126.5
(a) A doctor who has contracted with or is employed by an authorized workers’ compensation health care network established under Insurance Code Chapter 1305, (network doctor) may not perform a required medical examination, as those terms are used under the Texas Workers’ Compensation Act (the Act), for an employee receiving medical care through the same […]
126.6
(a) When a request is made by the insurance carrier (carrier), or the Division, for a medical examination, the Division shall determine if an examination should occur. The Division shall grant or deny the request within seven days of the date the request is received by the Division. A copy of the action of the […]
130.2
(a) A treating doctor shall either examine the injured employee (employee) and determine if the employee has any permanent impairment as a result of the compensable injury as soon as the doctor anticipates that the employee will have no further material recovery from or lasting improvement to the work-related injury or illness, based on reasonable […]
181.1
(a) The membership of the Texas Certified Self-Insurer Guaranty Association (the Association) shall consist of all certified self-insurers (members) that hold a certificate of authority to self-insure issued by the Commissioner of Workers’ Compensation of the Texas Department of Insurance, Division of Workers’ Compensation (the Commissioner). Only certified self-insurers may be members of the Association. […]
141.5
(a) Definitions. As used in this section, “participant” means an individual entitled or permitted to attend and take part in a benefit review conference. Participants include: (1) the parties; (2) the parties’ representatives; (3) the employer exercising the right to present evidence relevant to the disputed issue or issues; and (4) any other individual, at […]
126.14
(a) On request of the insurance carrier, an injured employee is required to submit to a single examination per workers’ compensation claim for the purpose of defining the compensable injury. The examination: (1) shall not be requested prior to the eighth day after the date of injury, and (2) shall be scheduled to occur no […]
133.1
(a) This chapter applies to medical billing and processing for health care services provided to injured employees subject to a workers’ compensation health care network established under Insurance Code Chapter 1305, and to injured employees not subject to such networks, with the following exceptions pertaining only to health care services provided to an injured employee […]
133.3
(a) Any communication between the health care provider and insurance carrier related to medical bill processing shall be of sufficient, specific detail to allow the responder to easily identify the information required to resolve the issue or question related to the medical bill. Generic statements that simply state a conclusion such as “insurance carrier improperly […]
133.210
(a) Medical documentation includes all medical reports and records, such as evaluation reports, narrative reports, assessment reports, progress report/notes, clinical notes, hospital records and diagnostic test results. (b) When submitting a medical bill for reimbursement, the health care provider shall provide required documentation in legible form, unless the required documentation was previously provided to the […]
133.230
(a) An insurance carrier may perform an audit of a medical bill that has been submitted by a health care provider to the insurance carrier for reimbursement. The insurance carrier may not audit a medical bill upon which it has taken final action. (b) If an insurance carrier decides to conduct an audit of a […]