reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter F - PHARMACEUTICAL BENEFITS › Section 134.504 - Pharmaceutical Expenses Incurred by the Injured Employee

Current through Reg. 49, No. 28; July 12, 2024
(a) It may become necessary for an injured
				  employee to purchase prescription drugs or over-the-counter alternatives to
				  prescription drugs prescribed or ordered by the treating doctor or referral
				  health care provider. In such instances the injured employee may request
				  reimbursement from the insurance carrier as follows:
(1) The injured employee shall submit to the
				  insurance carrier a letter requesting reimbursement along with a receipt
				  indicating the amount paid and documentation concerning the prescription. The
				  letter should include information to clearly identify the claimant such as the
				  claimant's name, address, date of injury, and social security number.
				  Documentation for prescription drugs submitted with the letter from the
				  employee must include the prescribing health care provider's name, the date the
				  prescription was filled, the name of the drug, employee's name and dollar
				  amount paid by the employee. As examples, this information may be provided on
				  an information sheet provided by the pharmacy, or the employee can ask the
				  pharmacist for a print out of work related prescriptions for a particular time
				  period. Cash register receipts alone are not acceptable.
(2) The insurance carrier shall make
				  appropriate payment to the injured employee in accordance with §134.503,
				  or notify the injured employee of a reduction or denial of the payment within
				  45 days of receipt of the request for reimbursement from the injured employee.
				  If the insurance carrier does not reimburse the full amount requested, or
				  denies payment the carrier shall include a full and complete explanation of the
				  reason(s) the insurance carrier reduced or denied the payment and shall inform
				  the injured employee of his or her right to request medical dispute resolution
				  in accordance with §
											133.305 of
				  this title (relating to Medical Dispute Resolution). The statement shall
				  include sufficient claim-specific substantive information to enable the
				  employee to understand the insurance carrier's position and/or action on the
				  claim. A general statement that simply states the carrier's position with a
				  phrase such as "not entitled to reimbursement" or a similar phrase with no
				  further description of the factual basis does not satisfy the requirements of
				  this section.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter F - PHARMACEUTICAL BENEFITS › Section 134.506 - Outpatient Open Formulary for Claims with Dates of Injury Prior to September 1, 2011

Current through Reg. 49, No. 28; July 12, 2024
(a) For claims with
				  dates of injury prior to September 1, 2011 (for the purposes of this section,
				  referred to as "legacy claims"), the open formulary as described in §
										134.500(9)
				  of this title (relating to Definitions) remains in effect until those claims
				  become subject to the closed formulary in accordance with §
										134.510
				  of this title (relating to Transition to the Use of the Closed Formulary for
				  Claims with Dates of Injury Prior to September 1, 2011).
(b) Health care, including a prescription
				  drug, for legacy claims not subject to a certified network shall be in
				  accordance with the division's adopted treatment guidelines under §
										137.100 of
				  this title (relating to Treatment Guidelines) except as provided by subsections
				  (d) and (f) of this section.
(c)
				  Health care, including a prescription drug, for legacy claims subject to a
				  certified network shall be in accordance with the certified network's treatment
				  guidelines pursuant to Insurance Code Chapter 1305 and Chapter 10 of this title
				  (relating to Workers' Compensation Health Care Networks).
(d) Drugs included in the open formulary
				  prescribed and dispensed for legacy claims not subject to a certified network
				  do not require preauthorization, except as required by Labor Code §
										413.014.
(e) Drugs included in the open formulary
				  prescribed and dispensed for legacy claims subject to a certified network shall
				  be preauthorized in accordance with Insurance Code Chapter 1305 and Chapter 10
				  of this title.
(f) Drugs included
				  in the open formulary that do not require preauthorization under subsections
				  (d) and (e) of this section and are prescribed and dispensed for legacy claims
				  are subject to retrospective review of medical necessity and reasonableness of
				  health care by the insurance carrier.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter F - PHARMACEUTICAL BENEFITS › Section 134.510 - Transition to the Use of the Closed Formulary for Claims with Dates of Injury Prior to September 1, 2011

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Applicability. This section applies to claims with dates of injury prior to
				  September 1, 2011 (for the purposes of this section, referred to as "legacy
				  claims"), which are subject to §
										134.530
				  of this title (relating to Requirements for Use of the Closed Formulary for
				  Claims Not Subject to Certified Networks), §
										134.540
				  of this title (relating to Requirements for Use of the Closed Formulary for
				  Claims Subject to Certified Networks), and §
										134.550
				  of this title (relating to Medical Interlocutory Order) on and after September
				  1, 2013.
(b) Transition of legacy
				  claims.
(1) At any time after September 1,
				  2011 and prior to September 1, 2013:
(A) The
				  prescribing doctor should include a statement of medical necessity as defined
				  in §
												134.500(13)
				  of this title (relating to Definitions) with the prescription for drugs
				  excluded from the closed formulary.
(B) The prescribing doctor or the insurance
				  carrier may contact each other for a discussion of ongoing pharmacological
				  management of the injured employee's claim.
(C) When a prescribing doctor or insurance
				  carrier is contacted by the other party regarding ongoing pharmacological
				  management, the parties must provide each other a name, phone number, and date
				  and time to discuss ongoing pharmacological management of the injured
				  employee's claim.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter F - PHARMACEUTICAL BENEFITS › Section 134.520 - Outpatient Closed Formulary for Dates of Injury On or After September 1, 2011

Current through Reg. 49, No. 28; July 12, 2024
The Commissioner of Workers' Compensation hereby adopts a
					 closed formulary as defined in §
										134.500(3)
					 of this title (relating to Definitions) for claims with dates of injury on or
					 after September 1, 2011.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter F - PHARMACEUTICAL BENEFITS › Section 134.530 - Requirements for Use of the Closed Formulary for Claims Not Subject to Certified Networks

Current through Reg. 49, No. 28; July 12, 2024
(a) Applicability.
				  The closed formulary applies to all drugs that are prescribed and dispensed for
				  outpatient use for claims not subject to a certified network on or after
				  September 1, 2011 when the date of injury occurred on or after September 1,
				  2011.
(b) Preauthorization for
				  claims subject to the Division's closed formulary.
(1) Preauthorization is only required for:
(A) drugs identified with a status of "N" in
				  the current edition of the
ODG Treatment in Workers' Comp
(ODG) / Appendix A,
ODG Workers' Compensation Drug Formulary,
and any updates;
(B) any
				  prescription drug created through compounding prescribed before July 1, 2018
				  that contains a drug identified with a status of "N" in the current edition of
				  the ODG Treatment in Workers' Comp (ODG) / Appendix A, ODG Workers'
				  Compensation Drug Formulary, and any updates;
(C) any prescription drug created through
				  compounding prescribed and dispensed on or after July 1, 2018; and
(D) any investigational or experimental drug
				  for which there is early, developing scientific or clinical evidence
				  demonstrating the potential efficacy of the treatment, but which is not yet
				  broadly accepted as the prevailing standard of care as defined in Labor Code
				  §
												413.014(a).
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter F - PHARMACEUTICAL BENEFITS › Section 134.540 - Requirements for Use of the Closed Formulary for Claims Subject to Certified Networks

Current through Reg. 49, No. 28; July 12, 2024
(a) Applicability.
				  The closed formulary applies to all drugs that are prescribed and dispensed for
				  outpatient use for claims subject to a certified network on or after September
				  1, 2011 when the date of injury occurred on or after September 1,
				  2011.
(b) Preauthorization for
				  claims subject to the Division's closed formulary. Preauthorization is only
				  required for:
(1) drugs identified with a
				  status of "N" in the current edition of the
ODG Treatment in Workers'
				  Comp
(ODG) / Appendix A,
ODG Workers' Compensation Drug
				  Formulary,
and any updates;
(2) any prescription drug created through
				  compounding prescribed before July 1, 2018 that contains a drug identified with
				  a status of "N" in the current edition of the
ODG Treatment in Workers'
				  Comp
(ODG) / Appendix A,
ODG Workers' Compensation Drug
				  Formulary,
and any updates;
(3) any prescription drug created through
				  compounding prescribed and dispensed on or after July 1, 2018; and
(4) any investigational or experimental drug
				  for which there is early, developing scientific or clinical evidence
				  demonstrating the potential efficacy of the treatment, but which is not yet
				  broadly accepted as the prevailing standard of care as defined in Labor Code
				  §
											413.014(a).
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter F - PHARMACEUTICAL BENEFITS › Section 134.550 - Medical Interlocutory Order

Current through Reg. 49, No. 28; July 12, 2024
(a) The
				  purpose of this section is to provide a prescribing doctor or pharmacy an
				  ability to obtain an medical interlocutory order (MIO) in instances where
				  preauthorization denials of a previously prescribed and dispensed drug(s)
				  excluded from the closed formulary poses an unreasonable risk of a medical
				  emergency as defined in §
										134.500(7)
				  of this title (relating to Definitions) and Insurance Code §
										1305.004(a)(13).
(b) A request for an interlocutory order that
				  does not meet the criteria described by this section may still be requested
				  pursuant to §
										133.306
				  of this title (relating to Interlocutory Order for Medical Benefits).
(c) An MIO will be issued if the request for
				  an MIO contains the following information:
(1)
				  injured employee name;
(2) date of
				  birth of injured employee;
(3)
				  prescribing doctor's name;
(4) name
				  of drug and dosage;
(5) MIO
				  requestor's name (pharmacy or prescribing doctor);
(6) MIO requestor's contact
				  information;
(7) a statement that a
				  preauthorization request for a previously prescribed and dispensed drug(s),
				  which is excluded from the closed formulary, has been denied by the insurance
				  carrier;
(8) a statement that an
				  independent review request has already been submitted to the insurance carrier
				  or the insurance carrier's utilization review agent in accordance with §
											133.308
				  of this title (relating to MDR by Independent Review Organizations);
(9) a statement that the preauthorization
				  denial poses an unreasonable risk of a medical emergency as defined in §
											134.500(7)
				  of this title;
(10) a statement
				  that the potential medical emergency has been documented in the
				  preauthorization process;
(11) a
				  statement that the insurance carrier has been notified that a request for an
				  MIO is being submitted to the division; and
(12) a signature and the following
				  certification by the MIO requestor for paragraphs (7) - (12) of this
				  subsection, "I hereby certify under penalty of law that the previously listed
				  conditions have been met."
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter I - MEDICAL BILL REPORTING › Section 134.800 - Applicability

Current through Reg. 49, No. 28; July 12, 2024
(a) This subchapter applies to all insurance
				  carriers as defined in Labor Code §
										401.011(27),
				  including insurance carriers that have contracted with or established a
				  workers' compensation health care network as defined in Labor Code §
										401.011(31-a)
				  and insurance carriers that provide medical benefits in a manner authorized by
				  Labor Code §
										504.053(b)(2).
				  All insurance carriers are required to report information prescribed by the
				  commissioner under Labor Code §
										413.007
				  and §
										413.008
				  for each medical bill on a workers' compensation claim.
(b) This section is effective September 1,
				  2011. Insurance carriers and trading partners may submit medical EDI records in
				  accordance with this subchapter prior to this effective date.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter I - MEDICAL BILL REPORTING › Section 134.801 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
(a) The purpose of this subchapter is to
				  prescribe the reporting requirements for information and data submitted to the
				  division and to adopt by reference the implementation guide and specifications
				  necessary for successful electronic data interchange transaction processing.
				  The reporting of information and data is necessary to maintain a statewide data
				  base of medical charges, actual payments, and treatment protocols pursuant to
				  Labor Code §
										413.007
				  and §
										413.008.
(b) This section is effective September 1,
				  2011.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter I - MEDICAL BILL REPORTING › Section 134.802 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
(a) The following words and terms, when used
				  in this subchapter, shall have the following meaning, 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 Adjustment Reason Code (CARC)--A
				  code that is used on a medical EDI record and an explanation of benefits to
				  communicate why the amount paid for a medical bill or service line does not
				  equal the amount charged. The term is synonymous with service adjustment reason
				  code in the IAIABC EDI Implementation Guide for Medical Bill Payment Records,
				  Release 1.0, dated July 4, 2002.
(3) Claim Administrator Claim Number--An
				  identifier that distinguishes a specific claim within a claim administrator's
				  claim processing system and is used throughout the life of the claim.
(4) Division--The Texas Department of
				  Insurance, Division of Workers' Compensation or its data collection
				  agent.
(5) EDI--Electronic data
				  interchange.
(6) Element
				  Requirement Table--A receiver specific list of requirement codes for each data
				  element depending on the bill submission reason code.
(7) IAIABC--The International Association of
				  Industrial Accident Boards and Commissions.
(8) Medical EDI Record--The accurate data
				  associated with a single medical bill which is being reported in a Medical EDI
				  Transaction obtained from all sources, including the medical bill, explanation
				  of benefits, and insurance carrier's claim file.
(9) Medical EDI Transmission--The data that
				  is contained within the interchange envelope.
(10) Medical EDI Transaction--The data that
				  is contained within the functional group.
(11) Person--An individual, 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 that has entered into an agreement with the insurance carrier to format
				  electronic data for transmission to the division, transmits electronic data to
				  the division, and responds to any technical issues related to the contents or
				  structure of an EDI file.
(13)
				  W3--A Texas-specific claim adjustment reason code to designate the medical EDI
				  record as a reconsideration or appeal.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter I - MEDICAL BILL REPORTING › Section 134.803 - 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 Medical Bill Payment Records, Release 1.0, dated
				  July 4, 2002 (IAIABC Guide) published by the IAIABC.
(b) The commissioner adopts by reference the
Texas EDI Medical Data Element Requirement Table,
Version 2.0,
				  dated September 2015, the
Texas EDI Medical Data Element Edits
				  Table,
Version 2.0, dated September 2015, and the
Texas EDI
				  Medical Difference Table,
Version 3.0, dated September 2015. All
				  tables are published by the division.
(c) The adopted division tables may be found
				  on the division's website:
				  http://www.tdi.texas.gov/wc/edi/index.html.
(d) In the event of a conflict between the
				  IAIABC Guide and the Labor Code or division rules, the Labor Code or division
				  rules shall prevail.
(e) This
				  section is effective September 1, 2015.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter I - MEDICAL BILL REPORTING › Section 134.805 - Records Required to be Reported

Current through Reg. 49, No. 28; July 12, 2024
(a) Insurance
				  carriers shall submit medical EDI records when the insurance carrier:
(1) pays a medical bill;
(2) reduces or denies payment for a medical
				  bill, including duplicate bills;
(3) receives a refund for a medical
				  bill;
(4) discovers that a medical
				  EDI record should not have been submitted to the division and the medical EDI
				  record had previously been accepted by the division;
(5) reimburses an injured employee for health
				  care paid in accordance with §133.270; or
(6) reimburses an employer for health care
				  paid in accordance with §133.280.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter I - MEDICAL BILL REPORTING › Section 134.806 - Records Excluded from Reporting

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Insurance carriers shall not report medical EDI records for health care
				  services:
(1) rendered outside the United
				  States;
(2) related to dates of
				  injury before January 1, 1991;
(3)
				  rendered at a Federal health care facility and the health care facility does
				  not provide the insurance carrier with the data required to be
				  reported;
(4) related to an injured
				  employee's travel reimbursement as provided in §
											134.110
				  of this title (relating to Reimbursement of Injured Employee for Travel
				  Expenses Incurred); or
(5) related
				  to a request for reimbursement by a health care insurer in accordance with the
				  provisions of Labor Code §
											409.0091.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter I - MEDICAL BILL REPORTING › Section 134.807 - State Specific Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) A medical
				  EDI transmission shall not exceed a file size of 1.5 megabytes. A transaction
				  set shall not contain more than 100 medical EDI records in a claimant
				  hierarchical loop.
(b) Insurance
				  carriers shall submit medical EDI transactions using Secure File Transfer
				  Protocol (SFTP). All alphabetic characters used in the SFTP file name must be
				  lower case and the file must be compressed/zipped. Files that do not comply
				  with these requirements or the naming convention may be rejected and placed in
				  appropriate failure folders. Insurance carriers must monitor these folders for
				  file failures and make corrections in accordance with §
										134.804(e)
				  of this title (relating to Reporting Requirements).
(c) SFTP files must comply with the following
				  naming convention:
(1) Two digit alphanumeric
				  state indicator of 'tx';
(2) Nine
				  digit trading partner Federal Employer Identification Number (FEIN);
(3) Nine digit trading partner postal
				  code;
(4) Nine digit insurance
				  carrier FEIN or 'xxxxxxxxx' if the file contains medical EDI transactions from
				  different insurance carriers;
(5)
				  Three digit record type '837';
(6)
				  One character Test/Production indicator ('t' or 'p');
(7) Eight digit date file sent
				  'CCYYMMDD';
(8) Six digit time file
				  sent 'HHMMSS';
(9) One character
				  standard extension delimiter of '.'; and
(10) Three digit alphanumeric standard file
				  extension of 'zip' or 'txt'.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter I - MEDICAL BILL REPORTING › Section 134.808 - Insurance Carrier EDI Compliance Coordinator and Trading Partners

Current through Reg. 49, No. 28; July 12, 2024
(a) Insurance carriers may submit medical EDI
				  records directly to the division or may 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 individual to the division
				  as the EDI Compliance Coordinator and provide the individual'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 a centrally-located employee of the
				  insurance carrier who has the responsibility 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 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter J - REVIEWS AND AUDITS › Section 134.900 - Medical Benefit Review and Audit

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  The division of medical review (the division) shall review and audit medical
				  services, to include, but not be limited to:
(1) treatments administered;
(2) services provided;
(3) fees charged;
(4) payments made for medical treatment or
				  services provided to injured employees; and
(5) compliance with other commission rules
				  regulating health care.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 136 - BENEFITS - VOCATIONAL REHABILITATION › Section 136.1 - Review of Employer Report of Injury

Current through Reg. 49, No. 28; July 12, 2024
(a) The division shall analyze each employer
				report of injury, within 30 days of its receipt, for any information indicating
				that the injured employee had or is likely to have:
(1) an amputation of:
(A) an arm or leg;
(B) three fingers or more; or
(C) the large toe or one-third of the foot or
				more;
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 137 - DISABILITY MANAGEMENT › Subchapter A - GENERAL PROVISIONS › Section 137.1 - Disability Management Concept

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Disability management is a process designed to optimize health care and return
				  to work outcomes for injured employees to avoid delayed recovery in the Texas
				  Workers' Compensation System.
(b)
				  This chapter is designed to provide disability management tools, such as
				  treatment and return to work guidelines, treatment protocols, treatment
				  planning, and case management to benchmark, manage, and achieve improved
				  outcomes. The Division may use these tools for the following purposes,
				  including, but not limited to:
(1) resolving
				  income benefit disputes;
(2)
				  resolving medical benefit disputes;
(3) establishing performance-based
				  tiers;
(4) defining
				  performance-based incentives;
(5)
				  determining sanctions or penalties;
(6) performing medical quality reviews;
				  or
(7) assessing other matters
				  deemed appropriate by the Commissioner of Workers' Compensation.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 137 - DISABILITY MANAGEMENT › Subchapter A - GENERAL PROVISIONS › Section 137.5 - Case Manager Certification

Current through Reg. 49, No. 28; July 12, 2024
(a) This
				  section applies to all case management services as defined by Labor Code §
										401.011(5-a)
				  that are provided under Labor Code Title 5 to injured employees by an insurance
				  carrier on or after September 1, 2011.
(b) This section does not apply to case
				  management services:
(1) subject to Insurance
				  Code Chapter 1305;
(2) subject to
				  Labor Code §
											504.053(b)(2);
				  or
(3) of a health care provider
				  subject to §
											134.204
				  of this title (relating to Medical Fee Guideline for Workers' Compensation
				  Specific Services).
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 137 - DISABILITY MANAGEMENT › Subchapter B - RETURN TO WORK › Section 137.10 - Return to Work Guidelines

Current through Reg. 49, No. 28; July 12, 2024
(a) Insurance
				  carriers, health care providers, and employers shall use the disability
				  duration values in the current edition of
The Medical Disability
				  Advisor, Workplace Guidelines for Disability Duration,
excluding all
				  sections and tables relating to rehabilitation, (MDA), published by the Reed
				  Group, Ltd. (Division return to work guidelines), as guidelines for the
				  evaluation of expected or average return to work time frames.
(b) Information on how to obtain or inspect
				  copies of the Division return to work guidelines may be found on the Division's
				  website:
www.tdi.state.tx.us.
(c) The Division return to work guidelines
				  provide disability duration expectancies. The Division return to work
				  guidelines shall be presumed to be a reasonable length of disability duration
				  and shall be used by:
(1) health care
				  providers to establish return to work goals or a return to work plan for safely
				  returning injured employees to medically appropriate work
				  environments;
(2) insurance
				  carriers as a basis for requesting a designated doctor examination to resolve
				  an issue regarding an injured employee's ability to return to work as well as a
				  basis to initiate case management and to refer an injured employee to
				  vocational rehabilitation providers; and
(3) employers, insurance carriers, health
				  care providers, and injured employees to facilitate and improve communications
				  among the parties regarding the return to work goals or plans established by
				  health care providers.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 137 - DISABILITY MANAGEMENT › Subchapter B - RETURN TO WORK › Section 137.41 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
The purpose of §§ 137.41-
					 137.51
					 of this title (relating to Disability Management) is to set forth the terms,
					 conditions, and requirements for the return-to-work reimbursement program for
					 employers.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 137 - DISABILITY MANAGEMENT › Subchapter B - RETURN TO WORK › Section 137.42 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms shall have the following
					 meanings only for the purposes of the return-to-work reimbursement program for
					 employers:
(1) Allowable expense--An
				  expenditure of funds, costs incurred, or costs that will be incurred by an
				  eligible employer for workplace modifications or other costs that are necessary
				  to reasonably assist an injured employee's doctor-identified restrictions that
				  are intended to facilitate the early and sustained return to work of an
				  employee who has a compensable injury. An indemnity benefit, medical benefit,
				  or health care for which an insurance carrier is liable is not an allowable
				  expense under the program.
(2)
				  Applicant--The employer requesting funds from the return-to-work reimbursement
				  program.
(3) Application--The
				  return-to-work reimbursement program application provided by the division for
				  reimbursement, preauthorization, or advancement of funds used or proposed to be
				  used by employers for workplace modifications.
(4) Alternative duty--Job duties that are
				  different from the injured employee's normal or regular pre-injury job duties
				  and that are assigned specifically to facilitate the injured employee's
				  doctor-identified work restrictions or limitations.
(5) Eligible employer--Any employer that:
(A) is not a state agency or political
				  subdivision of the state;
(B)
				  employed at least two but not more than 50 employees on each business day
				  during the preceding calendar year; and
(C) has workers' compensation insurance
				  coverage in Texas.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 137 - DISABILITY MANAGEMENT › Subchapter B - RETURN TO WORK › Section 137.43 - Return-to-Work Reimbursement Program Administrator

Current through Reg. 49, No. 28; July 12, 2024
The Commissioner of Workers' Compensation shall appoint a
					 qualified employee of the Texas Department of Insurance, Division of Workers'
					 Compensation to serve as the return-to-work reimbursement program administrator
					 to implement the provisions of this subchapter.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 137 - DISABILITY MANAGEMENT › Subchapter B - RETURN TO WORK › Section 137.44 - Return-to-Work Reimbursement Program for Employers

Current through Reg. 49, No. 28; July 12, 2024
(a) Disbursements of funds for the program
				  are dependent on the availability of funds identified by the
				  division.
(b) The disbursement that
				  any single employer may receive from the program may not exceed $5,000 for all
				  workplace modification expenditures made during the state appropriation year
				  for all injured employees.
(c)
				  Disbursements from the program to approved eligible employers shall be made on
				  a reimbursement basis, or at the discretion of the commissioner or the
				  commissioner's designee on an advancement basis, subject to verification of
				  employer eligibility, receipts and expenditures, workplace modifications, the
				  employee's return to work, approval of the employer's application, and any
				  other requirements listed in §§
										137.45-
				  137.50
				  of this title (relating to the Return-to-Work Reimbursement Program).
(d) Applications shall be processed in the
				  order that completed applications are received by the division.
(e) Approved applications shall be funded
				  from the program as funds become available.
(f) Applications may be denied in whole or in
				  part due to the lack of available funds for the program or if the division
				  determines that all or part of the application does not meet the requirements
				  listed in §§
										137.45-
				  137.50
				  of this title.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 137 - DISABILITY MANAGEMENT › Subchapter B - RETURN TO WORK › Section 137.45 - Employer Eligibility for Disbursements from the Return-to-Work Reimbursement Program

Current through Reg. 49, No. 28; July 12, 2024
(a) In order to be
				  eligible to receive a disbursement from the program, an employer must:
(1) be an eligible employer that has incurred
				  or will incur an allowable expense;
(2) have Texas workers' compensation
				  insurance coverage in effect on the date the employee is injured and be able to
				  provide proof of coverage;
(3)
				  submit an application for funds from the program;
(4) timely provide any additional or
				  supplemental information to the administrator that may be deemed necessary by
				  the division; and
(5) the
				  application must be approved by the division.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 137 - DISABILITY MANAGEMENT › Subchapter B - RETURN TO WORK › Section 137.46 - Application for Funds from the Return-to-Work Reimbursement Program

Current through Reg. 49, No. 28; July 12, 2024
(a) An eligible employer seeking funds from
				  the program shall submit to the division an application as defined in §
										137.42 of
				  this title (relating to Definitions).
(b) Applications shall be available on the
				  division's website (www.tdi.state.tx.us/wc) and through the division. Upon
				  request, the division shall provide an application form to an
				  employer.
(c) Applications shall be
				  submitted to the division in the form prescribed by the division and must meet
				  the minimum requirements provided in §
										137.47
				  of this title (relating to the Criteria for Return-to-Work Reimbursement
				  Program Applications).
(d) The date
				  the completed application is received by the division shall be the official
				  date for purposes of processing the application. An application shall not be
				  processed for approval until all required or requested documentation has been
				  received by the division and any other applicable requirements listed on the
				  application have been met.
(e) An
				  application that has information missing or that does not include the
				  information described in §
										137.47
				  of this title, receipts, or other documentation necessary to support the
				  application and to justify the workplace modification may be returned to the
				  employer for completion, documentation supplementation, or the application may
				  be denied.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 137 - DISABILITY MANAGEMENT › Subchapter B - RETURN TO WORK › Section 137.47 - Criteria for Return-to-Work Reimbursement Program Applications

Current through Reg. 49, No. 28; July 12, 2024
In order to be processed and approved by the division an
					 application must contain at a minimum:
(1) The date the employee returned to work or
				  will return to work, and the injured employee's name, date of injury, and Texas
				  Department of Insurance, Division of Workers' Compensation claim
				  number.
(2) An employer's statement
				  or certification that the injured employee returned to work or will return to
				  work in either a modified or alternative duty capacity.
(3) An employer's statement or certification
				  that the employer was able or will be able to sustain the employment of the
				  injured employee as a result of the workplace modification.
(4) A copy of the division's "Work Status
				  Report" as provided by §
										129.5 of this
				  title (relating to Work Status Reports) from the injured employee's doctor that
				  specifies the injured employee's physical restrictions or limitations, which
				  necessitated the provision of a workplace modification in order for the
				  employee to return to work in a modified or alternative duty capacity and
				  additional documentation, if any.
(5) A detailed description of the workplace
				  modification, including any supporting information such as receipts, photos or
				  diagrams of the modification, and how the modification facilitates the
				  doctor-identified physical restrictions or limitations.
(6) Documentation of the expenses, including
				  receipts, that provided the workplace modification or other costs necessary to
				  facilitate the injured employee's return to work or the estimated costs in
				  making those proposed workplace modifications.
(7) A signature by the employer or the
				  employer's authorized representative.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 137 - DISABILITY MANAGEMENT › Subchapter B - RETURN TO WORK › Section 137.48 - Return-to-Work Reimbursement Program Administrator Determinations

Current through Reg. 49, No. 28; July 12, 2024
(a) The administrator shall make
				  determinations regarding the following:
(1)
				  the employer's eligibility to participate in the program;
(2) the appropriateness of the workplace
				  modification in facilitating the injured employee's return to work based on
				  doctor-identified restrictions;
(3)
				  the effectiveness of the workplace modification in facilitating the injured
				  employee's early and sustained return to work;
(4) the cost of the workplace modification in
				  relation to usual and customary costs of the same or similar modification;
				  and
(5) the appropriateness of
				  other costs incurred or to be incurred by the employer to return the injured
				  employee to work in a modified or alternative duty capacity.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 137 - DISABILITY MANAGEMENT › Subchapter B - RETURN TO WORK › Section 137.49 - Optional Preauthorization Plan

Current through Reg. 49, No. 28; July 12, 2024
(a) An
				  eligible employer, as provided by §
										137.45
				  of this title (relating to Employer Eligibility for Disbursements from the
				  Return-to-Work Reimbursement Program), who participates in the return-to-work
				  reimbursement program for employers may apply to the division for a
				  preauthorized reimbursement of allowable expenses from the program prior to
				  making workplace modifications designed to accommodate an injured employee's
				  return to work.
(b) To apply for a
				  preauthorized reimbursement of allowable expenses, an eligible employer must
				  submit to the division a properly completed application as provided in §
										137.47
				  of this title (relating to the Criteria for Return-to-Work Reimbursement
				  Program Applications). The application may be obtained from the division as
				  provided by §
										137.46
				  of this title (relating to the Application for Funds from the Return-to-Work
				  Reimbursement Program).
(c)
				  Applications will be reviewed in accordance with §
										137.48
				  of this title (relating to Return-to-Work Reimbursement Program Administrator
				  Determinations).
(d) Upon receipt
				  of division approval of the application, the employer may begin all approved
				  workplace modifications set out in the approved application. Upon completion of
				  the approved workplace modifications, the employer may obtain reimbursement
				  from the program by submitting to the division sufficient documentation and
				  receipts to show that the approved workplace modification has been
				  completed.
(e) Upon receipt of the
				  information described in subsection (d) of this section and subject to §
										137.44
				  of this title (relating to the Return-to-Work Reimbursement Program for
				  Employers), the division shall reimburse the employer the costs incurred by the
				  employer in making the approved workplace modifications unless the division
				  determines that the modifications differ materially from the employer's
				  application.
(f) Release of funds
				  are subject to §
										137.45(c)
				  of this title.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 137 - DISABILITY MANAGEMENT › Subchapter B - RETURN TO WORK › Section 137.50 - Optional Advance of Funds Plan

Current through Reg. 49, No. 28; July 12, 2024
(a) An
				  eligible employer, as provided by §
										137.45
				  of this title (relating to Employer Eligibility for Disbursements from the
				  Return-to-Work Reimbursement Program), who participates in the return-to-work
				  reimbursement program for employers may apply to the division for an advance of
				  funds for allowable expenses from the program prior to making workplace
				  modifications designed to accommodate an injured employee's return to
				  work.
(b) To apply for an advance
				  of funds for allowable expenses, an eligible employer must submit to the
				  division a properly completed application as provided in §
										137.47
				  of this title (relating to the Criteria for Return-to-Work Reimbursement
				  Program Applications). The application may be obtained from the division as
				  provided by §
										137.46
				  of this title (relating to the Application for Funds from the Return-to-Work
				  Reimbursement Program).
(c)
				  Applications will be reviewed in accordance with §
										137.48
				  of this title (relating to Return-to-Work Reimbursement Program Administrator
				  Determinations).
(d) Upon receipt
				  of a completed application and subject to §
										137.44
				  of this title (relating to the Return-to-Work Reimbursement Program for
				  Employers), the division may advance funds to the employer to make approved
				  workplace modifications. The employer shall not make workplace modifications
				  that materially differ from the employer's approved application unless the
				  employer receives written approval from the division for the materially
				  different modifications.
(e) Upon
				  the receipt of the advanced funds from the division, the employer shall
				  complete all approved workplace modifications set out in the approved
				  application within six months of receiving funds from the division. For good
				  cause, the division or the administrator may extend this six-month requirement.
				  Any extension of time for completing workplace modifications must be granted by
				  the division in writing and for a determinable period of time.
(f) Upon completion of the approved workplace
				  modifications, the employer shall submit to the division all receipts for the
				  payments made by the employer for the approved modifications. Any funds not
				  spent after the six-month time frame must be immediately returned to the
				  division.
(g) Release of funds are
				  subject to §
										137.45(c)
				  of this title.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 137 - DISABILITY MANAGEMENT › Subchapter B - RETURN TO WORK › Section 137.51 - Monitoring and Enforcement

Current through Reg. 49, No. 28; July 12, 2024
(a) Once an
				  application is submitted, the commissioner or the commissioner's designated
				  representative(s), including the administrator, may inspect the applicant's
				  business to insure that the funds have been or will be spent according to what
				  was or could be authorized. The commissioner or the commissioner's designated
				  representative(s), including the administrator, are authorized to make a
				  complete on-site review of the operations of each applicant at the place of
				  business where the workplace modification has been or will be made, as often as
				  is deemed necessary.
(b) At a
				  minimum, notice of an on-site inspection shall be in writing and be presented
				  by the commissioner or the commissioner's designated representative(s),
				  including the administrator, upon arrival. On-site inspections shall not be
				  conducted during legal holidays as defined in the Government Code §
										662.003(a).
(c) During an on-site review or upon written
				  request of the commissioner or the commissioner's designated representative(s),
				  including the administrator, the applicant shall make available all records
				  relating to the requested or spent funds. Employers must maintain all relevant
				  records for at least one year from the date of disbursement from the
				  division.
(d) An employer commits
				  an administrative violation if any part of the reimbursed or advanced funds are
				  not used for the purpose or in the manner that the division previously approved
				  in writing. Any unused funds must be returned to the division within six months
				  of disbursement and any funds that are used not in accordance with the plan
				  approved by the division must be immediately returned to the
				  division.