The Texas Department of Insurance, Division of Workers’ Compensation (DWC) created this plain language glossary for your general use. Please see the Texas Labor Code if you need an exact definition of a workers’ compensation term.
Act – A set of Texas workers’ compensation laws created to protect both the employer and the employee.
Administrative review – When an agency considers the outcome of a dispute. For instance, the DWC Appeals Panel reviews an administrative law judge’s decision. Judicial review is when a court considers the DWC Appeals Panel’s decision.
Adverse determination – When a utilization review agent finds that the health care services provided or prescribed for an injured employee are not medically necessary or are experimental or investigational.
Agreement (in workers’ compensation) – A legal contract. An agreement exists when one party makes an offer, and the other party accepts it. Parties must write agreements on DWC Form-024, Benefit Dispute Agreement, and sign it. Certain DWC staff, such as a benefit review officer or an administrative law judge, must also approve and sign the agreement. It can also be stated on the record in a contested case hearing.
Annuity – An amount of money paid yearly or in a series of payments. An agreement by an insurer to make regular payments for the life of the injured employee or to their beneficiary for a certain period.
Balance billing – When a doctor or hospital bills the injured employee for the difference between what they were charged for services and the amount insurance paid. For example, if the medical fee is $100 and insurance only pays $70, a provider may try to bill an injured employee for the remaining $30. Billing injured employees for medical services is not allowed in the Texas workers’ compensation system.
Certified network (workers’ compensation) – A TDI-certified health care delivery system made up of physicians and providers who are on contract to deliver necessary medical and health care services to injured employees.
Certificate of authority – This gives an insurer the power to write insurance contracts in Texas. DWC issues this certificate to private employers that want to insure their own workers’ compensation claims. This could also be a document showing the powers that an insurance carrier grants to its agents.
Classification – A group of employees insured by a workers’ compensation policy who have the same general job characteristics and risk. These groups help an insurance carrier determine a company’s insurance rates.
Complaint – A written statement claiming a workers’ compensation law or rule has been violated.
Contested case hearing (CCH) – This hearing is usually scheduled when disputes cannot be resolved at a more informal meeting (benefit review conference). During this hearing, parties offer evidence about disputed issues before a DWC administrative law judge (ALJ). The ALJ listens as each party explains its side of the case and then decides each issue.
Contested case hearing decision – After a contested case hearing, a DWC administrative law judge will issue a written decision. The decision will have findings of fact and conclusions of law that resolve the disputed issue or issues. The decision includes whether benefits are due.
Contributing injury – A past work injury to the same body part as the current injury. There must be medical proof of an impairment (lasting harm) from the past work injury that continues to affect the injured employee.
Contribution – The insurance carrier can ask DWC to reduce the amount of certain benefits they pay an injured employee if there was a past work-related injury to the same body part. DWC may allow this only if the insurance carrier can show the past work injury still causes impairment or lasting harm (contributing injury).
Course and scope – An injury that happens while an employee is doing activities related to the business of their employer and while furthering the interests of their employer.
Coverage verification – A way to find out if an employer had workers’ compensation insurance coverage on a certain date using the “verify coverage” link on the TDI website.
Death benefits – Benefit payments that help families replace some of the money lost when an employee dies from a work-related injury or illness.
Disability – An employee may have a disability if their work-related injury keeps them from earning what they were paid in the 13 weeks before they were hurt. In workers’ compensation, disability means a loss of income from a job, not a physical or mental condition.
Direct result – This is one of the requirements for supplemental income benefits. To meet this requirement, an injured employee must show that the work-related injury was serious, had lasting effects (impairment), and keeps them from doing the work they did at the time of their injury.
Dispute – A disagreement between parties in a workers’ compensation claim. Most disputes are about whether an injured employee can get medical or income benefits and the amount to be paid.
Documentary evidence – Anything you want the DWC administrative law judge to considered at your hearing. This can include written documents such as reports from expert witnesses, medical records, written witness statements, employer records, DWC forms, and police reports. It can also include photos, recordings, and electronic files.
DWC – The Texas Department of Insurance, Division of Workers’ Compensation. DWC oversees the administration and operation of the Texas workers’ compensation system.
Electronic Data Interchange (EDI) – A process that allows a party to securely send information to another party electronically rather than with paper. Workers’ compensation insurance carriers in Texas must report claim, medical, and proof of insurance coverage data to DWC using EDI.
Emergency care – Medical or behavioral health services provided in a hospital or similar facility. This includes severe pain that, if left untreated, could place a person’s health in danger, impair bodily functions, or cause serious disfigurement, and for a pregnant woman, harm the health of the unborn child.
Exceptions to liability – Reasons that allow the insurance carrier to dispute the injured employee’s claim. An exception could be a work injury that was not reported or filed on time, or events leading up to an injury such as intoxication, horseplay, or injuries that happen off duty.
Exchange – Information that all parties must share before a benefit review conference or hearing.
Existence, duration, or extent of disability – These are some of the more common disputes in workers’ compensation. There may be a dispute about whether a disability exists (existence), the period of disability (duration), or whether the disability is related to the compensable injury (extent of disability).
Experience rating – A way of adjusting the workers’ compensation insurance premium for a specific risk, by comparing losses of an insured party with the average losses for employers in a similar industry.
Formulary – A list of prescription drugs, both generic and name brand. These drugs are listed as pre-approved, not approved, or require authorization before they can be given out.
First responder – Employees such as peace officers, paramedics, firefighters, detention officers, county jailers, or emergency medical services staff, who work for a political subdivision in Texas, like a city, county, or school district. Volunteer first responders should ask their manager if they have workers’ compensation.
Geographic service area – An area where health care benefits are available and accessible if injured employees live or work within that area. If an employer is part of a workers’ compensation network, an injured employee who lives in the network’s service area must get health care services from a doctor or hospital in that service area.
Health Insurance Portability and Accountability Act of 1996 – This Act, also known as HIPAA, required the Department of Health and Human Services to create national standards for electronic health care transactions and national I.D. numbers for providers, health plans, and employers. It also addresses the security and privacy of health data.
Impairment income benefits (IIBs) – Payments an injured employee may be able to get if they have a work-related injury or illness that affects their body as a whole. The amount of IIBs an injured employee can get is based on an impairment rating that is assigned by a health care provider.
Independent review organization (in workers’ compensation) – An organization that the insurance commissioner certifies to review workers’ compensation cases. This review determines whether health care services provided to or proposed for an injured employee are medically necessary and appropriate.
Insurance carrier – Could be an insurance company, a certified self-insurer, a certified self-insurance group, or a government entity that self-insures. An insurance carrier contracts with an employer to provide medical and income benefits to an injured employee if they are hurt or get sick at work.
Interlocutory order request – In workers’ compensation, a request from a party to pay or to stop paying medical or income benefits until there is a final decision about a dispute from a DWC contested case hearing. This is usually requested during a benefit review conference.
International Association of Industrial Accident Boards and Commissions (IAIABC) – An organization that workers’ compensation commissioners and agency heads from the United States and other counties govern. The organization provides data collection standards and analysis to promote uniform data collection, monitors workers’ compensation policies, and develops model laws for state legislatures to enact.
Interrogatories – Questions used during discovery before a DWC hearing to get written responses from the other party. There are questions an injured employee can send to the insurance carrier and questions an insurance carrier can send to the injured employee.
Judicial review – When a party goes through the DWC dispute resolution process (an administrative review) and still disagrees with the decision about their benefits, they may appeal the decision to another level such as a district court for judicial review.
Justified complaints – A valid concern about an activity that violates a policy, contract, rule, or statute. Something that a person with average knowledge of medicine and health would think is below the standards they would expect of a business or medical practice.
Large group employer – A person or organization that employed at least 51 eligible employees during the previous calendar year and that employs at least two employees on the first day of the plan year.
Lifetime income benefits (LIBs) – An injured employee may be able to get these benefits for certain severe injuries. LIBs are paid for the life of the employee.
Letter of clarification – Letter that an insurance carrier, injured employee, or their representative sends to DWC asking for more information about a designated doctor’s report. The designated doctor will get this letter only if DWC approves the request.
Medicaid – A state and federally funded health care coverage program for eligible residents of the state. The Texas Health and Human Services Commission manages and monitors the Medicaid program.
Multiple employment – When an employee is not able to work because of their injury and had more than one job at the time they were hurt. The insurance carrier can include the average weekly wages from these other employers when determining income benefits owed.
National Association of Insurance Commissioners (NAIC) – An organization that insurance commissioners from all 50 states govern. NAIC provides data and analysis to promote uniform insurance regulation, monitors insurance financial health, and develops model laws for state legislatures to enact.
National Council on Compensation Insurance (NCCI) – An association of insurers selling workers’ compensation coverage and operating as a rating organization. NCCI collects statistics, develops rates and policy forms, and makes state filings for its members. NCCI collects proof of coverage information from insurance carriers for DWC.
National Provider Identifier (NPI) – A unique I.D. number that all health care providers are required to have and use on all health care forms. A provider can apply for an NPI number at the Centers for Medicaid and Medicare Services.
Network (in workers' compensation) – Doctors or providers who have contracts with an insurance carrier to treat injured employees of an employer who chooses to use a health care network. A workers' compensation health care network must be certified according to Texas Insurance Code Chapter 1305, Texas Administrative Code Chapter 10, and other rules..
Non-network (in workers' compensation) – Medical services provided to an injured employee when the employer has chosen not to use a network. Services in a non-network are provided, billed, and reimbursed according to the Texas Labor Code and TDI rules.
Notice of denial – (in compensability disputes) Insurance carriers send this letter to an injured employee or their beneficiaries to let them know they are not going to pay benefits on their claim.
Notice of continuing investigation – A letter insurance carriers must use to let an injured employee or beneficiary and DWC know that they are still looking into whether the claim is presumed to be work-related under Government Code Chapter 607.
Notice of network requirements – Information from the employer that tells employees what to do if they are hurt at work. An employer who has workers’ compensation coverage through a network must give employees information such as how to contact the network and how to get emergency care.
Occupational disease – Sickness or disease that happens while an injured employee is performing duties related to their employment (course and scope).
Pecuniary wages - Wages paid in money, such as salary, commissions, and bonuses. Wages include all forms of payment for a given period. Pecuniary wages include the market value of room and board, laundry, fuel, and any other benefit that can be estimated in money.
Performance based oversight assessment – The Texas Labor Code requires DWC to measure the performance of insurance carriers and health care providers in the Texas workers’ compensation system every two years. Based on the results, they are placed into poor, average, and high performing tiers.
Permanent impairment – Lasting damage to an injured employee from a work-related injury. Injured employees who have permanent damage from an injury and get an impairment rating from a doctor may be able to get impairment income benefits.
Pertinent information – Information that the party asking for a benefit review conference must provide to all parties to help resolve the dispute. Examples may include witness statements, police reports, or medical records.
Plain language – Language you understand the first time you read or hear it. Federal agencies must use plain language, and Texas insurance carriers must write health insurance policies and contracts in ways that people can easily understand.
Political subdivision – A local government, such as a county, city, school district, or housing authority that provides workers’ compensation coverage to their employees through a self-insurance pool.
Precertification authorization – A way to control costs by requiring doctors to submit a treatment plan and an estimated bill before providing treatment. This allows the insurer to determine if procedures are appropriate. It also lets the insured and the doctor know which procedures the insurance carrier will cover and at what rate.
Reconsideration – A request to an insurance carrier or health care network to review its denial of medical services or income payments (adverse determination). This request comes from an injured employee or from a health care provider on behalf of an injured employee.
Referrals (in network) – A request from a primary care physician or treating doctor that allows the patient to get care from a specialist or other provider within the network’s geographic service area.
Referrals (out-of-network) – A request from a physician or provider to allow an injured employee to get health care services outside their geographic service area when care is not available in the network.
Required medical exam – DWC orders injured employees to get this exam at the request of an insurance carrier when there are questions about whether the injured employee’s health care was appropriate or when they disagree about the designated doctor’s report on the injury.
Rules – DWC's statements of law or policy, generally published in Texas Administrative Code Title 28, Part 2.
Secure File Transfer Protocol (SFTP) – A secure, electronic way to send documents to DWC.
Self-insured governmental entity – State, county, and local entities, such as the state of Texas, Travis County, or the City of Austin, that must self-insure their employees for workers’ compensation.
Self-funded/self-insured benefit plans – A benefit plan an employer may provide as an alternative to workers’ compensation. The employer arranges and pays claims from its employees or others enrolled in the plan.
Small group employer – A person or entity who had an average of at least two employees but not more than 50 eligible employees during the prior calendar year and who employs at least two employees on the first day of the policy year.
Statewide average weekly wage – The average of wages paid to workers in Texas for a set period. The Texas Workforce Commission calculates this amount each year. This amount is used to set the minimum and maximum amounts of workers' compensation benefits that an injured employee will be able to get.
Statutory maximum medical improvement – When an injured employee reaches the end of the 104 weeks of temporary income benefits allowed by law. This date is based on when the employee first began losing wages from their injury (disability).
Subsequent Injury Fund – DWC administers this fund to encourage employers to hire employees with pre-existing conditions. If an employee gets a new injury while at work, the fund can help pay a portion of lifetime income benefits they might be due.
Supplemental income benefits (SIBs) – Income benefits that the insurance carrier pays to an injured employee after their impairment income benefits end. Unlike with other income benefits, an injured employee must apply for SIBs, have an impairment rating of 15% or more, and complete certain work search requirements.
Temporary income benefits (TIBs) – An injured employee may be able to get TIBs if a work-related injury or illness causes them to lose some or all of their wages for more than seven days.
Underwriting – The process of selecting risks for insurance and classifying them by their degree of insurability so that insurance carriers can assign the appropriate rates. The process also includes rejecting risks that do not qualify for insurance.
Wage statement – When an employee is hurt at work, the employer must fill out the DWC Form-003 – Employer’s Wage Statement. This form shows the average amount of money they paid the employee each week in the 13 weeks before they were hurt and is used by the insurance carrier to determine the amount of benefits due.
Workers’ compensation – Insurance coverage that provides income and medical benefits to employees who have a work-related injury or illness. Texas employers are not required to provide workers' compensation insurance coverage, but most do. Your employer must have workers' compensation insurance coverage for you to get benefits.