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Advisory 96-05


BACKGROUND: The Texas Workers' Compensation Commission has noticed that many insurance carriers are filing a TWCC-21 for situations which do not require the filing of this form. This includes the filing of TWCC-21s which state: the insurance carrier certifies benefits will be paid as they accrue, no compensable lost time, no disability, and other similar statements. These unnecessary TWCC-21s increase the number of documents that Commission personnel must process even though the forms serve no statutory purpose.

In addition, some insurance carriers are filing TWCC-21s contesting the reasonableness and necessity of medical benefits. These types of disputes should be retrospective in nature and are required to be filed on the TWCC-62, Notice of Medical Payment Dispute, after the insurance carrier receives, audits, and adjusts the claims for medical treatment. The inclusion of this language on a TWCC-21 often impedes the claimant's ability to secure ongoing medical treatment and consumes an inordinate amount of time on the part of claimants, health care providers, and Commission personnel to rectify the situation.

When the Electronic Data Interchange (EDI) Project is fully implemented, the system will not have open blocks for this type of text. Therefore, this advisory serves as notice that carriers need to change their procedures to eliminate unnecessary paperwork at the present time and to be prepared for the implementation of the EDI Project in the future.

Effective immediately, an insurance carrier shall file the TWCC-21, "Payment of Compensation or Notice of Refused/Disputed Claim", with the Commission only when required by provisions of the Act or TWCC Rules.

Insurance carriers shall file a TWCC-21 with the Commission when:

  1. Income benefits are initiated (Rule 124.2);
  2. Income benefits are reduced or terminated (Rule 124.4); or
  3. The compensability of the injury and/or occupational disease is disputed (Rule 124.6) -- this includes any initial contests of compensability and any subsequent disputes regarding compensability or extent of injury.

Insurance carriers shall not file a TWCC-21 when:

  1. The insurance carrier certifies benefits will be paid as they accrue;
  2. Temporary income benefits are not due because there is no lost time;
  3. Compensability is not disputed, but the carrier disputes the existence of disability;
  4. The insurance carrier is disputing some or all medical treatment as not reasonable or necessary;
  5. The insurance carrier is paying statutorily allowed liens (TWCC approved Attorney Fees or child support liens are not a reduction in the amount of income benefits); or
  6. The filing of the TWCC-21 is for informational purposes only.

This advisory is consistent with the requirements of the Electronic Data Interchange (EDI) Project and serves to minimize the submission and transfer of unnecessary paperwork and/or documents. This advisory supplements Advisory 93-06 and does not relieve the carrier of the obligation to file the TWCC-21 in cases where compensability is being disputed.

Signed April 5, 1996

Todd K. Brown, Executive Director