The following words and terms, when used in this chapter, will
have the following meanings:
(1) Act--The Texas Workers' Compensation Act, Labor
Code, Title 5, Subtitle A.
(2) Administrative violation--A violation, failure
to comply with, or refusal to comply with the Act, or a rule, order,
or decision of the commissioner. This term is synonymous with the
terms "violation" or "violate."
(3) Agent--A person who a system participant uses or
contracts with for the purpose of providing claims service or fulfilling
duties under the Labor Code, Title 5 and rules. The system participant
who uses or contracts with the agent may also be responsible for the
administrative violations of that agent.
(4) Appropriate credentials--The certifications, education,
training, and experience to provide the health care that an injured
employee is receiving or is requesting to receive. Under Texas Labor
Code §408.0043, a physician who performs a peer review, utilization
review, or independent review of health care services requested, ordered,
provided, or to be provided by a physician must be of the same or
similar specialty as the physician who requested, ordered, provided,
or will provide the health care service. A dentist must meet the requirements
of Texas Labor Code §408.0044. A chiropractor must meet the requirements
of Texas Labor Code §408.0045.
(5) Commissioner--The commissioner of workers' compensation.
(6) Complaint--A written submission to the division
alleging a violation of the Act or rules by a system participant.
(7) Compliance Audit (also Performance Review)--An
official examination of compliance with one or more duties under the
Act and rules. A compliance audit does not include monitoring or review
activities involving the Medical Advisor or the Medical Quality Review
Panel.
(8) Conviction or convicted--
(A) A system participant is considered to have been
convicted when:
(i) a judgment of conviction has been entered against
the system participant in a federal, state, or local court;
(ii) the system participant has been found guilty in
a federal, state, or local court;
(iii) the system participant has entered a plea of
guilty or nolo contendere (no contest) that has been accepted by a
federal, state, or local court;
(iv) the system participant has entered a first offender
or other program and judgment of conviction has been withheld; or
(v) the system participant has received probation or
community supervision, including deferred adjudication.
(B) A conviction is still a conviction until and unless
overturned on appeal even if:
(i) it is stayed, deferred, or probated;
(ii) an appeal is pending; or
(iii) the system participant has been discharged from
probation or community supervision, including deferred adjudication.
(9) Department--Texas Department of Insurance.
(10) Division--Texas Department of Insurance, Division
of Workers' Compensation.
(11) Emergency--As defined in §133.2 of this title
(relating to Definitions). This definition does not apply to "emergency"
as used in the term "ex parte emergency cease and desist orders."
(12) Frivolous--That which does not have a basis in
fact or is not warranted by existing law or a good faith argument
for the extension, modification, or reversal of existing law.
(13) Frivolous complaint--A complaint that does not
have a basis in fact or is not warranted by existing law or a good
faith argument for the extension, modification, or reversal of existing
law.
(14) Immediate post-injury medical care--That health
care provided on the date that the injured employee first seeks medical
attention for the workers' compensation injury.
(15) Notice of Violation (NOV)--A notice issued to
a system participant by the division when the division has found that
the system participant has committed an administrative violation and
the division seeks to impose a sanction in accordance with Labor Code,
Title 5 or division rules.
(16) Peer Review--An administrative review by a health
care provider performed at the insurance carrier's request without
a physical examination of the injured employee.
(17) Remuneration--Any payment or other benefit made
directly or indirectly, overtly or covertly, in cash or in kind, including,
but not limited to, forgiveness of debt.
(18) Rules--The division's rules adopted under Labor
Code, Title 5.
(19) Sanction--A penalty or other punitive action or
remedy imposed by the commissioner on an insurance carrier, representative,
injured employee, employer, or health care provider, or any other
person regulated by the division under the Act, for an administrative
violation.
(20) SOAH--The State Office of Administrative Hearings.
(21) System Participant--A person or their agent subject
to the Act or a rule, order, or decision of the commissioner.
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| Source Note: The provisions of this §180.1 adopted to be effective July 29, 1991, 16 TexReg 3940; amended to be effective March 14, 2002, 27 TexReg 1817; amended to be effective September 14, 2003, 28 TexReg 7711; amended to be effective January 9, 2011, 35 TexReg 11873; amended to be effective February 14, 2012, 37 TexReg 691; amended to be effective February 10, 2021, 46 TexReg 928 |
