Performance Based Oversight Frequently Asked Questions

Health Care Provider Questions | Insurance Carrier Questions | Print Friendly FAQ (pdf)

Health Care Provider Questions   

1. My fax machine doesn’t print a confirmation sheet but the report had a fax stamp with a handwritten date and initials when it was faxed. Will that be accepted as proof of timely filing? Answer to #1
2. What is the rule for timely filing the DWC Form-73? Answer to #2
3. What is the definition of a “complete” DWC Form-73? Answer to #3
4. If I mailed the DWC Form-73 to the insurance carrier and have proof of payment is that considered a timely filing of the form? Answer to #4
5. Can I use phrases such as “upon follow-up” or “in 4 weeks” for the expiration date of the employees work status on the DWC Form-73? Answer to #5
6. Can I use “pain”, “rehab”, “pending testing” and other phrases to describe how the injury prevented the injured employee from returning to work on the DWC Form-73? Answer to #6
7. What are the rule requirements for a timely release to return to work? Answer to #7
8. Who at TDI-DWC will be reviewing my medical documents on the timely release to return to work measure? Answer to #8
9. What are the rule requirements for timely filing the DWC Form 69? Answer to #9
10. If I have to refer the patient for additional testing when is the DWC Form 69 due? Answer to #10
11. I have questions regarding PBO. Who do I contact to discuss? Answer to #11
12. Will TDI-DWC also be contacting my scheduling company for copies of requested documents/records/forms? Answer to #12

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1. What is the rule for timely submission of rejected electronic records? Answer to #1
2. Will TDI-DWC review documentation for late processing of medical bill and payment data? Answer to #2
3. Are claims that are reported as Full Salary included in the assessment? Answer to #3
4. If I filed a PLN-1, Notice of Denial of Compensability/Liability and Refusal to Pay timely with TDI-DWC would this record be included in the assessment? Answer to #4
5. Who do I contact to discuss PBO? Answer to #5

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Frequently Asked Questions & Answers

Health Care Provider Questions & Answers    

1. My fax machine doesn’t print a confirmation sheet but the report had a fax stamp with a handwritten date and initials when it was faxed. Will that be accepted as proof of timely filing?
Answer: Stamping the report with a “fax stamp” and writing in the date when the report was faxed is not verifiable supporting documentation. This type of documentation doesn’t show who the report was sent to and the actual date and time of the fax. The fax confirmation page is the best documentation for the submission date.     

2. What is the rule for timely filing the DWC Form-73?
Answer: 28 Texas Administrative Code (TAC) §129.5(e) provides that the Work Status Report shall be sent, not later than the end of the second working day after the date of the examination, to the insurance carrier and the employer.      

3. What is the definition of a “complete” DWC Form-73?
Answer: 28 Texas Administrative Code (TAC) §129.5 (c) states the doctor shall be considered to have filed a complete Work Status Report if the report is filed in the form and manner prescribed by the Commission, signed, and contains at minimum: (1) Identification of the employee's work status, (2) Effective and/or estimated expiration dates of current work status and restrictions, (3) Identification of any applicable activity restrictions, (4) Explanation of how the employee's workers' compensation injury prevents the employee from returning to work, (5) General information that identifies key information about the claim.     

4. If I mailed the DWC Form-73 to the insurance carrier and have proof of payment is that considered a timely filing of the form?
Answer: 28 Texas Administrative Code (TAC) §129.5 (h)(1) states the report (DWC Form-73) filed with the insurance carrier or its agent shall be filed by facsimile or electronic transmission. Proof of payment for the submission of the Work Status Report does not indicate a timely filing of the report.    

5. Can I use phrases such as “upon follow-up” or “in 4 weeks” for the expiration date of the employees work status on the DWC Form-73? 
Answer: 28 Texas Administrative Code (TAC) §129.5 (c)(2) requires effective dates and estimated expiration dates of current work status and restrictions (an expected expiration date is not binding and may be adjusted in future Work Status Reports, as appropriate, based on the condition and progress of the employee).    

6. Can I use “pain”, “rehab”, “pending testing” and other phrases to describe how the injury prevented the injured employee from returning to work on the DWC Form-73? 
Answer: “Pain”, “Rehab” and other similar phrases does not describe how the injury prevented the injured employee from returning to work. 28 Texas Administrative Code (TAC) §129.5 (c)(4) requires an explanation of why the injury is preventing the injured employee from returning to work. Perhaps, a better description might be (pain medication makes him drowsy and unable to drive/work, injured employee is having surgery the next day, etc).      

7. What are the rule requirements for a timely release to return to work?  
Answer: 28 Texas Administrative Code (TAC) §137.10 discuss utilizing The Medical Disability Advisor, Workplace Guidelines for Disability Duration for the evaluation of expected or average return to work time frames.    

8. Who at TDI-DWC will be reviewing my medical documents on the timely release to return to work measure? 
Answer: A medical provider will review your medical documents. The medical provider will either be on staff at TDI-DWC or a member of TDI-DWC’s Medical Quality Review Panel.     

9. What are the rule requirements for timely filing the DWC Form 69? 
Answer: 28 Texas Administrative Code (TAC) §130.1 discuss the requirements of completing and reporting of the DWC Form 69. A DWC Form 69 shall be filed not later than the seventh working day after the date of the certifying examination or the receipt of all the medical information required.     

10. If I have to refer the patient for additional testing when is the DWC Form 69 due? 
Answer: 28 Texas Administrative Code (TAC) §126.7(k) states that additional testing must be completed within ten working days of the designated doctor’s physical examination of the injured employee and can extend the amount of time the designated doctor has to file the report by ten working days.       

11. I have questions regarding PBO. Who do I contact to discuss? 
Answer: You may send an e-mail to the PBO staff at PBO@tdi.state.tx.us and a staff member will address your concerns or contact you directly to further discuss.    

12. Will TDI-DWC also be contacting my scheduling company for copies of requested documents/records/forms? 
Answer: No.  TDI-DWC does not always know who is involved with a scheduling company, therefore, we are making the request for the medical documents/records/forms directly to the health care provider.

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Insurance Carrier Questions & Answers    

1. What is the rule for timely submission of rejected electronic records?
Answer: 28 Texas Administrative Code (TAC) §102.5 (e)(1) states that rejected records are not considered received by the Commission and must be corrected and re-submitted. Rejected records must be re-submitted by the original due date to be considered timely filed.     

2. Will TDI-DWC review documentation for late processing of medical bill and payment data?  
Answer: No, TDI-DWC will not be reviewing documentation of late reporting or processing of medical bill and payment data. Insurance carriers have the ability to correct any issues of data errors that might indicate a late processing of a medical bill and are expected to correct those issues. Insurance carriers are not prohibited from filing a written response to any findings on late processing or late reporting of medical bill and payment data.     

3. Are claims that are reported as Full Salary included in the assessment? 
Answer: No. If a claim is reported as Full Salary (FS), that record will be removed from the assessment.    

4. If I filed a PLN-1, Notice of Denial of Compensability/Liability and Refusal to Pay timely with TDI-DWC would this record be included in the assessment?
Answer: Insurance carriers must timely notify TDI-DWC of a denial of a claim based on non-compensability or lack of coverage by filing both the PLN-1 and the 148-04. If the insurance carrier did not timely complete both actions, the record remains in the assessment because a complete dispute was not filed.    

5. Who do I contact to discuss PBO? 
Answer: You may send an e-mail to the PBO staff at PBO@tdi.state.tx.us and a staff member will address your concerns or contact you directly to further discuss.

 

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