Health Care Provider Frequently-Asked Questions
- What is required for a doctor to participate in the Texas workers’ compensation system providing treatment to injured employees?
- As a health care provider who treats injured employees, what forms do I need to file for workers' compensation?
- Can I perform impairment ratings?
- What is fraud under Texas workers' compensation?
- What professional service fee guidelines have been established for Texas workers' compensation claims?
- Can I pursue a private claim with the injured employee for medical care services provided?
- What is a Designated Doctor? How do I become one?
- What is medical fee dispute resolution?
- How can a Health Care Provider stay informed of changes in the Texas workers' compensation system?
- The Texas workers’ compensation system uses Medicare as a framework for its Fee Guidelines; how can I stay informed of changes made by the Centers for Medicare and Medicaid Services (CMS)?
- What is a Letter of Clarification (LOC)?
- How can a health care provider determine workers’ compensation insurance coverage for an injured employee?
1. What is required for a doctor to participate in the Texas workers’ compensation system providing treatment to injured employees?
Doctors are not required to be approved or trained by the Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) in order to provide treatment to injured employees in the Texas workers’ compensation system. However, a doctor must not have been denied or removed from the former TDI-DWC Approved Doctor List (ADL), or restricted from the Texas workers’ compensation system.
To treat injured employees a doctor is required to have an active medical license to practice in their jurisdiction. Also, a doctor who wishes to participate in the Texas workers’ compensation system in any capacity is required to disclose to the TDI-DWC the identity of any other health care provider in which they have financial interest. For additional information, see the TDI-DWC Financial Disclosure Fast Facts on the TDI website at http://www.tdi.texas.gov/pubs/fastfacts/fffinancialdisc.pdf.
If an injured employee is not covered by a certified workers’ compensation health care network (network) and wants to change treating doctors, the injured employee is required to submit a DWC Form-053, Employee Request to Change Treating Doctor, to the TDI-DWC for approval. An injured employee is not required to obtain prior approval from the TDI-DWC when first selecting a treating doctor. Prior approval is only required to change treating doctors. Please note that an injured employee cannot request a change of treating doctor to obtain a new impairment rating or medical report. The DWC Form-053 is available on the TDI website at http://www.tdi.texas.gov/forms/dwc/dwc053chngdoc.pdf.
A doctor is prohibited from directly billing an injured employee for medical treatment. However, payment may be the responsibility of the injured employee if the TDI-DWC determines that the workers’ compensation claim is not compensable or the TDI-DWC relieves the insurance carrier of payment, because the injured employee did not request a change of treating doctor.
If you are a doctor treating an injured employee covered by a certified network, you must contact the individual certified network to become an approved health care provider for that network or the injured employee must have received approval by the certified network for an out-of-network referral. To view the list of Certified Workers’ Compensation Networks approved by the TDI, visit the TDI website at http://www.tdi.texas.gov/wc/wcnet/wcnetworks.html.
To receive news and communications from the TDI-DWC that are important to health care providers treating injured employees, including rules, bulletins, educational sessions and training events, subscribe to the Division of Workers’ Compensation eNews Update on the TDI website at http://www.tdi.texas.gov/alert/emailnews.html. Sign up is easy, quick and free.
For further assistance, health care providers and doctors can call the TDI-DWC Comp Connection for Health Care Providers at 1-800-372-7713 option #3.
2. As a health care provider who treats injured employees, what forms may I need to file for Texas workers' compensation?
For forms, form purpose, and instructions please use the following links:
- Health Care Provider/Medical Forms Home Page
- All Division of Worker's Compensation (DWC) Forms
- All Texas Department of Insurance (TDI) Forms
Form quick links:
Must be filed:
- After the initial visit
- When there is a change in work status or a substantial change in activity restrictions
- On the schedule requested through or by an insurance carrier, not to exceed one report every two weeks.
- Other situations require filling form DWC Form-073, please see the full instructions for all situations in which this form must be filled
- Relates to Maximum Medical Improvement (MMI) and Impairment Ratings (IR).
- Please see FAQ Can I perform impairment ratings? in this section for additional information on being able to assign MMI and IR’s:
- Used when submitting a claim for an injured employee
- Used in the event that a medical bill has been denied for medical necessity
- For additional information please see the IRO web-page.
Used in the event that a medical bill has been denied for a claim related reason; examples of reasons:
- Condition for treatment is not a compensable injury
- Treatment is not related to the compensable injury (Extent of Injury)
- The insurance carrier is not liable for treatment
- Used in the event that a medical bill has been denied for a reimbursement reason
- NOTE: DWC Form-060 should only be filled after a bill has been:
- Correctly submitted and denied
- Correctly submitted for reconsideration and denied
- For additional information please see Medical Fee Dispute Resolution Basics
- Used to request the appeal of a decision on:
- Reimbursement of medical treatment (Medical fee Dispute)
- Compensability of an injury (Claims related dispute)
- Treatment related/not related to a compensable injury (Extent of Injury)
- Insurance carrier liability
For additional information on dispute resolution please see the Injured Employee dispute resolution page.
To assign an impairment rating and/or certify MMI, a doctor must meet all impairment rating requirements by completing the required training and testing and be approved by the Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC). A doctor whom TDI-DWC has not certified to assign impairment ratings is only authorized to determine whether an injured employee has permanent impairment resulting from a compensable injury and, in the event that the injured employee has no permanent impairment, certify MMI.
After I complete the IR training and take the IR test, can I perform impairment ratings?
After you have completed the IR training and passed the IR test, you will need to apply, via TXCOMP, for authorization to assign impairment ratings. The instructions specifying how to apply online for IR authorization can be found at online. After completing the online application, you will receive an electronic notification from TDI-DWC on the outcome of your application.
Fraud occurs when a person knowingly or intentionally conceals, misrepresents, or makes a false statement to either deny or obtain workers' compensation benefits or insurance coverage, or otherwise profit from the deceit.
For additional information on workers' compensation fraud in Texas visit the Workers' Compensation Fraud Section online. For general information on insurance fraud in Texas visit the Texas Department of Insurance Fraud section online.
A notice on how to report fraud in Texas can be downloaded from the Texas Department of Insurance (TDI) website and posted in your office and/or workplace. To report suspected fraud in Texas, please call the Texas Insurance Fraud Toll-Free Hotline at 1-800-252-3439 or report fraud in Texas online.
5. What professional service fee guidelines have been established for Texas workers' compensation claims?
The Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC) has adopted a medical fee guideline, hospital fee guideline, ambulatory surgical center fee guideline, dental fee guideline and a guideline on pharmaceutical benefits.
- Where can I find out more information about the Medical Fee Guideline (MFG)?
- Where can I find out more information about the Hospital Fee Guidelines?
- Where can I find out more about the Ambulatory Surgical Center (ASC) Fee Guideline?
- Where can I find out more information about the pharmaceutical benefits?
- 28 Texas Administrative Code (TAC) §134.203 and §134.204: http://www.tdi.texas.gov/wc/fee/index.html
- General Information: http://www.tdi.texas.gov/wc/fee/index.html
- Frequently Asked Questions: Medical Fee Guideline Frequently Asked Questions
- 28 TAC §134.403 Outpatient: http://www.tdi.texas.gov/wc/fee/index.html
- 28 TAC §134.404 Inpatient: http://www.tdi.texas.gov/wc/fee/index.html
- Frequently Asked Questions: http://www.tdi.texas.gov/wc/fee/index.html
- 28 TAC §134.402: Ambulatory Surgical Center (ASC) Fee Guideline
- Calculations Examples: http://www.tdi.texas.gov/wc/fee/documents/ascexamples.ppt
A medical care provider may not pursue a private claim against an injured employee for all or part of the cost of the health care services provided in most cases. Actions that would indicate pursuit of a private claim include:
1. Sending a bill to an injured employee when an information copy was not requested by the injured employee.
2. Contact by a health care provider trying to collect money for services.
3. Letters sent to the injured employee from a collection agency.
4. Filing a lawsuit in court.
5. Filing a claim with the injured employee's private health insurance.
A health care provider may pursue a private claim only when the work-related injury is finally adjudicated by TDI-DWC as non-compensable. Pursuing a private claim when the work-related injury has not been adjudicated by TDI-DWC as non-compensable is an administrative violation and subject to a penalty.
A Designated Doctor is a doctor, selected by TDI-DWC, to provide unbiased medical information about the injured employee's medical condition or to resolve a dispute about a work-related injury or occupational illness. The Designated Doctor can address issues and provide a medical information to resolve any questions regarding maximum medical improvement (MMI), impairment rating (IR), the extent of the injury, whether the employee's disability is a direct result of the work-related injury, the ability of the employee to return to work, and ability to return to work during the supplemental income benefits (SIBS) period.
To become a Designated Doctor, you must meet all of the Designated Doctor requirements. For more information regarding training and criteria, visit the TDI website at http://www.tdi.texas.gov/wc/hcprovider/dd.html.
Medical Fee Dispute Resolution is a disagreement about the denial or reduction of reimbursement for compensable and medically necessary health care already provided. Please click on the following links to find more information on Medical Fee Disputes.
- How do I file a medical fee dispute resolution request?
- How much time do I have to file the medical fee dispute resolution request?
- How do I appeal the Medical Fee Dispute Resolution decision?
- How can I find out more about Medical Fee Dispute Resolution?
If a dispute arises over medical fees of a claim, TDI-DWC administers a Medical Fee Dispute Resolution process to resolve the issue.
All requests for retrospective medical fee dispute resolution must be no later than one (1) year after the date of service(s) in dispute. See 28 Texas Administrative Code (TAC) § 133.307.
For disputes filed with MFDR prior to June 1, 2012
If you do not agree with the decision issued by Medical Fee Dispute Resolution, you may request a contested case hearing before the State Office of Administrative Hearings in which the amount of reimbursement sought is greater than $2,000.00. If the amount of reimbursement sought is equal to or less than $2,000.00, you may request a contested case hearing conducted by a TDI-DWC hearing officer. The request must be filed with TDI-DWC's Chief Clerk of Proceedings no later than 20 days from the date you received the decision. Follow the instructions under the "Your Right to Request a Hearing" section on the decision.
For disputes filed with MFDR on or after June 1, 2012
Requesting a Benefit Review Conference (BRC):
A party seeking review of an MFDR decision must request a BRC no later than 20 days from the date the MFDR decision is received by the party. The DWC Form-045M, Request to Schedule, Reschedule, or Cancel a Benefit Review Conference to Appeal a Medical Fee Dispute Decision, is required to be submitted to the TDI-DWC to request a BRC and may be found on the forms page.
Requesting arbitration or a contested case hearing (CCH) before the State of Administrative Hearings (SOAH):
If the medical fee dispute remains unresolved after a BRC, the parties may request arbitration or a CCH before the State Office of Administrative Hearings (SOAH) within 20 days after conclusion of the BRC. The DWC Form-044, Election to Engage in Arbitration, is required to be submitted to the TDI-DWC request arbitration and may be found on the forms page. The DWC Form-049, Request to Schedule a Medical Contested Case Hearing (MCCH), is required to be submitted to the TDI-DWC to request a SOAH hearing and may be found on the forms page.
Requesting Judicial Review:
A party seeking to appeal a decision by a SOAH administrative law judge must file a lawsuit in the appropriate court pursuant to Texas Labor Code §413.031 (k-1) and Chapter 2001, Subchapter G of the Government Code. The party seeking judicial review must file suit not later than the 45th day after the date on which SOAH mailed the party the notification of the decision. The mailing date is considered to be the fifth day after the date the decision was issued by SOAH.
TDI-DWC has developed a detailed slide presentation to assist workers' compensation system participants in understanding the Medical Fee Dispute Resolution process. The Medical Fee Dispute Resolution basics addresses the steps to follow when filing a Medical Fee Dispute Resolution request.
This process is for health care providers, insurance carriers, and injured employees who seek further review of disputed medical care or reimbursement.
9. How can a Health Care Provider stay informed of changes in the Texas workers' compensation system?
One of the most convenient methods to help you and your office stay up to date on Texas workers’ compensation specific information is to subscribe to the DWC eNews mailing list.
For recent changes and postings on the TDI-DWC website visit the What's New section and for current DWC initiatives visit DWC’s home page. Also, DWC hosts and is requested to present at many seminars and educational programs throughout the year around the state of Texas. DWC is very focused on ensuring education is provided for newly adopted rules. By being added to DWC's eNews mailing list you will receive notifications and instructions on how to register for offered seminars and educational programs or you can visit the Events & Training page to learn about the opportunities available to you and your office. You may also find it useful to visit the bulletins page for clarification on rules and laws.
Quick links to resources:
- Performance Based Oversight (PBO) of health care providers and insurance carriers
- Official Disability Guidelines (ODG)*
- Texas workers compensation fee guidelines
- E-billing requirements in the Texas workers' compensation system
- TDI-DWC Forms
- CARF Accredited Programs exempted from Preauthorization
- Texas State Board of Medical Examiners*
* See the TDI Linking Policy for information about links to external websites.
10. The Texas workers’ compensation system uses Medicare as a framework for its Fee Guidelines; how can I stay informed of changes made by the Centers for Medicare and Medicaid Services (CMS)?
Many providers in the Texas workers’ compensation system have found it useful to register with Novitas Solutions, Inc.*, the Medicare contract administrator for Texas, to help them stay informed of changes made by CMS. If you choose to register with Novitas Solutions, Inc.* you will be offered an option to receive automatic notifications detailing changes to Medicare procedures and policies.
To locate other resources for updates on CMS you may consider using a web search engine*; a few suggested search phrases are:
- Updates on CMS
- CMS updates
- Updates from the Centers for Medicare and Medicaid Services
- Medicare updates
Quick links to resources:
- Medicare home page*
- Centers for Medicare & Medicaid Services (CMS) Fee Schedules*
- Novitas Solutions, Inc.*
- Medicaid fee guideline* information for dental and home health services
- Cigna Government Services* the CMS Durable Medical Equipment contract administrator for Texas
* See the TDI Linking Policy for information about links to external websites.
A Letter of Clarification (LOC) is a letter drafted by the Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) and sent to a designated doctor requesting clarification on certain issues in a report the doctor submitted following the examination of an injured employee.
Under 28 Texas Administrative Code (TAC) §126.7(u) parties to a workers’ compensation claim who want clarification of a report of a designated doctor may file a request with the TDI-DWC for a LOC.
The TDI-DWC may contact the designated doctor requesting a LOC, “if it determines that clarification is necessary to resolve an issue" regarding the report [28 TAC §126.7(u)].
Under 28 TAC §126.7 (v), disputes regarding the designated doctor’s report shall be resolved through the dispute resolution process.
- How does a party request a LOC?
- When may a party submit the request of LOC?
- Do parties have a right to an LOC?
- Who will approve or deny my request for letter of clarification?
- What happens after a request is approved?
- When may the TDI-DWC reviewing officer order an examination?
- Who will schedule the TDI-DWC ordered examination?
- What happens if the TDI-DWC denies a request for a LOC?
- What are the options if a request for LOC is denied?
Parties to a workers’ compensation claim can submit a request for a LOC to the TDI-DWC field office handling the claim. For a list of TDI-DWC field offices and their contact information, visit the agency website at http://www.tdi.texas.gov/wc/dwccontacts.html#offices.
Parties may submit a request for a LOC to the TDI-DWC at any point in the dispute resolution process [i.e., prior to a Benefit Review Conference (BRC), during a BRC or during a Contested Case Hearing (CCH)]. Historically, most requests have been submitted prior to a BRC.
Parties are allowed by TDI-DWC rule to request an LOC. The ultimate determination of whether a Letter of Clarification is granted rests with the TDI-DWC.
Beginning September 1, 2010, all LOC requests will be approved or denied by TDI-DWC Benefit Review Officers or TDI-DWC Benefit Contested Case Hearing Officers. LOC requests received by the TDIDWC prior to a proceeding being scheduled will be approved or denied by a Benefit Review Officer. LOC requests will be approved if the reviewing officer determines that clarification is necessary to resolve an issue regarding the report pursuant to 28 TAC §126.7(u).
Should the TDI-DWC determine clarification is necessary, they send a letter to the designated doctor setting out the questions to be answered. Sometimes additional medical or other information is provided for consideration. The designated doctor has five days to provide a response to the request for clarification.
If the reviewing officer determines that additional information is necessary to resolve an issue regarding a designated doctor’s report but determines that an examination is necessary, the reviewing officer may approve the LOC request and order an examination to enable the designated doctor to adequately respond to the LOC request.
If the TDI-DWC orders an examination, the examination will be scheduled by the TDI-DWC, through the Designated Doctor Scheduling Section (DDS). The DDS will coordinate the appointment with the designated doctor and will notify the parties of the date, time and location of the examination.
If the TDI-DWC denies a request for a LOC, a denial letter will be sent to the requesting parties specifying the reasons for the denial.
If the TDI-DWC denies a request for a LOC, parties may:
(a) resubmit the request for an LOC, taking into account the reasons for the previous denial;
(b) request a Benefit Review Conference to dispute the issue for which the designated doctor was appointed and resubmit the request for an LOC at the Benefit Review Conference; or
(c) dispute the denial of a request for clarification through the TDI-DWC dispute resolution process.
12. How can a health care provider determine workers’ compensation insurance coverage for an injured employee?
Workers’ compensation insurance coverage information is available on the Texas Department of Insurance website at http://www.tdi.texas.gov/wc/employer/coverage.html. For additional assistance, call the Texas Department of Insurance, Division of Workers’ Compensation at 1-800-372-7713 and select option 6 (in Austin call 512-804-4345).
For more information contact:
Last updated: 07/24/2013