| (a) The Division prescribes standard electronic formats
by utilizing implementation guides for data requests and data reports
for the purpose of exchanging data between the Division and insurance
carriers, as defined in Labor Code §402.084.
(b) In this section, the following definitions apply:
(1) Claim Data Request and Report Implementation Guide
(Guide)--The division specification document for the Claim Data Request
and the Claim Data Report that defines specific data requirements,
data set transactions, data mapping, data edits, and fees per record
available at www.tdi.texas.gov/wc.
(2) Claim Data Report--The electronic report generated
by the Division in the format specified by the Guide. The report contains
data for claims meeting confidence match criteria defined in the Guide.
(3) Claim Data Request--The electronic request submitted
by a requester in the format specified by the Division in the Guide.
(4) Record--An electronic representation of one insured
person containing a set of unique identifiers including the full name,
date of birth, gender, and social security number, if available. Each
set of individual identifiers included in a Claim Data Request represents
a separate record.
(5) Requester--An insurance carrier that has adopted
an antifraud plan under Labor Code §402.084(b)(8) and qualifies
as an insurance carrier under Labor Code §402.084(c-1) or its
authorized representative.
(c) A Claim Data Request must contain the following
elements:
(1) all fields required in the applicable Guide as
defined in subsection (b) of this section;
(2) complete, current, and correct values as described
in the applicable Guide; and
(3) records of persons who are or were valid members
of the requesters' benefit programs and whose claims may be related
to a workers' compensation claim.
(d) A Claim Data Report must contain:
(1) all fields required in the applicable Guide; and
(2) complete, current, and correct values as described
in the applicable Guide.
(e) A Claim Data Request may be submitted by a requester.
(f) The Division will match the records submitted by
a requester against the Division's claim data using a matching methodology
published in the Guide. The search will include all claims on record
with the Division relating to injuries sustained on or after September
1, 2002. For each record submitted, the Division will report:
(1) the existence of a positive match with one or more
workers' compensation claims; or
(2) the failure to match the record to any recorded
workers' compensation claim.
(g) File transfers between requesters and the Division
shall be sent using secured file transfer protocol (SFTP) with access
controlled by a unique username and password.
(h) The data shall not be shared or disclosed to any
other person or entity, except as necessary to document and pursue
reimbursement with the appropriate workers' compensation carrier or
claims administrator or through Division dispute resolution procedures.
Requesters shall destroy all electronic or paper records related to
Claim Data Requests that are not needed to pursue subclaimant status
or recovery of reimbursement by an insurance carrier as defined by
Labor Code §402.084(c-1).
(i) A requester may submit a Claim Data Request once
every 30 days for each covered individual.
(j) Unless waived by the Division, the requester shall
pay to the Division a fee for each record included in a request. The
fee will be established in the Guide, but shall be no more than $.05
for each record included in the Claim Data Request. Claim Data Requests
that include previously submitted requests for records would also
be charged a fee of up to $.05 for each record.
(k) Prior to submitting a Claim Data Request, the requester
shall execute a trading partner agreement with the Division in the
form and manner prescribed by the Division. The trading partner agreement
shall contain:
(1) a statement that the requester agrees to abide
by all applicable federal and state laws and regulations;
(2) an agreement to submit only names and identifying
information related to bona fide beneficiaries of the requester's
benefit plans;
(3) an agreement to comply with Division standards
for secure transfer and storage of workers' compensation claim information;
(4) an agreement to comply with Division standards
regarding the confidentiality of workers' compensation claim information
and the approved uses of that information; and
(5) an agreement to pay applicable fees.
(l) After a match of a record has been determined,
the information may be used by the requester as the basis for identification
and filing of a subclaim under Labor Code §409.009. When a match
has been determined and a subclaim filed, the requester shall contact
the injured employee who received the health care and is the subject
of the subclaim. The requester shall provide the injured employee
written notice, which includes the following:
(1) the name of the subclaimant;
(2) the dates of service;
(3) the name of the injured employee;
(4) a statement declaring, "As the injured employee
in this matter, you will receive notice of all proceedings related
to this matter and may participate in those proceedings. To determine
whether to take any action in this matter, you may wish to consult
with an attorney. You can also contact the Office of Injured Employee
Counsel (OIEC) for ombudsman assistance."; and
(5) the phone number and website address of OIEC.
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