The purpose of this bulletin is to provide general direction and clarification of expectations to health care insurers and workers' compensation insurance carriers regarding sub-claimant reimbursement requests and payment or denials of these requests under Texas Labor Code §409.0091. It is not intended as a rulemaking and does not supersede any agency rulemaking on this subject.
REQUIRED FORMAT FOR DATA.
Section 409.0091(f) requires the Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC) to prescribe the form for the data elements that a health care insurer must include in its reimbursement requests. The TDI-DWC has prescribed DWC Form-026, Reimbursement Request for Payment Made by Health Care Insurer, for this use. To expedite processing, all data elements required by §409.0091(f) must be included in each reimbursement request and should be in the same data format as prescribed by DWC Form-026. If additional sheets are provided to present all required data, the required data elements should be in the same table format as prescribed by DWC Form-026. DWC Form-026 is available at http://www.tdi.state.tx.us/forms/dwc/dwc026hcpreim.pdf.
DATE OF DATA MATCH
The date of the data match is a threshold requirement for reimbursement eligibility. As such, health care insurers seeking reimbursement should provide the workers' compensation insurance carriers with information detailing the date of the data match.
CARRIER RESPONSE TO REQUEST FOR REIMBURSEMENT UNDER §409.0091
Upon receipt of the reimbursement request the workers' compensation insurance carrier should:
1) Pay the amount according to §409.0091(g) and (h);
2) If appropriate, request additional information according to §409.0091(i). If the workers' compensation insurance carrier requests additional information pursuant to §409.0091(i), the health care insurer has 30 days to respond to the request in accordance with §409.0091(j), unless the parties have agreed to an extended amount of time pursuant to §409.0091(k); or
3) Deny the request.
Health care insurers and workers' compensation insurance carriers should avoid actions that impede the efficient administration of this claims process. Health care insurers should verify the validity of their requests prior to submitting a reimbursement request. Workers' compensation insurance carriers should only request additional information that is actually needed to process a claim. Examples of information that is not required to process the request for reimbursement include, but are not limited to, evidence of a health care insurer anti-fraud plan (Texas Insurance Code Chapter 704 requires all health care insurers to have a anti-fraud plan), and required copies of DWC Form-066, Statement of Pharmacy Services, for pharmaceutical services since that form is only used when billing in the workers' compensation system.
Brent Hatch
Policy Advisor
Division of Workers' Compensation
Texas Department of Insurance