Current through Reg. 49, No. 38; September 20, 2024
(a) An insurance carrier may request:
(1) reimbursement from the Subsequent Injury
Fund (SIF) under Labor Code §
403.006(b)(2)
for an overpayment of income, death, or medical benefits when the insurance
carrier has made an unrecoupable overpayment pursuant to the decision of an
administrative law judge, the Appeals Panel, or an interlocutory order, and
that decision or order is reversed or modified by final arbitration, order, or
decision of the commissioner, State Office of Administrative Hearings, or a
court of last resort;
(2)
reimbursement from the SIF under Labor Code §
403.007(d)
for death benefits paid to the SIF before a legal beneficiary was determined to
be entitled to receive death benefits;
(3) for a compensable injury that occurs on
or after July 1, 2002, reimbursement from the SIF for the amount of income
benefits paid to an injured employee based on multiple employment and paid
under Labor Code §
408.042;
(4) for a compensable injury that occurs on
or after September 1, 2007, reimbursement from the SIF for the amount of
income, death benefits, or a combination paid to an injured employee or a legal
beneficiary based on multiple employment and paid under Labor Code §
408.042;
(5) reimbursement from the SIF, under Labor
Code §
408.0041(f) and
(f-1), for an overpayment of benefits made by
the insurance carrier based on the opinion of the designated doctor if that
opinion is reversed or modified by a final arbitration award or a final order
or decision of the commissioner or a court; or
(6) reimbursement from the SIF made in
accordance with rules adopted by the commissioner under Labor Code §
413.0141. For purposes of
this subsection only, an injury is determined not to be compensable following:
(A) The final decision of the commissioner or
the judgment of the court of last resort; or
(B) A claimant's failure to respond within
one year of a timely dispute of compensability filed by an insurance carrier.
In this instance only, the effective date of the determination of
noncompensability is one year from the date the insurance carrier filed the
dispute with the division.
(i) A
determination under this paragraph does not constitute final adjudication. It
does not preclude a party from pursuing their claim through the division's
dispute resolution process, and it does not permit a health care provider to
pursue a private claim against the claimant.
(ii) If the claim is later determined to be
compensable, the insurance carrier must reimburse the SIF for any initial
pharmaceutical payment that the SIF previously reimbursed to the insurance
carrier. The insurance carrier's reimbursement of the SIF must be paid within
the timeframe the insurance carrier has to comply with the agreement, decision
and order, or other judgment that found the claim to be compensable.
(b) The
amount of reimbursement the insurance carrier may be entitled to is equal to
the amount of unrecoupable overpayments paid and does not include any amounts
the insurance carrier overpaid voluntarily or as a result of its own errors. An
unrecoupable overpayment of income or death benefits for the purpose of
reimbursement from the SIF only includes those benefits that were overpaid by
the insurance carrier pursuant to an interlocutory order, a designated doctor's
opinion, or a decision, which were finally determined to be not owed and which,
in the case of an overpayment of income or death benefits to the injured
employee or legal beneficiary, were not recoverable or convertible from other
income or death benefits.
(c) To
request reimbursement under subsection (a)(1) of this section for insurance
carrier claims of benefit overpayments made under an interlocutory order or
decision of the commissioner that is later reversed or modified by final
arbitration, order, decision of the commissioner, the State Office of
Administrative Hearings, or court of last resort, an insurance carrier must:
(1) submit the request electronically in the
form and manner prescribed by the division;
(2) provide a claim-specific summary of the
reason the insurance carrier is seeking reimbursement and the total amount of
reimbursement requested, including how it was calculated;
(3) provide a detailed payment record showing
the dates and amounts of the payments, payees, type of benefits and periods of
benefits paid, all plain language notices (PLNs) about the payment of benefits,
all certifications of maximum medical improvement and assignments of impairment
rating, and documentation that shows the overpayment was unrecoupable as
described in subsection (b) of this section, if applicable;
(4) provide the name, address, and federal
employer identification number of the payee (insurance carrier) for any
reimbursement that may be due;
(5)
provide copies of all relevant orders and decisions (benefit review conference
reports, interlocutory orders, contested case hearing decisions and orders,
Appeals Panel decisions, and court orders) relating to the requested
reimbursement and show which document is the final decision on the
matter;
(6) provide copies of all
relevant reports and DWC forms the employer filed with the insurance carrier;
and
(7) provide copies of all
medical bills, preauthorization request documents, relevant independent review
organization (IRO) decisions, medical fee dispute decisions, contested case
hearing decisions and orders, Appeals Panel decisions, and court orders on
medical disputes associated with the overpayment, if the request is based on an
overpayment of medical benefits.
(d) To request reimbursement under subsection
(a)(2) of this section for reimbursement of death benefits paid to the SIF
before a legal beneficiary is determined to be entitled to receive death
benefits, an insurance carrier must:
(1)
submit the request electronically in the form and manner prescribed by the
division;
(2) provide a
claim-specific summary of the reason the insurance carrier is seeking
reimbursement and the total amount of reimbursement requested, including how it
was calculated;
(3) provide a
detailed payment record showing the dates and amounts of payments, payees, and
periods of benefits paid;
(4)
provide the name, address, and federal employer identification number of the
payee (insurance carrier) for any reimbursement that may be due;
(5) provide the documentation the legal
beneficiary submitted with the claim for death benefits under §
122.100
of this title (relating to Claim for Death Benefits); and
(6) provide the final award of the
commissioner or the final judgment of a court of competent jurisdiction
determining that the legal beneficiary is entitled to the death
benefits.
(e) To request
reimbursement under subsections (a)(3) or (4) of this section regarding
multiple employment, the requester must submit the request on an annual basis
for the payments made during the same or previous fiscal year. The fiscal year
begins each September 1 and ends on August 31 of the next calendar year. For
example, insurance carrier payments made during the fiscal year from September
1, 2009, through August 31, 2010, must be submitted by August 31, 2011. Any
claims for insurance carrier payments related to multiple employment that are
not submitted within the required timeframe will not be reviewed for
reimbursement. To request reimbursement under subsections (a)(3) or (4) of this
section, an insurance carrier must:
(1)
submit the request electronically in the form and manner prescribed by the
division;
(2) provide a
claim-specific summary of the reason the insurance carrier is seeking
reimbursement and the total amount of reimbursement requested, including how it
was calculated;
(3) provide a
detailed payment record showing the dates and amounts of payments, payees, type
of benefits and periods of benefits paid, all PLNs about the payment of
benefits, and documentation that shows the overpayment was unrecoupable as
described in subsection (b) of this section, if applicable;
(4) provide the name, address, and federal
employer identification number of the payee (insurance carrier) for any
reimbursement that may be due;
(5)
provide information documenting the injured employee's average weekly wage
amounts paid from all nonclaim employment held at the time of the work-related
injury under §
122.5
of this title (relating to Employee's Multiple Employment Wage Statement);
and
(6) provide information
documenting the injured employee's average weekly wage amounts paid based on
employment with the claim employer.
(f) To request reimbursement under subsection
(a)(5) of this section, for insurance carrier claims of benefit overpayments
made pursuant to a designated doctor's opinion that is later reversed or
modified by a final arbitration award or a final order or decision of the
commissioner or a court, an insurance carrier must:
(1) submit the request electronically in the
form and manner prescribed by the division;
(2) provide a claim-specific summary of the
reason the insurance carrier is seeking reimbursement and the total amount of
reimbursement requested, including how it was calculated;
(3) provide a detailed payment record showing
the dates and amounts of payments, payees, type of benefits and periods of
benefits paid, PLNs about the payment of benefits, and all certifications of
maximum medical improvement and assignments of impairment rating;
(4) provide the name, address, and federal
employer identification number of the payee (insurance carrier) for any
reimbursement that may be due;
(5)
provide copies of all relevant designated doctors' opinions (including
responses to letters of clarification) and orders and decisions (IRO decisions,
interlocutory orders, contested case hearing decisions and orders, arbitration
awards, Appeals Panel decisions, and court orders) relating to the designated
doctor's opinion and the payment made pursuant to the designated doctor's
opinion for which reimbursement is being requested, and indicate which document
is the final decision on the matter;
(6) provide copies of all relevant reports
and DWC forms the employer filed with the insurance carrier; and
(7) provide copies of all medical bills and
preauthorization request documents associated with an overpayment of medical
benefits.
(g) To request
reimbursement under subsection (a)(6) of this section regarding initial
pharmaceutical coverage, a requester must submit the request in the same or
following fiscal year after a determination that the injury is not compensable.
The fiscal year begins each September 1 and ends on August 31 of the next
calendar year. For example, if an injury is determined to be not compensable
during the fiscal year from September 1, 2009, through August 31, 2010, the
request for reimbursement under Labor Code §
413.0141 must be submitted
by August 31, 2011. Any claims for insurance carrier payments related to
initial pharmaceutical coverage that are not submitted within the required
timeframe will not be reviewed for reimbursement. An insurance carrier must:
(1) submit the request electronically in the
form and manner prescribed by the division;
(2) provide a claim-specific summary of the
reason the insurance carrier is seeking reimbursement and the total amount of
reimbursement requested;
(3)
provide a detailed payment record showing the dates of payments, including
documentation on dates of payment of initial pharmaceutical coverage (i.e.,
during the first seven days following the date of injury), payment amounts, and
payees;
(4) provide the name,
address, and federal employer identification number of the payee (insurance
carrier) for any reimbursement that may be due;
(5) provide documentation that the
pharmaceutical services were provided during the first seven days following the
date of injury, not counting the actual date the injury occurred, and identify
the prescribed pharmaceutical services; and
(6) provide documentation of:
(A) the final resolution of any dispute
either from the commissioner or court of last resort that determines the injury
is not compensable; or
(B) a
claimant's failure to respond in accordance with subsection (a)(6)(B) of this
section.
(h)
The prescribed forms under this section are on the division's website at
www.tdi.texas.gov/wc/index.html. An insurance carrier seeking reimbursement
from the SIF must timely provide to the SIF administrator by electronic
transmission, as that term is used in §
102.5(h)
of this title (relating to General Rules for Written Communications to and from
the Commission), all forms and documentation reasonably required by the SIF
administrator to determine entitlement to reimbursement or payment from the SIF
and the amount of reimbursement to which the insurance carrier is entitled. The
insurance carrier must also provide notice to the SIF of any relevant pending
dispute, litigation, or other information that may affect the request for
reimbursement.
