| (a) An insurance carrier shall notify the division
and the claimant of actions taken on or events occurring in a claim
as required by this title.
(b) The division shall prescribe the form, format,
and manner of required electronic submissions through publications
such as advisory(ies), instructions, specifications, the Texas Electronic
Data Interchange Implementation Guide, and trading partner agreements.
Trading partners will be responsible for obtaining a copy of the International
Association of Industrial Accident Boards and Commissions (IAIABC)
Electronic Data Interchange Implementation Guide.
(c) The insurance carrier shall electronically file,
as that term is used in §102.5(e) of this title (concerning General
Rules for Written Communications to and from the Commission), with
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) 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 or an occupational disease; or
(B) notification of lost time if the employer made
the Employer's First Report of Injury prior to the employee experiencing
absence from work as a result of the injury;
(2) any correction of division-identified errors in
a previously accepted electronic record as provided in §102.5(e)
of this title (Correction);
(3) information regarding a compensable death with
no beneficiary (Compensable Death No Beneficiaries/Payees) not later
than the 10th day after determining that an employee whose injury
resulted in death had no legal beneficiary; and
(4) a change in an electronic record initiated by the
insurance carrier (Change), 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 receipt of the new address.
(d) The insurance carrier shall notify the division
and the claimant of a denial of a claim (Denial) based on non-compensability
or lack of coverage in accordance with this section and as otherwise
provided by this title.
(e) The insurance carrier shall notify the division
and the claimant of the following:
(1) first payment of indemnity benefits on a claim
(Initial Payment) within 10 days of making the first payment;
(2) change in the net benefit payment amount caused
by a change in the employee's post-injury earnings (Reduced Earnings)
within ten days of making the first payment reflecting the change;
(3) change in the net benefit payment amount that was
not caused by a change in employee's post-injury earnings, this includes
but is not limited to subrogation, attorney fees, advances, and contribution
(Change in Benefit Amount), and the notice must be made within 10
days of making the first payment which reflects the change;
(4) change from one income benefit type to another
or to death benefits (Change in Benefit Type) within 10 days of making
the first payment reflecting the change;
(5) resumption of payment of income or death benefits
(Reinstatement of Benefits) within 10 days of making the first payment;
(6) termination or suspension of income or death benefits
(Suspension) within 10 days of making the last payment for the benefits;
or
(7) employer continuation of salary equal to or exceeding
the employee's Average Weekly Wage as defined by this title (Full
Salary) within:
(A) seven days of receipt of the Employer's First Report
of Injury or a Supplemental Report of Injury (if the report included
information that salary would be continued) if the insurance carrier
has not initiated temporary income benefits; or
(B) 10 days of making the last payment of temporary
income benefits due to the employer's continuation of full salary.
(f) 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, or Emergency Medical Technicians),
the insurance carrier shall take one of the following actions no later
than the 15th day following receipt of the notice of injury:
(1) initiate benefits as required by the 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.
(g) When applying subsection (f) 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).
(h) The insurance carrier shall 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 shall 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, facsimile number, and telephone number.
(2) An insurance carrier shall 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.
(i) Notification to the claimant as required by subsections
(d) - (h) of this section requires the insurance carrier to use plain
language notices in the form and manner prescribed by the division.
These notices shall 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.
(j) In addition to the denial notice requirements in
subsection (i), 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, or 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 upon its investigation, if
the insurance carrier concludes that a statutory presumption applies,
but that a notice of denial will be issued, a statement explaining
why and describing the claim-specific information reviewed prior to
issuance of 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.
(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.
(k) Notification to the division as required by subsections
(c) - (h) 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 Commission).
(1) In addition to the electronic filing requirements
of this subsection, when an insurance carrier notifies the division
of a denial as required by this section, it must provide the division
a written copy of the notice provided to the claimant as described
under subsections (i) - (j) 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.
(l) Notification to the division and the claimant of
a dispute of disability, extent of injury, or eligibility of a claimant
to receive death benefits shall 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
shall provide a full and complete statement describing the insurance
carrier's action and its reason(s) 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.
(m) The division shall send an acknowledgment to the
transmitting trading partner detailing whether an electronically submitted
record was accepted, accepted with errors, or rejected. The acknowledgment
shall be provided directly to the trading partner submitting the transmission,
not through the Austin representative box identified in §102.5
of this title. If the record was accepted with errors in conditional
elements, the insurance carrier must correct the errors in accordance
with §102.5 of this title.
(n) Except as otherwise provided by this title, insurance
carriers shall 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 shall not be provided to anyone in the system).
(o) Written requests for a waiver of the electronic
filing requirement for the Employer's First Report of Injury may be
submitted to the commissioner or their designee for consideration.
Waivers must be requested at least annually, and the requests must
include a justification for the waiver, the volume of the insurance
carrier's claims and total premium amounts, current automation capabilities,
Electronic Data Interchange (EDI) programming status, and a specific
target date to implement EDI. Waivers require written approval and
shall be granted at the discretion of and for the time frame noted
by the commissioner or their designee.
(p) If specifically directed by the division, such
as through division advisory or the Texas Electronic Data Interchange
Guide, the insurance carrier may provide the information required
in subsections (c) - (g) of this section to the division in hardcopy
or paper format.
(q) Notifications to the claimant and the claimant's
representative shall be filed by facsimile or electronic transmission
unless the recipient does not have the means to receive such a transmission
in which case the notifications shall be personally delivered or sent
by mail.
(r) Each insurance carrier shall 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.
Cont'd... |
