See also: Coronavirus resources
Q: How should carriers apply presumptions to claims at this time?
A. DWC expects insurance carriers to promptly comply with statute and rules relating to the investigation and payment of claims, including presumption claims. It is up to the insurance carrier to adjust the claim and assess whether a presumption is applicable.
Insurance carriers are expected to conduct a reasonable investigation of the claim and initiate benefits promptly when they are due to the injured employee. The statutory provisions for presumptions and entitlements to certain benefits for first responders can be found in Chapter 607 of the Government Code.
Q: Can carriers exchange documents with injured employees via email?
A. Yes. Until further notice, parties may file and exchange documents electronically, including with injured employees who have email addresses or fax numbers and agree to receive these documents electronically. DWC encourages parties to use fax or encrypted email and ensure that injured employees can access exchange documents sent electronically. Parties to CCHs must also send a copy of their exhibits to DWC and the other parties at least three working days before the CCH. You may send your exhibits to DWC in one of the following ways:
Q: Our operations have been impacted by the order to social distance/shelter in place, what will the division do if we miss certain deadlines?
A: DWC expects compliance with all deadlines that have not been waived. That said, DWC will consider the current situation when considering any possible enforcement actions. If you are experiencing specific issues, please share those with us. We need to know specifics.
Carriers should document specific details such as dates and locations of office closures, skeleton crews, late payments, etc. If complaints are filed, it could be months later that these details are needed to complete the investigation.
Q: What is being done about Performance Based Oversight? Is DWC still planning to review carriers using the same metrics?
A: Yes, DWC is statutorily required to assess carriers at least bi-annually. Selected carriers were assessed on timely payment of initial income benefits and timely processing of medical bills as well as their reports to DWC of that information. The preliminary findings of the assessment were issued on August 28, 2020. Management responses to the preliminary findings were due by October 5. DWC recognizes that the COVID-19 pandemic may have impacted the results of the assessment. Once the assessment is complete we will determine how best to recognize the unique circumstances and its impact on the final findings when announcing the results.
Q: Will you extend EDI reporting deadlines?
A: Not at this time. It is important that DWC has accurate and up-to-date data to monitor system performance.
When considering enforcement actions, we will take into account the challenges system participants are facing.
Q: Will 90-day finality for MMI/IR be stopped or disputed if a DWC Form-032 is submitted?
A: Yes. System participants must dispute a first certification of MMI or assigned IR by requesting and setting a Benefit Review Conference or, if a DD has not been appointed, by submitting a DWC Form-032 to request a DD exam.
You fulfill the requirement to dispute a certification of MMI and IR timely if DWC receives your DWC Form-032 within 90 days from the date the first MMI or IR determination was delivered to the injured employee.
Q: The bulletin authorizes payments to pharmacies up to a 90-day supply for any prescription medication. Does this include refills?
A: If the prescription allows for a 30-day prescription of a medication and three refills, the pharmacy could provide and be reimbursed for one 90-day supply, and the remainder of medication per the prescription (30 pills) could be issued as the final refill.
Q: Can carriers suspend sending correspondence to claimants via mail and send via email instead, if we have claimant’s email address?
A: Yes. Until further notice, insurance carriers may send documents electronically, including with injured employees who have email addresses or fax numbers and agree to receive these documents electronically. DWC encourages parties to use fax or encrypted email.
Q: Will DWC allow the correspondence information to be relayed via phone call with documentation of call content or a recorded call?
A: Nothing prohibits an insurance carrier from relaying information by phone call, but it does not relieve the insurance carrier from also sending the correspondence to the injured employee. Until further notice, insurance carriers may send documents electronically, including with injured employees who have email addresses or fax numbers and agree to receive these documents electronically. DWC encourages parties to use fax or encrypted email.
Q: Can MMI/IR services be delivered via telehealth/telemedicine?
A: No. Codes 99455 and 99456 are not among the CMS covered list of telehealth/telemedicine services in Texas.
Q: When should an insurance carrier report a COVID-19 exposure or report of injury under 28 Texas Administrative Code (TAC) §124.1 to DWC?
A: Insurance carriers must report any occupational disease to DWC no later than seven days from the receipt of a report of injury under 28 TAC §124.2(c). This includes first reports of injury from employers who have knowledge, either written or oral, that an employee has been diagnosed with an occupational disease under 28 TAC §120.2, regardless of whether the employee has lost time from work. Additionally, insurance carriers who take certain claim actions, such as a denial of compensability or liability, must electronically file a notice of the claim action as required under 28 TAC §§102.5 and 124.2 through electronic data interchange (EDI) and provide the required plain language notice to the injured employee and DWC.
While there is no legal requirement for insurance carriers to report exposure or quarantine notifications in the absence of a diagnosis or positive test result through EDI, DWC encourages them to do so for DWC to better assess the system impact of the disease. DWC also encourages insurance carriers to use the International Association of Industrial Accident Boards and Commissions codes for: “cause of injury” code 83 – Pandemic; and “nature of injury” code 83 – COVID-19 when filing EDI notices with DWC that involve COVID-19.
Insurance carriers must also report all medical bills paid, reduced, or denied for injured employees, including medical bills for COVID-19 tests, through EDI as required under 28 TAC §134.805.
DWC will issue a data call to selected insurance carriers in the near future to collect COVID-19 information, including summary information about number of exposures reported, the number of employees with positive tests or diagnoses, and the amount of workers’ compensation benefits paid to employees.