| (g) Report on other issues. A designated doctor who
resolves questions on issues other than those listed in subsections
(d), (e), and (f) of this section must file a designated doctor examination
data report that complies with §127.220(c) of this title and
a narrative report that complies with §127.220(a) of this title
within seven working days of the date the designated doctor examines
the injured employee.
(1) The designated doctor must file these reports with
the treating doctor, the division, and the insurance carrier by fax
or electronic transmission.
(2) The designated doctor must provide these reports
to the injured employee and the injured employee's representative
(if any) by fax or electronic transmission if the designated doctor
has a fax number or email for the recipient.
(3) If no fax number or email is provided for the recipient,
the designated doctor must send the reports by other verifiable means.
(h) Presumptive weight. The designated doctor's report
is given presumptive weight on the issue or issues the designated
doctor was properly appointed to address, unless the preponderance
of the evidence is to the contrary.
(i) Payment of benefits during dispute. The insurance
carrier must pay all benefits, including medical benefits, in accordance
with the designated doctor's report for the issue or issues in dispute.
(1) If the designated doctor provides multiple certifications
of MMI and impairment ratings, the insurance carrier must pay benefits
based on the conditions to which the designated doctor determines
the compensable injury extends.
(2) For medical benefits, the insurance carrier has
21 days from receipt of the designated doctor's report to reprocess
all medical bills previously denied for reasons inconsistent with
the designated doctor's findings. By the end of this period, insurance
carriers must pay these medical bills in accordance with the Labor
Code and Chapters 133 and 134 of this title.
(3) The insurance carrier must pay all other benefits
no later than five days after receiving the report.
(j) Record retention. The designated doctor must maintain
accurate records for, at a minimum, five years from the anniversary
date of the date of the designated doctor's last examination of the
injured employee.
(1) This requirement does not reduce or replace any
other record retention requirements imposed on a designated doctor
by an appropriate licensing board.
(2) These records must include the injured employee's
medical records, any analysis the insurance carrier or treating doctor
submits (including supporting information), reports the designated
doctor generates as a result of the examination, and narratives the
insurance carrier and treating doctor provide, to reflect:
(A) the date and time of any designated doctor appointments
scheduled with an injured employee;
(B) the circumstances for a cancellation, no-show,
or other situation where the examination did not occur as initially
scheduled or rescheduled, and if applicable, documentation of the
agreement to reschedule the examination and the notice that the doctor
provided to the division, the injured employee's treating doctor,
and the insurance carrier within 24 hours of rescheduling an appointment;
(C) the date of the examination;
(D) the date the designated doctor received medical
records from the treating doctor or any other person;
(E) the date the designated doctor submitted the reports
described in subsections (d), (e), and (f) of this section to all
required parties and documentation that these reports were submitted
to the division, treating doctor, and insurance carrier by fax or
electronic transmission and to other required parties by verifiable
means;
(F) if applicable, the names of any referral health
care providers the designated doctor used, the dates of referral health
care provider appointments, and the reason the designated doctor referred
them; and
(G) if applicable, the date the doctor contacted the
division for assistance in getting medical records from the insurance
carrier or treating doctor.
(k) Dispute resolution. Parties may dispute any entitlement
to benefits affected by a designated doctor's report through the dispute
resolution processes outlined in Chapters 140-144 and 147 of this
title (relating to dispute resolution processes, proceedings, and
procedures).
|
| Source Note: The provisions of this §127.10 adopted to be effective February 1, 2011, 35 TexReg 11324; amended to be effective September 1, 2012, 37 TexReg 5422; amended to be effective November 4, 2018, 43 TexReg 7149; amended to be effective April 30, 2023, 48 TexReg 2123 |
