Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 126 - GENERAL PROVISIONS APPLICABLE TO ALL BENEFITS › Section 126.5 - Entitlement and Procedure for Requesting Required Medical Examinations

Current through Reg. 49, No. 28; July 12, 2024
(a) A doctor who has contracted with or is
				employed by an authorized workers' compensation health care network established
				under Insurance Code Chapter 1305, (network doctor) may not perform a required
				medical examination, as those terms are used under the Texas Workers'
				Compensation Act (the Act), for an employee receiving medical care through the
				same network. It is the responsibility of the requesting party to ensure the
				doctor selected does not have a disqualifying association.
(b) The Division may authorize a required
				medical examination (RME) for any reason set forth in the Act, Texas Labor Code
				§
									408.004,
				§
									408.0041,
				or §
									408.151
				at the request of the insurance carrier (carrier). The request shall be made in
				the form and manner prescribed by the Division. A carrier is not entitled to
				take action with respect to benefits based on, and the Division shall not
				consider, a report of an RME doctor that was not approved or obtained in
				accordance with this section.
(c)
				Carriers are entitled to RMEs by a doctor of their choice in accordance with
				this subsection as follows:
(1) Pursuant to
				Texas Labor Code §
										408.004,
				once every 180 days, to resolve any questions about the appropriateness of the
				health care received by the injured employee (employee). The carrier's first
				RME may be requested at any time after the date of injury. A subsequent
				examination may be requested once every 180 days after the first examination
				and must be performed by the same doctor unless otherwise approved by the
				Division. This paragraph only applies to requests for required medical
				examinations of employees not receiving medical treatment through an authorized
				workers' compensation health care network.
(2) For the purpose of evaluating a
				designated doctor's determination on the issues listed under Labor Code §
										408.0041,
				a carrier is entitled to an examination under this subsection only after a
				Designated Doctor exam under § 126.7 of this title (relating to Designated
				Doctor Examinations: Requests and General Procedures).
(3) For the purpose of evaluating a
				designated doctor's determination pursuant to Texas Labor Code §
										408.151,
				to determine if the employee's medical condition resulting from the compensable
				injury has improved sufficiently to allow the employee to return to work. For
				the purposes of this paragraph, the carrier may not require an employee to
				submit to an RME more than once per year if:
(A) an employee is receiving supplemental
				income benefits on or after the second anniversary of the date of the
				employee's initial entitlement to supplemental income benefits, and
(B) in the year preceding the request for the
				RME, the employee's medical condition resulting from the compensable injury had
				not improved sufficiently to allow the employee to return to work during that
				year.