Texas Administrative Code
Title 28 - INSURANCE
Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION
Chapter 127 - DESIGNATED DOCTOR PROCEDURES AND REQUIREMENTS
Subchapter C - DESIGNATED DOCTOR DUTIES AND RESPONSIBILITIES
Section 127.220 - Designated Doctor Reports

Universal Citation: 28 TX Admin Code ยง 127.220

Current through Reg. 49, No. 38; September 20, 2024

(a) Format and submission. Designated doctor narrative reports must be filed in the form and manner required by the division. At a minimum, they must do all of the following:

(1) Identify the question or questions the division ordered to be addressed by the designated doctor examination.

(2) Provide a clearly defined answer for each question to be addressed by the designated doctor examination and only for each of those questions.

(3) Sufficiently explain how the designated doctor determined the answer to each question within a reasonable degree of medical probability.

(4) Demonstrate, as appropriate, application or consideration of the American Medical Association Guides to the Evaluation of Permanent Impairment, division-adopted return-to-work and treatment guidelines, and other evidence-based medicine, if available.

(5) Include general information about the identity of the designated doctor, injured employee, employer, treating doctor, and insurance carrier.

(6) State the date of the examination and the address where it took place.

(7) Summarize any additional testing conducted or referrals made as part of the evaluation, including:
(A) the identity of any health care providers to which the designated doctor referred the injured employee under § 127.10(c) of this title (relating to General Procedures for Designated Doctor Examinations);

(B) the types of tests conducted or referrals made;

(C) the dates the testing or referral examinations occurred;

(D) an explanation of why the testing or referral was necessary to resolve a question at issue in the examination; and

(E) the date the testing or referral examination was completed.

(8) Include a narrative description of the medical history, physical examination, and medical decisions the designated doctor made, including the time the designated doctor began taking the medical history of the injured employee, physically examined the employee, and engaged in medical decision making, and the time the designated doctor completed these tasks.

(9) List the specific medical records or other documents the designated doctor reviewed as part of the evaluation, including the dates of those documents and which medical records were provided by the injured employee.

(10) Provide the total amount of time required for the designated doctor to review the medical records.

(11) Be signed by the designated doctor who performed the examination.

(12) Include a statement that there is no known disqualifying association as described in § 127.140 of this title (relating to Disqualifying Associations) between the designated doctor and the injured employee, the injured employee's treating doctor, the insurance carrier, the insurance carrier's certified workers' compensation health care network, or a network established under Labor Code Chapter 504.

(13) Certify the date that the report was sent to all recipients as required and in the manner required by § 127.10 of this title.

(14) Indicate on the report that the designated doctor reviewed and approved the final version of the report.

(b) Additional forms required. Designated doctors who perform examinations under § 127.10(d) or (e) of this title must also complete and file the division forms required by those subsections with their narrative reports. Designated doctors must complete and file these forms in the manner required by applicable division rules.

(c) Designated doctor examination data report. Designated doctors who perform examinations under § 127.10(f) of this title must, in addition to filing a narrative report that complies with subsection (a) of this section, also file a designated doctor examination data report in the form and manner required by the division. A designated doctor examination data report must:

(1) include general information regarding the identity of the designated doctor, injured employee, insurance carrier, as well as the identity of the certified workers' compensation healthcare network under Insurance Code Chapter 1305, if applicable, or whether the injured employee is receiving medical benefits through a political subdivision health care plan under Labor Code § 504.053(b)(2) and the identity of that plan, if applicable;

(2) identify the question or questions the division ordered to be addressed by the designated doctor examination;

(3) provide a clearly defined answer for each question to be addressed by the designated doctor examination and only for each of those questions. For extent of injury examinations, the designated doctor should also provide, for informational purposes only, a diagnosis code for each disputed injury;

(4) state the date of the examination, the time the examination began, and the address where the examination took place;

(5) list any additional testing conducted or referrals made as part of the evaluation, including the identity of any healthcare providers to which the designated doctor referred the injured employee under § 127.10(c) of this title, the types of tests conducted or referrals made and the dates the testing or referral examinations occurred; and

(6) be signed by the designated doctor who performed the examination.

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