Current through Reg. 49, No. 38; September 20, 2024
(a) An insurance
carrier must notify the division and the claimant of actions taken on or events
occurring in a claim as required by this title.
(b) The insurance carrier must electronically
file, as that term is used in §
102.5(e)
of this title (concerning General Rules for Written Communications to and from
the Division), with the division, according to the requirements in Subchapter
B of this title (concerning Insurance Carrier Claim Electronic Data Interchange
Reporting to the Division):
(1) the
information from the original Employer's First Report of Injury; the insurance
carrier's Federal Employer Identification Number (FEIN); and the policy number,
policy effective date, and policy expiration date reported under §
110.1
of this title (concerning Insurance Carrier Requirements for Notifying the
Division of Insurance Coverage) for the employer associated with the claim, not
later than the seventh day after the later of:
(A) receipt of a required report where there
is lost time from work, an occupational disease, or a fatality; or
(B) notification of lost time if the employer
made the Employer's First Report of Injury before the employee experienced
absence from work as a result of the injury;
(2) information about an acquired claim no
later than the 37th day after the acquiring claim administrator has knowledge
of claim-specific information from the previous claim administrator;
(3) any correction of an electronic record
accepted with errors, as provided in §
102.5(e)
of this title (concerning General Rules for Written Communications to and from
the Division), within 30 days of the notification from the division detailed in
§ 124.104(b) of this title (concerning Reporting Requirements);
(4) information about a compensable death
with no beneficiary no later than the 10th day after determining that an
employee whose injury resulted in death had no legal beneficiary; and
(5) a change in an electronic record
initiated by the insurance carrier, the coverage information required by
paragraph (1) of this subsection if not available when the First Report of
Injury was submitted to the division, and any change in a claimant or employer
mailing address within seven days of receiving the new address.
(c) The insurance carrier must
notify the division and the claimant of its denial of a claim based on
noncompensability or lack of coverage in accordance with this section and as
otherwise provided by this title.
(d) The insurance carrier must notify the
division and the claimant of the following:
(1) first payment of indemnity benefits on a
claim within 10 days of making the first payment;
(2) first payment of indemnity benefits on an
acquired claim within 10 days of making the first payment;
(3) a change in the net benefit payment
amount without a change to the benefit type within 10 days of making the first
payment reflecting the change;
(4)
a change from one income benefit type to another or to death benefits within 10
days of making the first payment reflecting the change;
(5) resumption of payment of income or death
benefits within 10 days of making the first payment;
(6) termination or suspension of income or
death benefits within 10 days of making the last payment for the
benefits;
(7) employer continuation
of salary, as defined in §129.1(1) (concerning Definitions for Temporary
Income Benefits) of this title, equal to or exceeding the employee's average
weekly wage as defined by this title within:
(A) seven days of receiving the information
that salary would be continued in lieu of the insurance carrier initiating
temporary income benefits;
(B) ten
days of making the last payment of temporary income benefits due to the
employer's salary continuation; or
(C) ten days of resuming payment of the
employer's salary continuation;
(8) lump sum payment of income or death
benefits within 10 days of making the payment; or
(9) refusal to pay accrued income benefits
due to dispute of disability.
(e) If an insurance carrier receives a
written notice of injury for a disease or illness identified by Texas
Government Code, Chapter 607, Subchapter B (relating to Diseases or Illnesses
Suffered by Firefighters, Peace Officers, and Emergency Medical Technicians),
the insurance carrier must take one of the following actions no later than the
15th day after receiving the notice of injury:
(1) initiate benefits as required by the
Texas Workers' Compensation Act and the division's rules;
(2) file a notice of denial as described in
this section; or
(3) provide the
claimant and the division with notice as required under Labor Code §
409.021(a-3)
(Notice of Continuing Investigation) for a claim for benefits received on or
after June 10, 2019.
(f)
When applying subsection (e) of this section and Government Code, Chapter 607,
Subchapter B, a "claim for benefits" means the first written notice of injury
as provided in §
124.1
of this title (concerning Notice of Injury).
(g) The insurance carrier must issue a Notice
of Continuing Investigation as a plain language notice in the form and manner
prescribed by the division. The notification requirements of this section are
not considered complete until a copy of the notice provided to the claimant is
received by the division.
(1) A Notice of
Continuing Investigation must include the following:
(A) a statement describing all steps taken by
the insurance carrier to investigate the disease or illness before the notice
was given;
(B) a list of any
claim-specific evidence, releases, or documentation the insurance carrier
reasonably believes is both relevant and necessary to complete its
investigation; and
(C) contact
information for the adjuster, including the adjuster's email address, fax
number, and telephone number.
(2) An insurance carrier must provide a
reasonable amount of time for a claimant to respond to the notice.
(3) The notice may not include a request for
additional diagnostic testing, mental health records, generic requests (such as
"the claimant's medical records"), or requests for records that are not
directly related to either the disease or illness or eligibility for
application of a statutory presumption.
(4) Notwithstanding the issuance of a Notice
of Continuing Investigation, an insurance carrier must continue taking
reasonable steps to acquire claim-specific information necessary to complete
its investigation of the claim.
(h) Notification to the claimant as required
by subsections (c) - (e) of this section requires the insurance carrier to use
plain language notices in the form and manner prescribed by the division. These
notices must provide a full and complete statement describing the insurance
carrier's action and rationale. The statement must contain sufficient
claim-specific substantive information to enable the claimant to understand the
insurance carrier's position or action taken on the claim. A generic statement
that simply states the insurance carrier's position with phrases such as
"employee returned to work," "adjusted for light duty," "liability is in
question," "compensability in dispute," "under investigation," or other similar
phrases with no further description of the factual basis for the action taken
does not satisfy the requirements of this section.
(i) In addition to the denial notice
requirements in subsection (h), if the insurance carrier receives a written
notice of injury for a disease or illness identified by Texas Government Code,
Chapter 607, Subchapter B (relating to Diseases or Illnesses Suffered by
Firefighters, Peace Officers, and Emergency Medical Technicians), the denial
must also include the following:
(1) if the
insurance carrier asserts that a statutory presumption does not apply, a
statement explaining why and describing the claim-specific information that the
insurance carrier reviewed;
(2)
alternatively, based on its investigation, if the insurance carrier concludes
that a statutory presumption applies, but a notice of denial will be issued, a
statement explaining why and describing the claim-specific information reviewed
before issuing the notice that supports a reasonable belief that risk factors,
accidents, hazards, or other causes not associated with their employment were a
substantial factor in bringing about the injured employee's disease or illness,
without which the disease or illness would not have occurred; and
(3) if the insurance carrier provided a
timely Notice of Continuing Investigation as permitted by law, the denial
notice must also include a statement describing whether the claimant provided a
timely response to the notice.
(j) Notification to the division as required
by subsections (b) - (e) of this section requires the insurance carrier to use
electronic filing, as that term is used in §
102.5(e)
of this title (concerning General Rules for Written Communications to and from
the Division) with the division, according to the requirements in Subchapter B
of this title (concerning Insurance Carrier Claim Electronic Data Interchange
Reporting to the Division).
(1) In addition to
the electronic filing requirements of this subsection, when an insurance
carrier notifies the division of a denial, Notice of Continuing Investigation,
or dispute of disability as required by this section, it must provide the
division a written copy of the notice provided to the claimant as described
under subsections (g) - (i) and (k) of this section, as applicable.
(2) The notification requirements of this
section are not considered completed until the copy of the notice provided to
the claimant is received by the division.
(k) Notification to the division and the
claimant of a dispute of disability, extent of injury, or eligibility of a
claimant to receive death benefits must be made as otherwise prescribed by this
title and requires the insurance carrier to use plain language notices in the
form and manner prescribed by the division. These notices must provide a full
and complete statement describing the insurance carrier's action and its
reasons for such action. The statement must contain sufficient claim-specific
substantive information to enable the claimant to understand the insurance
carrier's position or action taken on the claim. A generic statement that
simply states the insurance carrier's position with phrases such as "no medical
evidence to support disability," "not part of compensable injury," "liability
is in question," "under investigation," "eligibility questioned," or other
similar phrases with no further description of the factual basis for the action
taken does not satisfy the requirements of this section.
(l) Except as otherwise provided by this
title, insurance carriers must not provide notices to the division that explain
that:
(1) benefits will be paid as they
accrue;
(2) a wage statement has
been requested;
(3) temporary
income benefits are not due because there is no lost time;
(4) the insurance carrier is disputing some
or all medical treatment as not reasonable or necessary;
(5) compensability is not denied, but the
insurance carrier disputes the existence of disability (if there are no
indications of lost time or disability and the employee is not claiming
disability); or
(6) future medical
benefits are disputed (notices of which must not be provided to anyone in the
system).
(m)
Notifications to the claimant and the claimant's representative must be filed
by fax or electronic transmission unless the recipient does not have the means
to receive such a transmission, in which case, the notifications must be
personally delivered or sent by mail.
(n) Each insurance carrier must provide to
the division, through its Austin representative in the form and manner
prescribed by the division, the contact information for all workers'
compensation claim service administration functions performed by the insurance
carrier either directly or through third parties.
(1) The contact information for each function
must include mailing address, telephone number, fax number, and email address,
as appropriate. This contact information may be provided either in the form of
a single Uniform Resource Locator (URL) for a web page created and maintained
by the insurance carrier that contains the required information or through an
online submission to the division. The claim service administration functions
requiring contact information to be reported are:
(A) coverage verification (policy issuance
and effective dates of the policy);
(B) claim adjustment;
(C) medical billing;
(D) pharmacy billing (if different from
medical billing);
(E)
preauthorization; and
(F) workers'
compensation health care network.
(2) If the web page option is used, the page
must contain the date it was last updated and an email address or other contact
information a user may report problems or inaccuracies to.
(3) The insurance carrier must update the
contact information or URL within 10 working days after any such change is
made.
(o) All notices to
a claimant required under this section must be stated in plain language and in
no less than 12-point font. This subsection applies to notices sent on or after
April 1, 2020.
(p) The section is
effective July 26, 2023.
