| (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.
(j) Notification to the division as required by subsections
(b) - (e) 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 Division)
with the division, according to the requirements in Subchapter B of
this title (concerning Insurance Carrier Claim Electronic Data Interchange
Reporting to the Division).
(1) In addition to the electronic filing requirements
of this subsection, when an insurance carrier notifies the division
of a denial, Notice of Continuing Investigation, or dispute of disability
as required by this section, it must provide the division a written
copy of the notice provided to the claimant as described under subsections
(g) - (i) and (k) 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.
(k) Notification to the division and the claimant of
a dispute of disability, extent of injury, or eligibility of a claimant
to receive death benefits must 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
must provide a full and complete statement describing the insurance
carrier's action and its reasons 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.
(l) Except as otherwise provided by this title, insurance
carriers must 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 must not be provided to anyone in the system).
(m) Notifications to the claimant and the claimant's
representative must be filed by fax or electronic transmission unless
the recipient does not have the means to receive such a transmission,
in which case, the notifications must be personally delivered or sent
by mail.
(n) Each insurance carrier must 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.
(1) The contact information for each function must
include mailing address, telephone number, fax number, and email address,
as appropriate. This contact information may be provided either in
the form of a single Uniform Resource Locator (URL) for a web page
created and maintained by the insurance carrier that contains the
required information or through an online submission to the division.
The claim service administration functions requiring contact information
to be reported are:
(A) coverage verification (policy issuance and effective
dates of the policy);
(B) claim adjustment;
(C) medical billing;
(D) pharmacy billing (if different from medical billing);
(E) preauthorization; and
(F) workers' compensation health care network.
(2) If the web page option is used, the page must contain
the date it was last updated and an email address or other contact
information a user may report problems or inaccuracies to.
(3) The insurance carrier must update the contact information
or URL within 10 working days after any such change is made.
(o) All notices to a claimant required under this section
must be stated in plain language and in no less than 12-point font.
This subsection applies to notices sent on or after April 1, 2020.
(p) The section is effective July 26, 2023.
|
| Source Note: The provisions of this §124.2 adopted to be effective August 29, 1999, 24 TexReg 6503; amended to be effective June 5, 2003, 28 TexReg 4285; amended to be effective January 12, 2020, 45 TexReg 348; amended to be effective July 26, 2023, 47 TexReg 1095 |
