Texas Administrative Code
Title 28 - INSURANCE
Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION
Chapter 140 - DISPUTE RESOLUTION-GENERAL PROVISIONS
Section 140.6 - Subclaimant Status: Establishment, Rights, and Procedures
Universal Citation: 28 TX Admin Code ยง 140.6
Current through Reg. 49, No. 38; September 20, 2024
(a) Applicability. This section is applicable to a subclaim pursued under Labor Code § 409.009, including a subclaim pursued by a health care insurer.
(b) Party status. A subclaimant as described in §409.009 is a party to a claim concerning workers' compensation benefits.
(c) Rights in Relation to the Injured Employee.
(1) A subclaimant may
file and pursue a claim for reimbursement of a benefit that has been provided
to an injured employee, and is entitled to appropriate dispute resolution in
accordance with the Texas Workers' Compensation Act (Act) and Division of
Workers' Compensation (Division) rules.
(2) A subclaimant may pursue a claim for
reimbursement of a benefit that has been provided to an injured employee and
participate in the dispute resolution process without the participation of the
injured employee if:
(A) there is no prior
written agreement between the injured employee and the workers' compensation
insurance carrier or no final decision by the Division on the issue in
dispute;
(B) the workers'
compensation insurance carrier has denied the entitlement to benefits under the
Act and Division rules;
(C) the
injured employee is not pursuing dispute resolution to establish the injured
employee's entitlement to benefits with reasonable diligence; and
(D) the subclaimant has provided the injured
employee with written notice of:
(i)
subclaimant's intent to pursue a claim for reimbursement of a
benefit;
(ii) warning that a
decision rendered may be binding against the injured employee; and
(iii) contact information for the Office of
the Injured Employee Counsel.
(3) At a contested case hearing without the
participation of the injured employee, the subclaimant must show, in addition
to other facts:
(A) subclaimant provided
written notice to the injured employee as specified in paragraph (2)(D) of this
subsection;
(B) it has contacted
the injured employee and the injured employee is not pursuing the dispute with
reasonable diligence; or
(C) it has
been unable to contact the injured employee through the exercise of reasonable
diligence.
(d) Claims for Reimbursement of Medical Benefits.
(1) Subclaimants, other than
subclaimants described in §409.0091, must pursue a claim for reimbursement
of medical benefits and participate in medical dispute resolution in the same
manner as an injured employee or in the same manner as a health care provider,
as appropriate, under Chapters 133 and 134 of this title (relating to General
Medical Provisions and Benefits--Guidelines for Medical Services, Charges, and
Payments).
(2) A health care
insurer subclaimant must submit a reimbursement request in the form/format and
manner prescribed by the Division and must contain all the required elements
listed on the form.
(3) Workers'
compensation insurance carriers must process reimbursement requests from
subclaimants pursuant to Chapters 133 and 134 of this title.
(e) Contested Case Hearing. A subclaimant may pursue a contested case hearing under the provisions of Chapters 140 - 143 of this title (relating to Dispute Resolution).
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