| (1) submit the request electronically in the form and
manner prescribed by the division;
(2) provide a claim-specific summary of the reason
the insurance carrier is seeking reimbursement and the total amount
of reimbursement requested, including how it was calculated;
(3) provide a detailed payment record showing the dates
and amounts of payments, payees, type of benefits and periods of benefits
paid, PLNs about the payment of benefits, and all certifications of
maximum medical improvement and assignments of impairment rating;
(4) provide the name, address, and federal employer
identification number of the payee (insurance carrier) for any reimbursement
that may be due;
(5) provide copies of all relevant designated doctors'
opinions (including responses to letters of clarification) and orders
and decisions (IRO decisions, interlocutory orders, contested case
hearing decisions and orders, arbitration awards, Appeals Panel decisions,
and court orders) relating to the designated doctor's opinion and
the payment made pursuant to the designated doctor's opinion for which
reimbursement is being requested, and indicate which document is the
final decision on the matter;
(6) provide copies of all relevant reports and DWC
forms the employer filed with the insurance carrier; and
(7) provide copies of all medical bills and preauthorization
request documents associated with an overpayment of medical benefits.
(g) To request reimbursement under subsection (a)(6)
of this section regarding initial pharmaceutical coverage, a requester
must submit the request in the same or following fiscal year after
a determination that the injury is not compensable. The fiscal year
begins each September 1 and ends on August 31 of the next calendar
year. For example, if an injury is determined to be not compensable
during the fiscal year from September 1, 2009, through August 31,
2010, the request for reimbursement under Labor Code §413.0141
must be submitted by August 31, 2011. Any claims for insurance carrier
payments related to initial pharmaceutical coverage that are not submitted
within the required timeframe will not be reviewed for reimbursement.
An insurance carrier must:
(1) submit the request electronically in the form and
manner prescribed by the division;
(2) provide a claim-specific summary of the reason
the insurance carrier is seeking reimbursement and the total amount
of reimbursement requested;
(3) provide a detailed payment record showing the dates
of payments, including documentation on dates of payment of initial
pharmaceutical coverage (i.e., during the first seven days following
the date of injury), payment amounts, and payees;
(4) provide the name, address, and federal employer
identification number of the payee (insurance carrier) for any reimbursement
that may be due;
(5) provide documentation that the pharmaceutical services
were provided during the first seven days following the date of injury,
not counting the actual date the injury occurred, and identify the
prescribed pharmaceutical services; and
(6) provide documentation of:
(A) the final resolution of any dispute either from
the commissioner or court of last resort that determines the injury
is not compensable; or
(B) a claimant's failure to respond in accordance with
subsection (a)(6)(B) of this section.
(h) The prescribed forms under this section are on
the division's website at www.tdi.texas.gov/wc/index.html. An insurance
carrier seeking reimbursement from the SIF must timely provide to
the SIF administrator by electronic transmission, as that term is
used in §102.5(h) of this title (relating to General Rules for
Written Communications to and from the Commission), all forms and
documentation reasonably required by the SIF administrator to determine
entitlement to reimbursement or payment from the SIF and the amount
of reimbursement to which the insurance carrier is entitled. The insurance
carrier must also provide notice to the SIF of any relevant pending
dispute, litigation, or other information that may affect the request
for reimbursement.
|
| Source Note: The provisions of this §116.11 adopted to be effective February 11, 1992, 17 TexReg 689; amended to be effective March 13, 2000, 25 TexReg 2090; amended to be effective August 15, 2002, 27 TexReg 7123; amended to be effective January 7, 2010, 35 TexReg 100; amended to be effective January 7, 2019, 44 TexReg 102; amended to be effective February 11, 2021, 46 TexReg 925 |
