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TITLE 28INSURANCE
PART 2TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION
CHAPTER 127DESIGNATED DOCTOR PROCEDURES AND REQUIREMENTS
SUBCHAPTER BDESIGNATED DOCTOR CERTIFICATION, RENEWAL, AND QUALIFICATIONS
RULE §127.100Designated Doctor Certification

(a) Qualifications to get or renew certification. The division will not assign examinations to a designated doctor who does not meet all requirements for certification or renewal. All designated doctors must:

  (1) Have a complete designated doctor certification application as described in subsection (b) of this section on file with the division.

  (2) Complete all division-required trainings within 12 months of the date of application and have current documentation confirming their completion on file with the division.

  (3) Pass all division-required testing on the specific duties of a designated doctor under the Labor Code and division rules and have current documentation confirming their passage on file with the division. Required testing must have been completed on or after May 13, 2013, and includes demonstrated proficient knowledge of the currently adopted edition of:

    (A) the American Medical Association Guides to the Evaluation of Permanent Impairment; and

    (B) the division's adopted:

      (i) treatment guidelines; and

      (ii) return-to-work guidelines.

  (4) Have maintained an active practice for at least three years during the doctor's career. For the purposes of this subsection, a doctor has an active practice if the doctor maintains or has maintained routine office hours of at least 20 hours per week for 40 weeks per year to treat patients.

  (5) For the duration of the doctor's term as a designated doctor:

    (A) be licensed in Texas;

    (B) own or subscribe to the current edition of the American Medical Association Guides to the Evaluation of Permanent Impairment adopted by the division to assign impairment ratings and all return-to-work and treatment guidelines adopted by the division; and

    (C) comply with financial disclosure requirements in §180.24 (relating to Financial Disclosure) of this title.

(b) Application. To be considered complete, an application for certification must include, and a renewal application must update or confirm:

  (1) contact information for the doctor;

  (2) information on the doctor's education;

  (3) a description of the doctor's license or licenses, certifications, and professional specialty, if any;

  (4) a description of the doctor's work history and hospital or other health care provider affiliations;

  (5) a description of any affiliations the doctor has with a workers' compensation health care network certified under Insurance Code Chapter 1305 or political subdivision under Labor Code §504.053(b)(2);

  (6) information on the doctor's current practice locations;

  (7) detailed answers to disclosure questions on the doctor's professional background, education, training, and fitness to perform the duties of a designated doctor, including disclosure and summary of any disciplinary actions taken against the doctor by any state licensing board or other appropriate state or federal agency;

  (8) the identity of any person the doctor has contracted with to assist in performing or administering the doctor's designated doctor duties;

  (9) an attestation that:

    (A) all information provided in the application is accurate and complete to the best of the doctor's knowledge;

    (B) the doctor will inform the division of any changes to this information as required by §127.200(a)(8) of this title (relating to Duties of a Designated Doctor); and

    (C) the doctor will consent to any on-site visits, as provided by §127.200(a)(15) of this title, by the division at facilities that the designated doctor uses or intends to use to perform designated doctor examinations for the duration of the doctor's certification.

(c) Retesting. If a doctor passes a division-required test, the doctor may not retest within a twelve-month period. If a doctor fails a division-required test, the doctor may not retest more than three times within a six-month period.

  (1) After the first or second attempt, the doctor must wait 14 days before retaking the test.

  (2) After the third attempt, the doctor must wait six months before retaking the test.

(d) Additional certification testing. On receipt of an application for designated doctor certification renewal, the division may require a designated doctor to complete additional certification testing to demonstrate proficient knowledge on the specific duties of a designated doctor under the Labor Code and division rules. Examples of circumstances that may require additional certification testing include, but are not limited to, individual need for retesting based on substandard performance, changes in the duties of a designated doctor, updates to the guidelines, and legislative changes.

(e) Notice of approval, denial, suspension, or revocation. The division will notify a doctor in writing of the commissioner's approval or denial of the doctor's application to be certified or renewed as a designated doctor; or of the division's suspension or revocation of the doctor's certification.

(f) Term and qualification. Approvals certify a doctor for a term of two years and will include:

  (1) the effective date of the certification;

  (2) the expiration date of the certification; and

  (3) the designated doctor's examination qualifications under §127.130 of this title (relating to Qualification Standards for Designated Doctor Examinations).

(g) Renewal. A designated doctor who seeks to renew their certification immediately after their current term expires, without interruption, must apply for certification no later than 45 days before the end of the term.

  (1) If the division does not receive all of the information required under subsection (b)(1) - (9) above no later than 45 days before the end of the designated doctor's term, the division will not assign examinations to the designated doctor during the last 45 days of an expiring term.

  (2) The designated doctor may still provide services on claims the division had previously assigned to them during this 45-day period.

(h) Approval of renewal application with restrictions. An application for renewal may be approved with restrictions. The division may restrict a designated doctor's certification until the doctor complies with the requirements in the designated doctor's approval of certification. Designated doctors whose certification is restricted may dispute the restriction through the procedure described in subsection (k) of this section.

(i) Adverse certification actions. The division may deny, suspend, or revoke a designated doctor's certification for any of the following reasons:

  (1) if the doctor did not submit a complete application for certification as required under subsection (b) of this section;

  (2) for having a relevant restriction on their practice imposed by a state licensing board, certification authority, or other appropriate state or federal agency, including the division;

  (3) if the doctor failed to update their application for certification properly; or

  (4) for other activities, events, or occurrences that the commissioner determines warrant denial of a doctor's application for certification as a designated doctor, including, but not limited to:

    (A) the quality of the designated doctor's past reports;

    (B) the designated doctor's history of complaints;

    (C) excess requests for deferral from the designated doctor list by the designated doctor;

    (D) a pattern of overturned reports by the division or a court;

    (E) a demonstrated lack of ability to apply or properly consider the American Medical Association Guides to the Evaluation of Permanent Impairment adopted by the division to assign impairment ratings and all return-to-work and treatment guidelines adopted by the division;

    (F) a demonstrated lack of ability to consistently perform designated doctor examinations in a timely manner;

    (G) a demonstrated failure to identify disqualifying associations;

    (H) a demonstrated lack of ability to ensure the confidentiality of injured employee medical records and claim information provided to or generated by a designated doctor;

    (I) a history of unnecessary referral examinations or testing;

    (J) a failure to comply with the requirements of §180.24 of this title (relating to Financial Disclosure) when they requested referral examinations or additional testing;

    (K) applying for certification less than a year from denial of a previous designated doctor certification application; or

    (L) any grounds that would allow the division to sanction a health care provider under the Labor Code or division rules.

(j) Response to denial of certification. Within 15 working days after receiving a written denial, a doctor may file a written response with the division addressing the reasons the division gave to the doctor for its denial.

  (1) If the division does not receive a written response by the 15th working day after the date the doctor received the notice, the denial will be final effective the next day. The division will not send further notice.

  (2) If the division timely receives a written response that disagrees with the denial, the division will review the response and notify the doctor in writing of the commissioner's final decision.

    (A) If the final decision is still a denial, the division's final notice will provide the reasons the doctor's response did not change the commissioner's decision to deny the doctor's application for certification as a designated doctor.

    (B) The denial will be effective the day after the doctor receives notice of the denial, unless the notice specifies otherwise.

(k) Request for informal conference. A designated doctor whose renewal application is denied, or whose certification is suspended or revoked, may either respond in writing using the procedure in subsection (j) of this section or submit a written request for an informal conference before the division to address those reasons.

  (1) If the division does not receive a written request for an informal conference by the 15th working day after the date the doctor received the notice, the denial, suspension, or revocation will be final effective the next day. The division will not send further notice.

  (2) If the division timely receives a written request for an informal conference, it will set the informal conference to occur no later than 31 days after it received the request.

    (A) At the informal conference, the designated doctor may present evidence that addresses the reasons the doctor was denied certification, or the reasons the doctor's certification was suspended or revoked, to the commissioner's designated representatives.

    (B) The designated doctor may have an attorney present.

    (C) At the end of the informal conference, the commissioner's designated representatives will provide the designated doctor with their final recommendation on the doctor's certification.

      (i) If the final recommendation is still a denial, suspension, or revocation, the commissioner's designated representatives will provide the reasons for not certifying the doctor as a designated doctor.

      (ii) After the informal conference, the commissioner's designated representatives will send their final recommendation to the commissioner, who will review it and all evidence presented at the informal conference and make a final decision.

      (iii) The division will notify the designated doctor of the commissioner's final decision in writing.

      (iv) The decision will be effective the day after the doctor receives notice of the decision, unless the notice specifies otherwise.


Source Note: The provisions of this §127.100 adopted 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

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