reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 34 - STATE FIRE MARSHAL › Subchapter M - SCHEDULED ADMINISTRATIVE PENALTIES › Section 34.1304 - Notice of Violation and Penalty

Current through Reg. 49, No. 28; July 12, 2024
After investigation of a possible violation and the facts
					 surrounding the possible violation the state fire marshal's office may issue to
					 the licensee a notice of alleged violation stating:
(1) a brief summary of the alleged
				  violation;
(2) the amount of the
				  recommended administrative penalty; and
(3) that the licensee has the right to accept
				  the department's determination and recommended administrative penalty by
				  submitting payment, show compliance with all requirements of all applicable law
				  and rules, or request a hearing.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 34 - STATE FIRE MARSHAL › Subchapter M - SCHEDULED ADMINISTRATIVE PENALTIES › Section 34.1305 - Penalty to be Paid or Hearing Requested

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  No later than the 30th day after the date the licensee receives the notice of
				  alleged violation and recommended administrative penalty, the licensee may:
(1) accept the department's determination and
				  recommended administrative penalty by submitting payment;
(2) show compliance with all requirements of
				  all applicable law and rules; or
(3) request a hearing.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 34 - STATE FIRE MARSHAL › Subchapter M - SCHEDULED ADMINISTRATIVE PENALTIES › Section 34.1306 - Request for Hearing

Current through Reg. 49, No. 28; July 12, 2024
If the licensee requests a hearing, the state fire marshal
					 will refer the matter to the Texas Department of Insurance, Enforcement
					 Section. The state fire marshal may assert other matters and claims against the
					 licensee at the hearing and seek any disciplinary action available under
					 Insurance Code Chapters 82, 83, and 84, Occupations Code Chapter 2154, and this
					 chapter, including additional penalty amounts in excess of the penalty schedule
					 amount.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 34 - STATE FIRE MARSHAL › Subchapter M - SCHEDULED ADMINISTRATIVE PENALTIES › Section 34.1307 - Failure to Pay Penalty

Current through Reg. 49, No. 28; July 12, 2024
If a licensee fails to pay the administrative penalty, the
					 state fire marshal may refer the alleged violation to the Texas Department of
					 Insurance, Enforcement Section as described in §
										34.1301(d)
					 of this title (relating to Imposition of Penalty) and seek additional
					 sanctions.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 34 - STATE FIRE MARSHAL › Subchapter M - SCHEDULED ADMINISTRATIVE PENALTIES › Section 34.1308 - Dispute of Penalty

Current through Reg. 49, No. 28; July 12, 2024
A licensee may dispute the imposition of the penalty or the
					 amount of the penalty imposed in the manner prescribed by Insurance Code
					 Chapter 84, Subchapter C.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 41 - PRACTICE AND PROCEDURE › Subchapter A - COMMUNICATIONS › Section 41.1 - Name Change

Current through Reg. 49, No. 28; July 12, 2024
Pursuant to Senate Bill 1 (71st Legislature, 2nd Called
					 Session, 1989), the following revisions are effective April 1, 1990.
(1) The state agency known since 1913 as the
				  Industrial Accident Board is renamed the Texas Workers' Compensation
				  Commission. Wherever the term "Industrial Accident Board," "Board," or "board,"
				  meaning the agency, appears in these rules, it shall mean "Texas Workers'
				  Compensation Commission."
(2) The
				  executive director of the Texas Workers' Compensation Commission exercises all
				  authority necessary to administer Texas Civil Statutes, Articles 8306-8309-1.
				  Wherever the terms "Industrial Accident Board" or "Board," meaning one or more
				  members of Industrial Accident Board, appears in these rules, the terms shall
				  mean the executive director or delegatee.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 41 - PRACTICE AND PROCEDURE › Subchapter A - COMMUNICATIONS › Section 41.5 - Compliance and Suspension of Rules

Current through Reg. 49, No. 28; July 12, 2024
All parties seeking any action of the board shall comply
					 with these rules, unless in its judgment the board determines that compliance
					 with any of the rules under particular circumstances will result in injustice
					 to either or both parties. Accordingly, rules may be suspended at the
					 discretion of the board and additional hearings held or cases scheduled for
					 hearing out of their regular order (1968).
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 41 - PRACTICE AND PROCEDURE › Subchapter A - COMMUNICATIONS › Section 41.8 - Contents of Rule-Making Petitions

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Changes to these rules may be petitioned by any party. Rule-making petitions
				  shall contain the following:
(1) a brief
				  statement summarizing the proposed section;
(2) the text of the proposed section:
(A) if an existing section, state the title
				  and code number, and prepare the text to indicate the words and punctuation to
				  be added, changed, or deleted;
(B)
				  if a new section, prepare the text in the exact form proposed for
				  adoption;
(3) a
				  statement of the statutory source of the section;
(4) a suggested effective date;
(5) a cost-benefit analysis, estimating the
				  public benefits to be expected as a result of adoption of the proposed section,
				  and the probable economic cost to persons who are required to comply with the
				  section. This provision is optional;
(6) any other matter required by
				  law;
(7) the petitioner's name,
				  complete mailing address, and telephone number; and
(8) the petitioner's signature.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 41 - PRACTICE AND PROCEDURE › Subchapter A - COMMUNICATIONS › Section 41.10 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in these sections,
					 shall have the following meanings, unless the context clearly indicates
					 otherwise.
(1) Health provider--Used
				  in these board rules in a generic sense, having reference to licensed
				  practitioners of medicine, osteopathic, chiropractic, and podiatry.
(2) Insurance carrier or carrier--Shall be
				  synonymous with the term "association," as defined in Texas Civil Statutes,
				  Article 8309, §1, to mean any insurance company authorized to insure
				  payment of workers' compensation including political subdivisions according to
				  Texas Civil Statutes, Article 8309h, §3(b).
(3) Medical expenses--Shall include health
				  provider care by licensed medical doctors, osteopathic physicians, chiropractic
				  physicians, and podiatrists, as well as hospital care, drugs and prescriptions,
				  appliances, nursing care, psychological care, therapy and physical
				  rehabilitation, where the same are prescribed by a health provider named under
				  the Workers' Compensation Law, and rendered or provided by a licensed
				  source.
(4) Medical report or
				  medical treatment--Shall also include, where applicable, osteopathic,
				  chiropractic, podiatric care, and the reports thereof.
(5) Subscriber and employer--Are
				  synonymous.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 41 - PRACTICE AND PROCEDURE › Subchapter A - COMMUNICATIONS › Section 41.15 - Social Security Number

Current through Reg. 49, No. 28; July 12, 2024
All forms, reports, and other documents filed with the
					 board which pertain to a claim shall include the social security number of the
					 injured employee.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 41 - PRACTICE AND PROCEDURE › Subchapter A - COMMUNICATIONS › Section 41.20 - Adjuster Identification

Current through Reg. 49, No. 28; July 12, 2024
Each adjuster employed by or on behalf of an insurance
					 company, self-insured, insurance agent, or corporation or by an employer in
					 connection with either the investigation or handling of a workers' compensation
					 claim shall provide the board with his/her license number as issued under the
					 Insurance Code, Article 21.07-4. This shall be accomplished in each file as
					 soon as practical.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 41 - PRACTICE AND PROCEDURE › Subchapter A - COMMUNICATIONS › Section 41.25 - Attorney Identification

Current through Reg. 49, No. 28; July 12, 2024
Each attorney engaged by either a claimant, insurance
					 carrier, or self-insured in connection with the handling of a workers'
					 compensation claim shall provide the board with his/her permanent state bar
					 identification number promptly upon retention in the claim.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 41 - PRACTICE AND PROCEDURE › Subchapter A - COMMUNICATIONS › Section 41.27 - Employer's Identification

Current through Reg. 49, No. 28; July 12, 2024
Each carrier and employer shall provide the employer's
					 federal tax identification number on:
(1) the employer's first report of
				  injury;
(2) the employer's
				  supplemental report of injury;
(3)
				  the wage statement;
(4) a Form A-1,
				  A-2, and A-4 (initial filing only);
(5) a statement of controversion;
(6) a notice that employer has become
				  subscriber, Form IAB-20;
(7) a
				  cancellation or nonrenewal notice for workers' compensation insurance, Form
				  IAB-9; and
(8) other forms as the
				  board shall direct (effective 1987).
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 41 - PRACTICE AND PROCEDURE › Subchapter A - COMMUNICATIONS › Section 41.30 - Self-Insureds

Current through Reg. 49, No. 28; July 12, 2024
Unless otherwise specifically noted therein, whenever a
					 board rule makes reference to an insurance carrier or association, this shall
					 be interpreted to include also all self-insured entities as
					 well.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 41 - PRACTICE AND PROCEDURE › Subchapter A - COMMUNICATIONS › Section 41.35 - Designation of Insurance Carriers' Austin Representative

Current through Reg. 49, No. 28; July 12, 2024
All insurance carriers writing and issuing workers'
					 compensation insurance policies effective in Texas shall designate in writing
					 to the board their Austin representative to the Industrial Accident Board for
					 purposes of communication with the board. The name, business address, and phone
					 number of such representative shall be supplied and kept current at all times.
					 Written notification or communication by the board with such representative
					 shall be deemed notification to the carrier for all purposes.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 41 - PRACTICE AND PROCEDURE › Subchapter A - COMMUNICATIONS › Section 41.40 - General Policy Concerning Communications

Current through Reg. 49, No. 28; July 12, 2024
The board hereby promulgates its general policy concerning
					 communications to and from the Industrial Accident Board.
(1) The carrier shall send a copy of all
				  written communications relating to a pending claim before the board to the
				  claimant, or if claimant is represented by counsel, directly to his attorney
				  and to the board. Without limiting the generality of the foregoing, the term
				  "written communications" shall include board approved Form A-1, A-2, A-4, and
				  A-2 Lump Sum Transmittal Letter, Statements of Controversion, and Notices of
				  Intention to Appeal.
(2) The
				  attorney representing the claimant shall send a copy of all written
				  communications relating to a pending claim before the board to the insurance
				  carrier and to the board. Without limiting the generality of the foregoing, the
				  term "written communication" shall include written claim for compensation,
				  affidavit of hardship, power of attorney, notice of appeal.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 41 - PRACTICE AND PROCEDURE › Subchapter A - COMMUNICATIONS › Section 41.45 - Communication to Claimants

Current through Reg. 49, No. 28; July 12, 2024
All notices and written communications to claimant will be
					 mailed to the last address supplied, either on the employer's first report of
					 injury or by claimant's letter. If the board is notified that claimant is
					 represented by an attorney, copies of forms, notices, and correspondence will
					 thereafter be mailed to his attorney and not to the claimant. However, copies
					 of compromise approval notices, prehearing setting, and awards of the board
					 will be mailed to the claimant and his attorney.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 41 - PRACTICE AND PROCEDURE › Subchapter A - COMMUNICATIONS › Section 41.55 - Communication to Employers

Current through Reg. 49, No. 28; July 12, 2024
All notices and written communications to employers,
					 including notice of conduct which may result in the imposition of a statutory
					 penalty by the board, will be mailed to the last address supplied either on the
					 employer's first report of injury form or on the notice that the employer has
					 become a subscriber form.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 41 - PRACTICE AND PROCEDURE › Subchapter A - COMMUNICATIONS › Section 41.60 - Communication to Insurance Carriers

Current through Reg. 49, No. 28; July 12, 2024
Unless otherwise required by statute, or provided by a
					 board rule, all notices and other communications to insurance carriers will be
					 sent either to an address designated by the carrier as its principal Texas
					 mailing address or to its designated Austin representative.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 41 - PRACTICE AND PROCEDURE › Subchapter A - COMMUNICATIONS › Section 41.65 - Communication to Health Care Provider

Current through Reg. 49, No. 28; July 12, 2024
A health care provider shall send a copy of all written
					 communications relative to a pending claim for compensation and the treatment
					 thereof or concerning a statement for professional services rendered to the
					 insurance carrier and to the claimant or his attorney, if
					 represented.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 41 - PRACTICE AND PROCEDURE › Subchapter A - COMMUNICATIONS › Section 41.70 - Filing of Instruments

Current through Reg. 49, No. 28; July 12, 2024
(a) The following
				  shall be filed only with the board in Austin:
(1) notice of injury and claim for
				  compensation (Texas Civil Statutes, Article 8307, §4a);
(2) employer's first report of injury (Texas
				  Civil Statutes, Article 8307, §7);
(3) employer's response to board request for
				  information (Texas Civil Statutes, Article 8307, §7);
(4) notice that employer has become
				  subscriber (Texas Civil Statutes, Article 8308, §18a);
(5) response to request for notice that
				  employer has become subscriber (Texas Civil Statutes, Article 8308,
				  §18a);
(6) notice of
				  cancellation or nonrenewal of compensation insurance (Texas Civil Statutes,
				  Article 8308, §20a);
(7) form
				  A-1, Report of Initial Payment of Compensation (Texas Civil Statutes, Article
				  8306, §3b);
(8) statement of
				  controversion (Texas Civil Statutes, Article 8306, §18a(a));
(9) application to suspend compensation
				  (Texas Civil Statutes, Article 8306, §12a and Article 8307,
				  §4);
(10) formal statements of
				  position (Texas Civil Statutes, Article 8307, §10);
(11) statement of position in death cases
				  (Texas Civil Statutes, Article 8306, §18a(a));
(12) notice of intention to appeal (Texas
				  Civil Statutes, Article 8307, §5);
(13) response to notice of possible violation
				  (Texas Civil Statutes, Article 8306, §18a(a));
(14) carrier's designation of board
				  representative (Texas Civil Statutes, Article 8306, §18a).
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 41 - PRACTICE AND PROCEDURE › Subchapter A - COMMUNICATIONS › Section 41.75 - Timely Filing

Current through Reg. 49, No. 28; July 12, 2024
Forms, reports, and other documents required to be filed
					 before a specified time will be considered timely only if received by the board
					 at Austin or at an appropriate regional office prior to or during business
					 hours on the last permissible day of filing. When the last day for filing is a
					 legal holiday, or is Sunday, then the time is extended so as to include the
					 next succeeding business day.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 41 - PRACTICE AND PROCEDURE › Subchapter A - COMMUNICATIONS › Section 41.80 - Filing Subsequent to Final Order or Award

Current through Reg. 49, No. 28; July 12, 2024
In order for it to continue monitoring a claim for future
					 medical and compensation benefits after a final award, carriers must continue
					 filing with the board in Austin, and in accordance with existing board rules,
					 the following documents: A-1, A-2, A-4, notice of suspension of medical
					 benefits, a copy of the instruments reflecting final disposition of the case,
					 whether by compromise, settlement agreement, court judgment, or dismissal
					 without judgment entry, and upon request a copy of all available medical
					 information.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 41 - PRACTICE AND PROCEDURE › Subchapter A - COMMUNICATIONS › Section 41.85 - Translation of Documents

Current through Reg. 49, No. 28; July 12, 2024
Whenever a party submits or files a medical report, witness
					 statement, or other instrument written in a foreign language, a true and
					 correct English translation shall be filed simultaneously.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 41 - PRACTICE AND PROCEDURE › Subchapter A - COMMUNICATIONS › Section 41.90 - Responsibility of Translators

Current through Reg. 49, No. 28; July 12, 2024
Whenever a non-English speaking party appears before the
					 board or any member thereof at a prehearing conference or a formal hearing, a
					 translator who is proficient in the English language must accompany the party.
					 The responsibility for providing an interpreter rests with the party producing
					 the non-English speaking witness.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 41 - PRACTICE AND PROCEDURE › Subchapter A - COMMUNICATIONS › Section 41.95 - Wage Information

Current through Reg. 49, No. 28; July 12, 2024
The board will accept in lieu of other wage information a
					 stipulated wage agreement executed by the injured employee and the insurance
					 carrier which establishes by mutual agreement an average weekly wage and a
					 weekly compensation rate on a standard form approved by the board. Such
					 stipulation may be considered by the Industrial Accident Board, along with any
					 other evidence concerning the wage rate, but it will not necessarily be binding
					 upon the board. No action by the board on the claim shall be taken as formal
					 approval of such stipulation, and the same shall be regarded only as an
					 informal waiver of proof for purposes of the hearing before the
					 board.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter A - GENERAL MEDICAL PROVISIONS › Section 42.5 - Applicability and Scope of Rules

Current through Reg. 49, No. 28; July 12, 2024
(a) General.
				  These sections govern all providers of health care services and supplies
				  covered under the Texas Workers' Compensation Act (the Act).
(b) Out-of-state providers. Out-of-state
				  providers of health care services and supplies covered under the Act are
				  governed by these sections.
(c)
				  Effective date. These sections shall be applicable to all services and supplies
				  provided subsequent to November 1, 1988.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter A - GENERAL MEDICAL PROVISIONS › Section 42.10 - Acceptance of Rules and Guidelines

Current through Reg. 49, No. 28; July 12, 2024
The filing by a health care provider of a report, the
					 submitting of a bill for services or supplies, or the rendering of treatment to
					 an injured worker entitled to benefits under the Act constitutes acceptance of
					 and agreement to comply with these sections.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter A - GENERAL MEDICAL PROVISIONS › Section 42.15 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this part,
					 shall have the following meanings, unless the context clearly indicates
					 otherwise.
(1) Accrual of medical
				  benefits--The right to medical benefits for a compensable injury accrues as of
				  the date of injury and continues for the life of the injured worker, or until
				  terminated by agreement between the injured worker and the carrier, and is
				  limited in amount only according to the reasonableness of the expense and the
				  necessity of the treatment.
(2)
				  Act--Texas Civil Statutes, Articles 8306-8309(i).
(3) Association--See carrier.
(4) Billing by report--The billing procedure
				  to be used by a health care provider when:
(A)
				  no procedural definition and/or dollar value is established in the board's fee
				  guidelines for the treatment or service rendered; or
(B) when the provider determines that the
				  procedural definition and/or dollar value established in the fee guidelines
				  does not adequately describe the treatment or service rendered. (See §
											42.145 of this
				  title (relating to Billing.))
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter A - GENERAL MEDICAL PROVISIONS › Section 42.20 - Who May Treat

Current through Reg. 49, No. 28; July 12, 2024
(a) Licensed
				  doctors of medicine, osteopathy, chiropractic, and podiatry may act as treating
				  doctors for injured workers entitled to benefits under the Act.
(b) Treating doctors may prescribe treatment
				  to be rendered by other persons licensed to provide health care, or by persons
				  not licensed to provide health care who work under the direct supervision and
				  control of the treating doctor.
(c)
				  Treating doctors may prescribe nursing care to be rendered by unlicensed
				  persons, including, but not limited to, members of the injured worker's
				  family.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter A - GENERAL MEDICAL PROVISIONS › Section 42.25 - Prohibited Practices

Current through Reg. 49, No. 28; July 12, 2024
(a) The following,
				  when committed knowingly or willfully, shall be deemed prohibited practices by
				  health care providers, and may result in action by the board, including
				  referral to professional grievance committees, licensing agencies, or the
				  attorney general's office:
(1) failing,
				  neglecting, or refusing to observe and comply with the board's rules;
(2) failing, neglecting, or refusing to
				  submit complete, adequate, and detailed reports, when required, or to respond
				  to requests by the carrier, the claimant or claimant's representative, or the
				  board for additional reports or other claim-related information. (See §
											42.33(c)
				  of this title (relating to Health Care Providers' Reporting
				  Requirements));
(3) submitting
				  false or misleading reports, or colluding with other persons in the submission
				  of false or misleading reports;
(4)
				  submitting inaccurate or misleading bills;
(5) repeated overcharging;
(6) knowingly submitting a bill to an injured
				  worker for treatment of a compensable injury or illness;
(7) charging or attempting to charge fees for
				  required reports, handling fees, interest, or any surcharge whatsoever to an
				  injured worker for treatment of a compensable injury or illness;
(8) persistently using contraindicated or
				  hazardous treatment measures;
(9)
				  repeated overutilization;
(10)
				  using or prescribing narcotic, addictive, or dependency-inducing drugs for
				  other than therapeutic purposes; or
(11) practicing after suspension or
				  revocation of a provider's practice privilege by the appropriate licensing
				  agency, after conviction in any court of any offense involving moral turpitude,
				  or after a declaration of mental incompetency by a court of competent
				  jurisdiction.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter A - GENERAL MEDICAL PROVISIONS › Section 42.28 - Confirmation of Coverage

Current through Reg. 49, No. 28; July 12, 2024
The carrier shall confirm medical benefits coverage upon
					 the request of a health care provider when no bona fide dispute exists as to
					 liability.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter A - GENERAL MEDICAL PROVISIONS › Section 42.30 - Written Communications

Current through Reg. 49, No. 28; July 12, 2024
(a) A health
				  care provider shall send copies of all written communications related to a
				  claim, including reports, to the carrier and, except for bills, to the injured
				  worker or his or her representative. The provider may require written evidence
				  of representative capacity from the claimant's representative.
(b) A provider shall submit bills for
				  services or supplies to the carrier only. A provider shall send copies of bills
				  to the injured worker, or his or her representative, only upon
				  request.
(c) A provider shall send
				  copies of all written communications, including reports and bills, to the board
				  upon the board's request.
(d) All
				  written communications from providers shall contain the following identifying
				  information, if known:
(1) the patient's full
				  name, address, and social security number;
(2) the patient's IAB claim number;
(3) the date and nature of the injury or
				  illness;
(4) the employer's name
				  and address;
(5) the carrier's
				  name;
(6) the provider's name,
				  address, and federal tax identification number.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter A - GENERAL MEDICAL PROVISIONS › Section 42.33 - Health Care Providers' Reporting Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) Providers shall prepare written reports
				  according to the specifications set out in the sections of this subchapter
				  relating to required reports, and shall submit them to the carrier and the
				  injured worker, or his or her representative, as provided in §
										42.30 of
				  this title (relating to Written Communications).
(b) All required reports shall contain the
				  identifying information required by §
										42.30(d)
				  of this title (relating to Written Communications).
(c) A provider who fails to comply with the
				  reporting requirements, when applicable, as determined by the board, shall lose
				  his or her right to payment for treatment or services rendered under the Act,
				  pursuant to Texas Civil Statutes, Article 8306, §7.
(d) The board may prescribe forms for
				  reporting purposes.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter A - GENERAL MEDICAL PROVISIONS › Section 42.35 - Required Reports: First Report

Current through Reg. 49, No. 28; July 12, 2024
(a) The
				  treating doctor shall make an initial report, and submit it to the carrier and
				  the injured worker, or his or her representative, as provided in §
										42.30 of
				  this title (relating to Written Communications) no later than seven working
				  days after the injured worker's first visit.
(b) The first report shall contain the
				  following information:
(1) all identifying
				  information required by §
											42.30(d)
				  of this title (relating to Written Communications);
(2) complete history, as related by the
				  claimant, of the occupational accident or illness;
(3) complete listing of positive physical
				  findings;
(4) specific diagnosis
				  with appropriate procedural and diagnostic code(s) and narrative definition(s)
				  relating to the injury;
(5) type of
				  treatment rendered;
(6) anticipated
				  date the worker may achieve maximum medical recovery, if possible;
				  and
(7) anticipated date of release
				  to return to work, if possible.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter A - GENERAL MEDICAL PROVISIONS › Section 42.40 - Required Reports: Subsequent Reports

Current through Reg. 49, No. 28; July 12, 2024
(a) Subsequent reports shall be submitted to
				  the carrier and the injured worker, or his or her representative, as provided
				  in §
										42.30 of
				  this title (relating to Written Communications), and shall contain the
				  following information:
(1) all identifying
				  information required by §
											42.30(d)
				  of this title (relating to Written Communications);
(2) type of treatment rendered;
(3) anticipated date the worker will achieve
				  maximum medical recovery, if possible; and
(4) anticipated date of release to return to
				  work, if possible.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter A - GENERAL MEDICAL PROVISIONS › Section 42.55 - Required Reports: Change of Status Reports

Current through Reg. 49, No. 28; July 12, 2024
(a) The treating doctor shall submit a change
				  of status report to the carrier and the injured worker, or his or her
				  representative, as provided in §
										42.30 of
				  this title (relating to Written Communications) within seven days of:
(1) determining that the patient has achieved
				  maximum medical recovery;
(2)
				  releasing the patient to return to work; or
(3) receiving notice that the patient has
				  changed treating doctors.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter A - GENERAL MEDICAL PROVISIONS › Section 42.65 - Changing Treating Doctors

Current through Reg. 49, No. 28; July 12, 2024
(a) When
				  an injured worker elects to change treating doctors, the subsequent doctor
				  shall make a diligent effort to secure from the prior doctor or from the
				  carrier all available medical information. The prior doctor shall immediately
				  forward, upon proper request, all requested information, including x-rays, to
				  the new treating doctor.
(b) The
				  carrier shall identify all prior treating doctors and provide all relevant
				  medical records in its claim file to the subsequent doctor upon
				  request.
(c) All reasonable costs
				  incurred in transferring records under this section shall be borne by the
				  carrier.
(d) The subsequent doctor
				  is responsible for submitting all required reports.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter A - GENERAL MEDICAL PROVISIONS › Section 42.75 - Excess Recovery from Third Party Actions

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  When an injured worker has received an excess recovery in a third party action,
				  pursuant to Texas Civil Statutes, Article 8307, §6a(c), the carrier shall
				  immediately:
(1) notify all providers of the
				  date of the judgment or agreed judgment, and the amount of the excess;
				  and
(2) file a copy of the judgment
				  or agreed judgment with the board.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter A - GENERAL MEDICAL PROVISIONS › Section 42.78 - Reports To Be Filed by the Carrier

Current through Reg. 49, No. 28; July 12, 2024
The carrier shall file current medical reports with the
					 board under the following conditions:
(1) after the expiration of four weeks of
				  disability;
(2) when filing a
				  notice of controversion based on medical grounds;
(3) upon receipt of narrative reports
				  submitted by the treating doctor pursuant to §
										42.40
				  of this subchapter (relating to Required Reports: Subsequent
				  Reports);
(4) when filing an A-2
				  giving return to work date or release to return to work date;
(5) when filing an A-4 showing additional
				  lost time;
(6) when requesting a
				  prehearing conference;
(7) when
				  filing a CSA;
(8) when filing an
				  A-2 lump sum showing payment for permanent partial disability resulting from a
				  specific injury; and
(9) when
				  requested by the board.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter A - GENERAL MEDICAL PROVISIONS › Section 42.80 - Assignment of Medical Benefits

Current through Reg. 49, No. 28; July 12, 2024
A health or accident insurance company which has been
					 assigned an injured worker's right to medical benefits under the Act shall file
					 a true copy of the assignment with the carrier and the board within five days
					 of said assignment.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter A - GENERAL MEDICAL PROVISIONS › Section 42.85 - Voluntary Arbitration

Current through Reg. 49, No. 28; July 12, 2024
The board shall establish procedures for selection of
					 voluntary arbitration panels to assist the board in regulating fees and charges
					 submitted by health care providers to the full extent authorized by Texas Civil
					 Statutes, Article 8306, §7.
(1)
				  The executive director of the board shall prepare bylaws subject to the final
				  approval of the board governing the operation and functions of the various
				  voluntary arbitration panels.
(2)
				  The executive director of the board shall implement the procedures so adopted
				  by the board. The executive director or designee shall supervise the
				  arbitration panels established by the board, and shall serve as chairman of
				  each panel. However, the executive director may from time to time designate the
				  assistant executive director of the board or other person to act as chairman in
				  his or her place.
(3) The
				  procedures for selection of panels and the bylaws shall be available to all
				  parties.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter A - GENERAL MEDICAL PROVISIONS › Section 42.90 - Demand for Surgical Operation

Current through Reg. 49, No. 28; July 12, 2024
Any written demand for a surgical operation under Texas
					 Civil Statutes, Article 8306, §12e, or any application for reduction or
					 suspension of compensation pursuant to Article 8307, §4, must be filed
					 with the board at least seven calendar days prior to the date of hearing.
					 However, where good cause for waiving strict compliance is approved by the
					 board, parties may file demand for or tender of surgery on or before the
					 scheduled date of hearing.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter A - GENERAL MEDICAL PROVISIONS › Section 42.95 - Scars and Deformities

Current through Reg. 49, No. 28; July 12, 2024
In all cases involving severe and disfiguring burns or
					 lacerations, a descriptive medical report of the scars or deformity shall be
					 submitted by either the carrier or the claimant. In all such cases involving
					 scars to the face, arms, or hands, a color photograph taken after maximum
					 healing has occurred must be submitted at or prior to any final board action on
					 the claim.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter B - MEDICAL COST EVALUATION › Section 42.101 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
The fee guidelines promulgated in this subchapter are
					 intended to establish presumptively fair and reasonable charges for health care
					 services and supplies which may be covered under the Act.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter B - MEDICAL COST EVALUATION › Section 42.105 - Medical Fee Guideline

Current through Reg. 49, No. 28; July 12, 2024
(a) The maximum
				  allowable charge under the Medical Fee Guideline for Services Rendered under
				  the Texas Workers' Compensation Act is the lesser of:
(1) the provider's usual fees and charges;
				  or
(2) the fees and charges
				  established by use of a relative value scale adopted under subsection (b) of
				  this section.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter B - MEDICAL COST EVALUATION › Section 42.115 - Pharmaceutical Fee Guideline

Current through Reg. 49, No. 28; July 12, 2024
(a) The maximum
				  allowable charge for pharmaceuticals under the Pharmaceutical Fee Guideline for
				  Services Rendered Under the Workers' Compensation Law is the lesser of:
(1) the provider's usual charge; or
(2) the fees established by the formulas for
				  brand-name and generic pharmaceuticals as described in subsection (c) of this
				  section.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter B - MEDICAL COST EVALUATION › Section 42.135 - Liability for Covered Health Care

Current through Reg. 49, No. 28; July 12, 2024
(a) The
				  carrier is solely liable to pay a provider for health care which is covered
				  under the Act.
(b) The injured
				  worker shall not be billed for covered health care, nor for any amounts in
				  excess of the amount adjudicated as fair and reasonable. The injured worker
				  shall not be billed for reports, handling fees, interest, or any other
				  surcharge related to the covered health care. The provider shall not refer the
				  injured worker to a collection agency or a retail credit
				  organization.
(c) This section does
				  not apply if the injured worker has received an excess recovery from a third
				  party, pursuant to Texas Civil Statutes, Article 8307, §6a, and §
										42.60
				  of this title (relating to Excess Recovery from Third Party Actions.)
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter B - MEDICAL COST EVALUATION › Section 42.137 - Utilization Review

Current through Reg. 49, No. 28; July 12, 2024
(a) The claimant
				  and the carrier may jointly request the board for an informal review and
				  determination of the necessity or proposed medical treatment.
(b) The application shall be accompanied by
				  supporting documentation from one or more health care providers.
(c) The determination of necessity shall be
				  informal, for the purpose of resolving disputes, and shall not be binding on
				  either party.
(d) The carrier shall
				  bear the cost of a review provided under this section.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter B - MEDICAL COST EVALUATION › Section 42.140 - Amount of Payment

Current through Reg. 49, No. 28; July 12, 2024
(a) General. A
				  provider will be paid an amount that is fair and reasonable. It shall be
				  presumed that fair and reasonable amounts are those established in the fee
				  guidelines. Any adjudication by the board as to fair and reasonable amount will
				  be consistent with fee guidelines unless evidence has been properly filed with
				  the board indicating that a different amount is fair and reasonable. The board
				  will consider any request for payment in excess of the fee guidelines when
				  filed by report.
(b) Payment for
				  services billed by report. The carrier shall base payment for services billed
				  by report upon review of the submitted documentation and recommendations from
				  the carrier's medical consultant.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter B - MEDICAL COST EVALUATION › Section 42.145 - Billing

Current through Reg. 49, No. 28; July 12, 2024
(a) General. All bills submitted to carriers
				  shall:
(1) contain the identifying
				  information required by §
											42.30(d)
				  of this title (relating to Written Communications), if available;
(2) itemize services and goods provided;
				  and
(3) after January 1, 1989,
				  identify services and goods provided by appropriate procedural and diagnostic
				  codes, with descriptions, as established in the fee guidelines.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter B - MEDICAL COST EVALUATION › Section 42.155 - Carrier Review of Bills

Current through Reg. 49, No. 28; July 12, 2024
(a) General. The
				  carrier shall promptly date stamp each health care provider bill with the date
				  the same was received by the carrier. Failure on the carrier's part to comply
				  with this rule shall create a rebuttable presumption that such health care
				  provider bill was received by the carrier within five business days of the date
				  of such bill.
(b) Time for review.
(1) General. The carrier shall complete its
				  review of a bill within 30 days of receipt. The review may include an audit, as
				  described by §
											42.160
				  of this title (relating to Carrier Desk Audit of Bills). A bill may not be
				  reduced unless the carrier conducts an audit.
(2) Pharmaceutical bills. The carrier shall
				  complete its review of a pharmaceutical bill within 10 days of
				  receipt.
(3) Hospital bills;
				  on-site audit. If the carrier decides to conduct an on-site audit of a hospital
				  bill, the carrier shall proceed according to the provisions of §
											42.165
				  of this title (relating to Carrier On-Site Audit of Hospital Bills). The time
				  for review shall be extended until completion of the on-site audit.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter B - MEDICAL COST EVALUATION › Section 42.160 - Carrier Desk Audit of Bills

Current through Reg. 49, No. 28; July 12, 2024
(a) During the
				  audit, the carrier and the provider shall make reasonable attempts to resolve
				  any questions or problems regarding the bill under audit. The provider shall
				  submit to the carrier any additional information requested that is relevant to
				  the audit. If a hospital bill is under review, the hospital shall submit the
				  medical record at the carrier's request.
(b) Every audit shall be documented on the
				  medical audit summary sheet, which shall include the following information:
(1) claimant's name;
(2) IAB claim number;
(3) provider's name, address, and federal tax
				  identification number;
(4) health
				  care provider-reviewer's report; and
(5) for each audited item, the following:
				  applicable code; code description; amount billed; amount paid; and, if
				  appropriate, amount reduced or denied, accompanied by a sufficient explanation
				  for each reduction or denial.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter B - MEDICAL COST EVALUATION › Section 42.165 - Carrier On-Site Audit of Hospital Bills

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  The carrier may request an on-site audit of a hospital bill.
(b) The request shall:
(1) be made in writing;
(2) be made no later than 40 days after
				  receipt of the bill; and
(3) be
				  accompanied by payment of either 75% of the bill as submitted, or a $50 audit
				  fee.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 42 - MEDICAL BENEFITS › Subchapter B - MEDICAL COST EVALUATION › Section 42.175 - Miscellaneous Covered Services

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Medical reports.
(1) The carrier shall pay
				  the fair and reasonable charges of the provider for the preparation and
				  submission of all required medical reports, records, and information. There
				  shall be no additional charge made to the patient or the patient's
				  representative for copies of these documents except clinical reports (hospital)
				  when a separate request is made. There shall be no additional charge made to
				  the board for copies of any of these documents.
(2) The following shall serve as guidelines
				  for fair and reasonable charges for required reports and records under this
				  chapter:
Attached
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