRIER CLAIM ELECTRONIC DATA INTERCHANGE REPORTING TO THE DIVISION › Section 124.108 - Insurance Carrier EDI Compliance Coordinator and Trading Partners

Current through Reg. 49, No. 28; July 12, 2024
(a) Insurance
				  carriers may submit claim EDI records directly to the division or contract with
				  an external trading partner to submit the records on the insurance carrier's
				  behalf.
(b) Each insurance carrier,
				  including those using external trading partners, must designate one person to
				  the division as the EDI compliance coordinator and provide the person's name,
				  working title, mailing address, email address, and telephone number in the form
				  and manner prescribed by the division. The EDI compliance coordinator must:
(1) be an employee of the insurance carrier
				  with knowledge and experience in EDI reporting, who is responsible for EDI
				  reporting;
(2) receive and
				  appropriately disperse data reporting information received from the division;
				  and
(3) serve as the central
				  compliance control for data reporting under this subchapter.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 126 - GENERAL PROVISIONS APPLICABLE TO ALL BENEFITS › Section 126.1 - Definitions Applicable to All Benefits

Current through Reg. 49, No. 28; July 12, 2024
The following terms shall have the following meanings unless
				  the context clearly indicates otherwise:
(1) Employer Initiation of Benefits - Money
				paid by an employer to the employee to compensate the employee for lost wages
				or paid by the employer for medical expenses during a period in which the
				carrier has either:
(A) contested
				compensability of the injury;
(B)
				contested liability for the injury; or
(C) has not completed its initial
				investigation of the injury which is limited to seven days after the carrier
				receives first written notice of the injury as defined in §
										124.1
				of this title (relating to Notice of Injury).
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 126 - GENERAL PROVISIONS APPLICABLE TO ALL BENEFITS › Section 126.2 - Payment of Benefits to Minors

Current through Reg. 49, No. 28; July 12, 2024
(a) If an
				injured employee is a minor, benefits will be paid by the carrier to the
				custodial parent or guardian, for the use and benefits of the minor, until the
				minor turns 18 year of age, except as otherwise provided in this
				section.
(b) If a court-ordered
				relationship that affects the minor exists and is brought to the attention of
				the carrier or the commission, the carrier will pay benefits in accordance with
				that order.
(c) A parent, managing
				conservator, or guardian may agree, in writing, for direct payment of benefits
				to the minor.
(d) An injured
				employee who is a minor may petition the commission for direct payment of
				benefits. The carrier shall pay benefits directly to the minor if so ordered by
				the executive director, after a hearing, and a reasonable attempt is made to
				locate the parent or guardian for purpose of the hearing.
(e) When the carrier and commission receive
				proof that a minor has attained the age of 18 years, or that a guardianship has
				ended, benefits will be paid directly to the injured employee.
(f) This section will also apply to payment
				of death benefits to legal beneficiaries who are minors.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 126 - GENERAL PROVISIONS APPLICABLE TO ALL BENEFITS › Section 126.3 - Payment of Benefits to Legally Incompetent Persons

Current through Reg. 49, No. 28; July 12, 2024
(a) Benefits for an injured employee found to
				be legally incompetent shall be paid by the carrier to the court-appointed
				guardian for the use and benefit of the injured employee, in accordance with
				the terms of any court order.
(b)
				If the carrier and the commission receive a certified copy of the court order
				declaring the injured employee legally competent, benefits shall once again be
				paid directly to the injured employee.
(c) The Ombudsman Program may provide
				information to the parties to a claim about available options if no court has
				declared an employee to be legally incompetent.
(d) This rule will also apply to payment of
				death benefits to legally incompetent beneficiaries of deceased
				employees.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 126 - GENERAL PROVISIONS APPLICABLE TO ALL BENEFITS › Section 126.4 - Advance of Benefits Based on Financial Hardship

Current through Reg. 49, No. 28; July 12, 2024
(a) An injured employee seeking an advance of
				income benefits based on financial hardship shall submit a written application
				to the Commission in the form and manner prescribed by the Commission that
				states the basis for the hardship The application must state the employee
				understands that if an advance is granted the amount of future weekly benefit
				payments will be reduced as directed by the Commission.
(b) The Commission shall forward a copy of
				the employee's application to the insurance carrier and shall consider the
				employee's application and may order an advance if it determines that both a
				hardship exists for the employee and the employee is likely to be entitled to
				income benefits sufficient to cover the amount of the advance.
(c) An advance will not be granted to an
				employee whose combined post-injury earnings, as defined by §
									129.2
				of this title (relating to Entitlement to Temporary Income Benefits), and
				income benefits under this Act equals or exceeds 90% of the employee's net
				pre-injury wage. In the absence of specific evidence to the contrary, the net
				pre-injury wage of an employee shall be presumed to be 80% of the average
				weekly wage, for this section.
(d)
				The Commission shall notify the carrier and the employee in writing when an
				advance is ordered. The notice shall include the amount of the advance to be
				paid; this amount shall not exceed four times the maximum weekly benefit for
				temporary income benefits as computed under the Act, §408.061(a). The
				carrier shall pay an advance ordered by the Commission within seven days of the
				receipt of notice from the Commission by the carrier's Austin
				representative.
(e) After the
				carrier has paid an advance, it shall reduce the amount of the weekly income
				benefits in an amount set by the Commission, which takes into account the
				amount advanced and the number of weeks that benefits are likely to be paid in
				the future. The weekly benefits may be paid in this reduced amount until the
				carrier has recouped the amount advanced.
(f) The total amount of benefits paid to the
				employee through weekly payments and advances based on hardship shall not
				exceed the amount the employee would have received under a normal payment
				schedule. No more than three advances shall be granted based on the same
				injury.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 126 - GENERAL PROVISIONS APPLICABLE TO ALL BENEFITS › Section 126.8 - Commission Approved Doctor List

Current through Reg. 49, No. 28; July 12, 2024
(a) On or
				after January 1, 1993, except in emergency situations, injured employees must
				receive medical treatment from a doctor on the commission approved doctor list
				(the list). This list initially includes all doctors licensed in Texas on or
				after January 1, 1993, and doctors licensed in other jurisdictions who have
				been added to the list by the commission.
(b) Doctors licensed in other jurisdictions
				may ask to be added to the list by submitting a written request containing
				information prescribed by the commission. Unless the doctor has been deleted
				from the list by the commission, a carrier shall not withhold reimbursement to
				doctors licensed in other jurisdictions when the only reason for nonpayment is
				that the doctor is not presently on the list.
(c) This section is no longer effective on or
				after September 1, 2003.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 126 - GENERAL PROVISIONS APPLICABLE TO ALL BENEFITS › Section 126.9 - Choice of Treating Doctor and Liability for Payment

Current through Reg. 49, No. 28; July 12, 2024
(a) The injured employee is entitled to the
				employee's initial choice of treating doctor from the list of doctors approved
				by the Texas Workers' Compensation Commission. As of January 1, 1993, any
				change in treating doctor after the initial choice requires approval from the
				commission. The term "doctor," as used in this section, has the meaning defined
				in Texas Civil Statutes, Article 8308-1.03(17).
(b) The commission shall include, with the
				information mailed to the employee as required by the Act, §5.09, the
				requirements related to the selection of a treating doctor from the
				commission-approved doctor list and to changing treating doctors as described
				in this section.
(c) The first
				doctor who provides health care to an injured employee shall be known as the
				injured employee's initial choice of treating doctor. The following do not
				constitute an initial choice of treating doctor:
(1) a doctor salaried by the
				employer;
(2) a doctor recommended
				by the carrier or employer, unless the injured employee continues, without good
				cause as determined by the commission, to receive treatment from the doctor for
				a period of more than 60 days; or
(3) any doctor providing emergency care
				unless the injured employee receives treatment from the doctor for other than
				follow-up care related to the emergency treatment.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 126 - GENERAL PROVISIONS APPLICABLE TO ALL BENEFITS › Section 126.12 - Payment of Interest on Accrued but Unpaid Income Benefits

Current through Reg. 49, No. 28; July 12, 2024
(a) Accrued but unpaid income benefits are
				those benefits which either:
(1) have accrued
				during a period of dispute over insurance carrier (carrier) liability for the
				claim or injured employee entitlement to the benefits; or
(2) have not been paid by the date the
				carrier was required to pay them.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 126 - GENERAL PROVISIONS APPLICABLE TO ALL BENEFITS › Section 126.13 - Employer Initiation of Benefits and Reimbursement

Current through Reg. 49, No. 28; July 12, 2024
(a) Applicability
(1) This section applies only to the employer
				initiation of benefits as described in subsection (a)(2) of this section.
				Employer payments made after the insurance carrier has accepted or been found
				to be liable for a claim such as salary continuation, as defined in §129.1
				(relating to Definitions for Temporary Income Benefits), are covered by Chapter
				129 of this title (relating to Temporary Income Benefits).
(2) An employer may initiate benefits
				including medical benefits to compensate an employee during a period in which
				the carrier has:
(A) contested compensability
				of the injury;
(B) contested
				liability for the injury; or
(C)
				has not completed its initial investigation of the injury, which is limited to
				seven days after the carrier receives first written notice of the injury as
				defined in §
											124.1
				of this title (relating to Notice of Injury).
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 126 - GENERAL PROVISIONS APPLICABLE TO ALL BENEFITS › Section 126.14 - Treating Doctor Examination to Define the Compensable Injury

Current through Reg. 49, No. 28; July 12, 2024
(a) On request of the insurance carrier, an
				injured employee is required to submit to a single examination per workers'
				compensation claim for the purpose of defining the compensable injury. The
				examination:
(1) shall not be requested prior
				to the eighth day after the date of injury, and
(2) shall be scheduled to occur no earlier
				than 15 days and no later than 30 days from the date the notice of examination
				is sent to the injured employee.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 126 - GENERAL PROVISIONS APPLICABLE TO ALL BENEFITS › Section 126.15 - Procedures for Resolution of Underpayments of Income Benefits

Current through Reg. 49, No. 28; July 12, 2024
(a) This section applies to insurance carrier
				underpayment of income benefits. It does not apply to:
(1) insurance carrier underpayment of death,
				burial, or medical benefits; or
(2)
				redesignation of income benefits.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 126 - GENERAL PROVISIONS APPLICABLE TO ALL BENEFITS › Section 126.16 - Procedures for Recouping Overpayments of Income Benefits

Current through Reg. 49, No. 28; July 12, 2024
(a) This section applies to insurance carrier
				overpayment of income benefits. It does not apply to:
(1) insurance carrier overpayment of death,
				burial, or medical benefits;
(2)
				redesignation of income benefits; or
(3) repayments pursuant to Labor Code §
										415.008.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 126 - GENERAL PROVISIONS APPLICABLE TO ALL BENEFITS › Section 126.17 - Guidelines for Examination by a Treating Doctor or Referral Doctor After a Designated Doctor Examination to Address Issues Other Than Certification of Maximum Medical Improvement and the Evaluation of Permanent Impairment

Current through Reg. 49, No. 28; July 12, 2024
(a) An examination by the injured employee's
				treating doctor or another doctor to whom the injured employee is referred by
				the treating doctor to determine any issue other than certification of maximum
				medical improvement and the evaluation of permanent impairment may be
				appropriate after a designated doctor examination if:
(1) the designated doctor issued an opinion
				on the issue;
(2) the injured
				employee is not satisfied with the designated doctor's opinion; and
(3) the treating doctor or the referral
				doctor has not already provided the injured employee with a written report that
				meets the standard described by subsection (b) of this section on the issue
				addressed by the designated doctor.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 127 - DESIGNATED DOCTOR PROCEDURES AND REQUIREMENTS › Subchapter A - DESIGNATED DOCTOR SCHEDULING AND EXAMINATIONS › Section 127.1 - Requesting Designated Doctor Examinations

Current through Reg. 49, No. 28; July 12, 2024
(a) Initiating an
				  examination. At the request of the insurance carrier, an injured employee, the
				  injured employee's representative, or on its own motion, the division may order
				  a medical examination by a designated doctor to resolve questions about:
(1) the impairment caused by the injured
				  employee's compensable injury;
(2)
				  the attainment of maximum medical improvement (MMI);
(3) the extent of the injured employee's
				  compensable injury;
(4) whether the
				  injured employee's disability is a direct result of the work-related
				  injury;
(5) the ability of the
				  injured employee to return to work; or
(6) issues similar to those described by
				  paragraphs (1) - (5) of this subsection.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 127 - DESIGNATED DOCTOR PROCEDURES AND REQUIREMENTS › Subchapter A - DESIGNATED DOCTOR SCHEDULING AND EXAMINATIONS › Section 127.5 - Scheduling Designated Doctor Appointments

Current through Reg. 49, No. 28; July 12, 2024
(a) Order assigning
				  a designated doctor. Within 10 days after approving a valid request, the
				  division will issue an order that assigns a designated doctor and will notify
				  the designated doctor, the treating doctor, if any, the injured employee, the
				  injured employee's representative, if any, and the insurance carrier that the
				  designated doctor is directed to examine the injured employee. The order will:
(1) indicate the designated doctor's name,
				  license number, examination address, fax number, telephone number, and the date
				  and time of the examination or the date range for the examination to be
				  conducted;
(2) explain the purpose
				  of the designated doctor examination;
(3) require the injured employee to submit to
				  an examination by the designated doctor;
(4) require the designated doctor to perform
				  the examination at the indicated examination address; and
(5) require the treating doctor, if any, and
				  insurance carrier to forward all medical records to the designated doctor in
				  compliance with §
											127.10(a)(3) of
				  this title (relating to General Procedures for Designated Doctor
				  Examinations).
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 127 - DESIGNATED DOCTOR PROCEDURES AND REQUIREMENTS › Subchapter A - DESIGNATED DOCTOR SCHEDULING AND EXAMINATIONS › Section 127.10 - General Procedures for Designated Doctor Examinations

Current through Reg. 49, No. 28; July 12, 2024
(a) Authorization
				  to receive documents. The designated doctor is authorized under Labor Code
				  §
										408.0041(c)
				  to receive the injured employee's confidential medical records and analyses of
				  the injured employee's medical condition, functional abilities, and
				  return-to-work opportunities without a signed release from the injured employee
				  to help resolve a dispute under this subchapter. The following requirements
				  apply to the designated doctor's receipt of medical records and analyses:
(1) The treating doctor and insurance carrier
				  must provide the designated doctor copies of all the injured employee's medical
				  records in their possession relating to the medical condition to be evaluated
				  by the designated doctor.
(A) For subsequent
				  examinations with the same designated doctor, the treating doctor and insurance
				  carrier must provide only those medical records not previously sent.
(B) The cost of copying must be reimbursed in
				  accordance with §
												134.120 of this title (relating to
				  Reimbursement for Medical Documentation).
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 127 - DESIGNATED DOCTOR PROCEDURES AND REQUIREMENTS › Subchapter A - DESIGNATED DOCTOR SCHEDULING AND EXAMINATIONS › Section 127.15 - Undue Influence on a Designated Doctor

Current through Reg. 49, No. 28; July 12, 2024
(a) Communication
				  about medical condition or history. To avoid undue influence on the designated
				  doctor:
(1) except as provided by §
											127.10(a) of this
				  title (relating to General Procedures for Designated Doctor Examinations), only
				  the injured employee or appropriate division staff may communicate with the
				  designated doctor about the injured employee's medical condition or history
				  before the designated doctor examines the injured employee;
(2) after the examination is completed, only
				  appropriate division staff may communicate with the designated doctor about the
				  injured employee's medical condition or history; and
(3) the designated doctor may initiate
				  communication with:
(A) any health care
				  provider who previously treated or examined the injured employee for the
				  work-related injury; or
(B) a peer
				  review doctor that the insurance carrier identifies as having reviewed the
				  injured employee's claim or any information about that claim.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 127 - DESIGNATED DOCTOR PROCEDURES AND REQUIREMENTS › Subchapter A - DESIGNATED DOCTOR SCHEDULING AND EXAMINATIONS › Section 127.20 - Requesting a Letter of Clarification Regarding Designated Doctor Reports

Current through Reg. 49, No. 28; July 12, 2024
(a) Filing a
				  clarification request. Parties may file a request with the division for
				  clarification of the designated doctor's report.
(1) The requesting party must provide copies
				  of the request to all parties.
(2)
				  The division may contact the designated doctor if it determines that
				  clarification is necessary to resolve an issue regarding the designated
				  doctor's report.
(3) Parties may
				  only request clarification on issues already addressed by the designated
				  doctor's report or on issues that the designated doctor was ordered to address
				  but did not.
(4) A designated
				  doctor must only respond to the questions or requests submitted to the
				  designated doctor in the request for clarification and must not reconsider
				  their previous decision, issue a new or amended decision, or provide
				  clarification on their previous decision.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 127 - DESIGNATED DOCTOR PROCEDURES AND REQUIREMENTS › Subchapter A - DESIGNATED DOCTOR SCHEDULING AND EXAMINATIONS › Section 127.25 - Failure to Attend a Designated Doctor Examination

Current through Reg. 49, No. 28; July 12, 2024
(a) Suspension of
				  benefits. An insurance carrier may suspend temporary income benefits (TIBs) if
				  an injured employee fails, without good cause, to attend a designated doctor
				  examination or a referral examination under §
										127.10(c) of this
				  title.
(b) No good cause. If there
				  is no division finding that good cause exists, an insurance carrier may presume
				  that the injured employee did not have good cause to fail to attend the
				  examination if, by the day the examination was originally scheduled to occur,
				  the injured employee has both:
(1) failed to
				  submit to the examination; and
(2)
				  failed to contact the designated doctor's office to reschedule the
				  examination.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 127 - DESIGNATED DOCTOR PROCEDURES AND REQUIREMENTS › Subchapter B - DESIGNATED DOCTOR CERTIFICATION, RENEWAL, AND QUALIFICATIONS › Section 127.100 - Designated Doctor Certification

Current through Reg. 49, No. 28; July 12, 2024
(a) Qualifications
				  to get or renew certification. The division will not assign examinations to a
				  designated doctor who does not meet all requirements for certification or
				  renewal. All designated doctors must:
(1) Have
				  a complete designated doctor certification application as described in
				  subsection (b) of this section on file with the division.
(2) Complete all division-required trainings
				  within 12 months of the date of application and have current documentation
				  confirming their completion on file with the division.
(3) Pass all division-required testing on the
				  specific duties of a designated doctor under the Labor Code and division rules
				  and have current documentation confirming their passage on file with the
				  division. Required testing must have been completed on or after May 13, 2013,
				  and includes demonstrated proficient knowledge of the currently adopted edition
				  of:
(A) the American Medical Association
				  Guides to the Evaluation of Permanent Impairment; and
(B) the division's adopted:
(i) treatment guidelines; and
(ii) return-to-work guidelines.
(4) Have maintained an
				  active practice for at least three years during the doctor's career. For the
				  purposes of this subsection, a doctor has an active practice if the doctor
				  maintains or has maintained routine office hours of at least 20 hours per week
				  for 40 weeks per year to treat patients.
(5) For the duration of the doctor's term as
				  a designated doctor:
(A) be licensed in
				  Texas;
(B) own or subscribe to the
				  current edition of the American Medical Association Guides to the Evaluation of
				  Permanent Impairment adopted by the division to assign impairment ratings and
				  all return-to-work and treatment guidelines adopted by the division;
				  and
(C) comply with financial
				  disclosure requirements in §
												180.24(relating to Financial
				  Disclosure) of this title.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 127 - DESIGNATED DOCTOR PROCEDURES AND REQUIREMENTS › Subchapter B - DESIGNATED DOCTOR CERTIFICATION, RENEWAL, AND QUALIFICATIONS › Section 127.120 - Exception to Certification as a Designated Doctor for Out-of-State Doctors

Current through Reg. 49, No. 28; July 12, 2024
If the injured employee is temporarily located or resides
					 out of state, the division may waive any of the requirements in this chapter
					 for an out-of-state doctor to serve as a designated doctor to help timely
					 resolve a dispute or perform a particular examination.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 127 - DESIGNATED DOCTOR PROCEDURES AND REQUIREMENTS › Subchapter B - DESIGNATED DOCTOR CERTIFICATION, RENEWAL, AND QUALIFICATIONS › Section 127.140 - Disqualifying Associations

Current through Reg. 49, No. 28; July 12, 2024
(a) Definition. A
				  disqualifying association is any association that may reasonably be perceived
				  as having potential to influence the conduct or decision of a designated
				  doctor. Disqualifying associations may include:
(1) receipt of income, compensation, or
				  payment of any kind not related to health care the doctor provides;
(2) shared investment or ownership
				  interest;
(3) contracts or
				  agreements that provide incentives, such as referral fees, payments based on
				  volume or value, and waiver of beneficiary coinsurance and deductible
				  amounts;
(4) contracts or
				  agreements for space or equipment rentals, personnel services, management
				  contracts, referral services, billing services agents, documentation management
				  or storage services or warranties, or any other services related to managing or
				  operating the doctor's practice;
(5) personal or family
				  relationships;
(6) a contract with
				  the same workers' compensation health care network certified under Insurance
				  Code Chapter 1305 or a contract with the same political subdivision or
				  political subdivision health plan under Labor Code §
											504.053(b)(2)
				  that is responsible for providing medical benefits to the injured employee;
				  or
(7) any other financial
				  arrangement that would require disclosure under the Labor Code, the Insurance
				  Code, or applicable rules, or any other association with the injured employee,
				  the employer, or insurance carrier that may give the appearance of preventing
				  the designated doctor from rendering an unbiased opinion.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 127 - DESIGNATED DOCTOR PROCEDURES AND REQUIREMENTS › Subchapter C - DESIGNATED DOCTOR DUTIES AND RESPONSIBILITIES › Section 127.200 - Duties of a Designated Doctor

Current through Reg. 49, No. 28; July 12, 2024
(a) Duties. All
				  designated doctors must:
(1) Perform
				  designated doctor examinations in a facility:
(A) currently used and properly equipped for
				  medical examinations or other similar health care services; and
(B) that ensures safety, privacy, and
				  accessibility for injured employees, injured employee medical records, and
				  other records containing confidential claim information.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 128 - BENEFITS - CALCULATION OF AVERAGE WEEKLY WAGE › Section 128.1 - Average Weekly Wage: General Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a)
				The average weekly wage (AWW) calculation for an injured employee (employee)
				shall be calculated depending on whether the employee was employed in one of
				the following five courses of employment:
(1)
				full-time (see §
										128.3
				of this title (relating to Average Weekly Wage Calculation for Full-Time
				Employees, And For Temporary Income Benefits For All Employees));
(2) part-time (see §
										128.4
				of this title (relating to Average Weekly Wage Calculation For Part-Time
				Employees));
(3) seasonal (see
				§
										128.5
				of this title (relating to Average Weekly Wage Calculation for Seasonal
				Employees));
(4) school district
				employed (see §
										128.7
				of this title (relating to Average Weekly Wage for School District Employees));
				and
(5) multiple employment (see
				Texas Labor Code §
										408.042
				and subsection (h) of this section).
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 128 - BENEFITS - CALCULATION OF AVERAGE WEEKLY WAGE › Section 128.2 - Carrier Presumption of Employee's Average Weekly Wage

Current through Reg. 49, No. 28; July 12, 2024
(a) An insurance carrier (carrier) shall
				promptly initiate the payment of income benefits as required by the Workers'
				Compensation Act (Act). To expedite payment, the carrier shall presume that
				multiplying the employee's hourly rate times the average number of hours in the
				employee's standard work week, or, if such information is not available, that
				the employer's last payment to the employee for personal services based on a
				full week's work (a partial work week shall be prorated for a full week)
				accurately reflects the employee's average weekly wage (AWW) until:
(1) the employer files a complete wage
				statement required by §
										120.4
				of this title (relating to Employer's Wage Statement); or
(2) the correct AWW is determined by other
				evidence (such as that described in subsections (b) and (c) of this section),
				if the employer does not file a complete wage statement or if the employee
				files an Employee's Multiple Employment Wage Statement in accordance with
				§
										122.5
				of this title (relating to Employee's Multiple Employment Wage
				Statement).
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 128 - BENEFITS - CALCULATION OF AVERAGE WEEKLY WAGE › Section 128.5 - Average Weekly Wage Calculation for Seasonal Employees

Current through Reg. 49, No. 28; July 12, 2024
(a) A seasonal employee is an employee who as
				a regular course of conduct engages in seasonal or cyclical employment which
				may or may not be agricultural in nature, that does not continue throughout the
				year.
(b) The average weekly wage
				used to determine temporary income benefits for seasonal employees shall be
				determined according to the procedure described in §
									128.3(d)
				or (e) of this title (relating to Average
				Weekly Wage Calculation for Full-Time Employees, and for Temporary Income
				Benefits for All Employees), subject to the periodic adjustment described in
				this rule.
(c) The average weekly
				wage for computing temporary income benefits may be increased or decreased to
				more accurately reflect the seasonal nature of the employment, if such an
				adjustment would more accurately reflect the wages the employee could
				reasonably have expected to earn during the period that temporary income
				benefits are paid. Evidence of earnings shall be submitted at the time an
				adjustment is requested. The evidence should include proof of the employee's
				earnings in corresponding time periods of previous years. In case of a dispute,
				the commission shall set a benefit review conference to consider whether an
				adjustment should be made.
(d) The
				average weekly wage used to determine impairment income benefits, lifetime
				income benefits, supplemental income benefits, or death benefits for a seasonal
				employee shall be calculated by:
(1) adding
				together the total wages received by the employee in the 12 months preceding
				the date of injury and dividing the result by 50; or
(2) if it is impractical to compute the
				average weekly wage as provided by paragraph (1) of this subsection, another
				fair, just, and reasonable method as determined in a benefit review conference
				if requested by the person claiming income benefits or the insurance
				carrier.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 128 - BENEFITS - CALCULATION OF AVERAGE WEEKLY WAGE › Section 128.6 - Average Weekly Wage Adjustment for Certain Employees Who Are Also Minors, Apprentices, Trainees, or Students

Current through Reg. 49, No. 28; July 12, 2024
(a) In
				order to adjust average weekly wage under this rule, for purposes of computing
				impairment income, supplemental income, lifetime income, and death benefits, an
				injured employee must come within one of the following definitions, on the date
				of injury:
(1) a minor is an employee less
				than 18 years of age and not emancipated by marriage or judicial action, and is
				also an apprentice, trainee, or student;
(2) an apprentice is an employee learning a
				skilled trade or art by practical experience under the direction of a skilled
				crafts person or artisan;
(3) a
				trainee is an employee undergoing systematic instruction and practice in some
				art, trade, or profession with a view towards proficiency in it; and
(4) a student is an employee enrolled in a
				course of study or instruction in a high school, college, university, or other
				institute of higher education or technical training.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 128 - BENEFITS - CALCULATION OF AVERAGE WEEKLY WAGE › Section 128.7 - Average Weekly Wage for School District Employees

Current through Reg. 49, No. 28; July 12, 2024
(a) This rule applies only to school district
				employees injured on or after December 1, 2001. The calculations in this rule
				apply to the portion of the employee's average weekly wage (AWW) based upon the
				employee's employment with the school district where the school district is the
				"Claim Employer" as that term is used in §
									122.5
				of this title (relating to Employee's Multiple Employment Wage Statement). The
				AWW of a school district employee injured before December 1, 2001, is computed
				using the law and commission rules in effect on the date of the
				injury.
(b) For determining the
				amount of temporary income benefits of school district employees under Texas
				Labor Code Chapter 504, the AWW is computed on the basis of wages earned in a
				week. "Wages earned in a week" are equal to the amount that would be deducted
				from an employee's salary if the employee were absent from work for one week
				and the employee did not have personal leave available to compensate the
				employee for lost wages for that week. For this calculation "wages" includes
				only pecuniary wages.
(c) For
				determining the amount of temporary income benefits of a school district
				employee, the AWW shall be computed as follows.
(1) For a school district employee working
				under a written contract with the school district, the AWW shall be computed by
				dividing the amount the employee would have been paid had the employee fully
				completed the terms of the contract (including any stipend the employee was
				earning or scheduled to receive under the contract) by:
(A) the number of days that the employee was
				required to work under that contract and multiplied by five (if the contract
				has specified the number of work days); or
(B) the number of months that the contract
				was to cover and then dividing the result by 4.34821.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 129 - INCOME BENEFITS-TEMPORARY INCOME BENEFITS › Section 129.1 - Definitions for Temporary Income Benefits

Current through Reg. 49, No. 28; July 12, 2024
The following terms shall have the following meanings unless
				  the context clearly indicates otherwise:
(1) Salary Continuation (also Wage
				Continuation)--Monies paid by the employer to compensate the injured employee
				(employee) for wages lost as a result of a compensable injury. Salary
				continuation does not include monies paid to an employee as compensation for
				work such as wages paid while an employee is on modified duty.
(2) Salary Supplementation (also Wage
				Supplementation)--Monies paid by the employer to supplement the amount of
				income benefits an insurance carrier pays to an employee with a compensable
				injury. This includes monies paid to the employee based on the employee's
				voluntary use of sick leave or annual leave in a supplementary
				manner.
(3) Weekly Earnings After
				the Injury--Post-Injury Earnings (PIE), further described in §
									129.2
				of this title (relating to Entitlement to Temporary Income Benefits).
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 129 - INCOME BENEFITS-TEMPORARY INCOME BENEFITS › Section 129.2 - Entitlement to Temporary Income Benefits

Current through Reg. 49, No. 28; July 12, 2024
(a)
				Once temporary income benefits (TIBs) accrue, an injured employee (employee) is
				entitled to TIBs to compensate the employee for lost wages due to the
				compensable injury during a period in which the employee has disability and has
				not reached maximum medical improvement.
(b) Lost wages are the difference between the
				employee's gross average weekly wage (AWW) and the employee's gross Post-Injury
				Earnings (PIE). If the employee's PIE equals or exceeds the employee's AWW, the
				employee has no lost wages.
(c) PIE
				shall include, but not be limited to, the documented weekly amount of:
(1) all pecuniary wages paid to the employee
				after the date of injury including wages based on work performed while on
				modified duty and pecuniary fringe benefits which are paid to the employee
				whether the employee has returned to work or not;
(2) any employee contribution to benefits
				such as health insurance that the employee normally pays but that the employer
				agrees to pay for the employee in order to continue the benefits (which does
				not include the portion of the benefits that the employer normally pays
				for);
(3) the weekly amount of any
				wages offered as part of a bona fide job offer which is not accepted by the
				employee which the insurance carrier (carrier) is permitted to deem to be PIE
				under §
										129.6
				of this title (relating to Bona Fide Offers of Employment);
(4) the value of any full days of accrued
				sick leave or accrued annual leave that the employee has voluntarily elected to
				use after the date of injury;
(5)
				the value of any partial days of accrued sick leave or accrued annual leave
				that the employee has voluntarily elected to use after the date of injury that,
				when combined with the employee's TIBs, exceeds the AWW; and
(6) any monies paid to the employee by the
				employer as salary continuation based on:
(A)
				a contractual obligation between the employer and the employee including
				through a collective bargaining agreement;
(B) an employer policy; or
(C) a written agreement with the
				employee.