Claims Kit

Penalties for Late Reporting  409.021 (e)

An insurance carrier may be found to have committed an administrative violation if they do not initiate payments or file a notice of refusal as required statute.

Carriers must either commence payment of benefits (for accepted compensable injuries) or notify the Division and employee in writing of its refusal to pay benefits (for claim not accepted or otherwise requiring further investigation) no later than the 15th day after the date on which the carrier received written notice of the injury. 

Posting Requirements  Rule 110.101

An employer who has secured and purchased workers' compensation insurance coverage is considered a subscriber. As a subscribing employer, these parties are required to post notice at their workplace that provides all employees with the employer's insurance carrier name, information regarding the Ombudsman program at the Texas Department of Insurance within the Division of Workers' Compensation, and a contact number for reporting unsafe work conditions. This notice must be placed in the employer's personnel office and in a prominent place where employees can see it regularly. The following notice is to be completed and posted to satisfy these requirements. 

Notice to Employees Concerning Workers Compensation in Texas - Notice 6-English, Notice 6-Spanish

Such employers are also required to provide written notice of their applicable coverage to new employees upon hire. They must inform these new hire employees of their right to reject the employer's workers' compensation coverage and retain their common law right for action in district court. If at any time the employer's coverage lapses and is later retained, they are required to provide all employees with the information effected during and following the change of coverage.This must be provided to employees in writing. The following notice should be provided to satisfy these requirements.

New Employee Notice-English, New Employee Notice-Spanish

If an employer does not carry workers' compensation insurance coverage they are considered a "non-subscriber." These employers must must notify their employees and the Division that they do not have workers' compensation insurance.

Any notices posted so as to meet the above requirements should be posted in the language common to the employer's employee population. In all cases these notices must be posted and prominently displayed in the employer's personnel office, if any, and located about the workplace in such a way that each employee is likely to see the notice on a regular basis;

Employer Notice of No Coverage or Termination of Coverage - DWC005-English, DWC005S-Spanish

Notice to Employees Concerning Workers Compensation in Texas - Notice 5-English, Notice 5-Spanish

Failure to post or to provide notice as required in the above rule is a violation of the Act and Division rules. The violator may be subject to administrative penalties.

TDI adopts NCCI code changes for vaccination reactions

The Texas Department of Insurance (TDI) adopts National Council on Compensation Insurance (NCCI) filing Item U-1402—Injury Description Codes for Adverse Reaction to Vaccination for COVID-19 and Other Diseases. The changes apply to claims with an accident date of December 1, 2020, and later.

Reporting COVID-19 and COVID-19 Vaccine Reaction Claims

The Texas Department of Insurance, Division of Workers' Compensation (DWC) provides the following guidance to insurance carriers when submitting a First Report of Injury to DWC using electronic data interchange (EDI) for COVID-19 or a reaction to the COVID-19 vaccine.

How should I report a COVID-19 First Report of Injury to DWC?

On March 27, 2020, DWC published guidance advising insurance carriers to submit a COVID-19 First Report of Injury using the International Association of Industrial Accident Boards and Commissions’ (IAIABC) codes for EDI claims reports: “cause of injury” code 83 -Pandemic and “nature of injury” code 83 -COVID-19.

DWC reminds insurance carriers to use these specific codes when reporting a First Report of Injury involving a COVID-19 exposure or infection. Insurance carriers should also clearly indicate whether the claim involves COVID-19 in the incident description field. Following this guidance allows DWC to accurately monitor the frequency, cost, and outcome of these reported claims.

Should I file a First Report of Injury with DWC if an employee has an adverse reaction to a COVID-19 vaccine?

If a COVID-19 vaccination relates to an employee’s job, and it causes the employee to miss one or more days of work, you should file a First Report of Injury with DWC. Submitting a First Report of Injury to DWC does not mean that a COVID-19 vaccine reaction is work-related or that the insurance carrier is liable for payment.

How should I report a First Report of Injury to DWC that involves an adverse reaction to a COVID-19 vaccine?

The IAIABC and the Workers’ Compensation Insurance Organizations (WCIO) have developed new coding guidance for reporting an adverse reaction to a COVID-19 vaccine.

Insurance carriers should report COVID-19 vaccine reaction claims using the new "nature of injury" code 38 -Adverse Reaction to a Vaccination or Inoculation combined with the "cause of injury" code 83 -Pandemic. Insurance carriers should also clearly indicate whether the claim involves a COVID-19 vaccine reaction in the incident description field by using language such as “COVID-19 vaccine reaction.”

Do not report vaccine reaction claims using “nature of injury” code 83 - COVID-19.

Questions?

Insurance carriers should contact their trading partners to discuss claim EDI reporting requirements. For questions, contact Martha Luevano at 512-804-4858 or martha.luevano@tdi.texas.gov.

On June 2, 2020, the Division of Workers’ Compensation (DWC) issued a mandatory data call for certain information related to COVID-19 injuries reported to selected insurance carriers on or after December 1, 2019. DWC requested this information under Texas Labor Code §§401.024, 402.00111(b), 402.00128(b)(10) and (12), and Chapter 405.

To ensure that DWC has sufficient information to determine the impact of COVID-19 injuries on the Texas workers’ compensation system, DWC has extended the data call through June 2021.

As a reminder:

• Only selected insurance carriers/groups are required to comply with the data call. Selected insurance carriers must provide summary data using the COVID-19 data callreporting forms and instructions. Each selected insurance carrier or group is required to provideonedata submission per insurance carrier or group.
• Insurance carriers/groups must submit the requested data to DWC through the insurance carrier Austin representative’s secure file transfer protocol box no later than 5 p.m., Central time to be considered timely. See the schedule attached to this bulletin for a complete list of data call submission deadlines.
• Data call submissions are cumulative.

For questions about this bulletin, please contact the Workers’ Compensation Research and Evaluation Group atWCResearch@tdi.texas.gov.

COVID-19 Data Call Submission Deadlines

DWC Encourages Use of Fax for Form Submission

Due to COVID-19 and increased telecommuting, DWC will be forwarding all field office mail to the DWC headquarters in Austin. For quicker processing times, DWC encouragessystem participants to:

• Fax forms to DWC using the specific fax number listed on forms, proceedings-related documents to Hearings at 512-804-4011, or other documents to the DWC main fax number at 844-275-8915; or
• Mail documents to DWC headquarters in Austin at the address below.

National Council on Compensation Insurance Filing Item U-140-Nature and Cause of Injury Codes for COVID-19 (Coronavirus) Claims

The subject of this order is the adoption of amendments to the National Council on Compensation Insurance (NCCI) Statistical Plan for Workers Compensation and Employers Liability Insurance (Statistical Plan), as proposed in Item U-1401-Nature and Cause of Injury Codes for COVID-19 (Coronavirus) Claims (TDI ECase No. 24464; SERFF Tracking No. NCCI—132330992).

Background

NCCI filed Item U-1401 to amend the NCCI Statistical Plan. The amendments add a rule for reporting COVID-19 claims to NCCI using two new injury description codes: 83-COVID-19 and 83-Pandemic. These changes will allow proper reporting of these types of claims. After considering the filing, TDI adopts the following findings of fact and conclusions of law.

Findings of Fact

1. NCCI filed Item U-1401 with TDI on April 10, 2020, under the workers' compensation manual rule filing procedure adopted in Commissioner's Order No. 3142, dated March 21, 2014.

2. Item U-1401 amends the Statistical Plan to add a rule to report COVID-19 claims using two new injury codes: 83-COVID-19 and 83-Pandemic.

3. The rule and these codes are being added to identify claims attributable to COVID19.

4. NCCI proposed that the changes in Item U-1401 apply for new and renewal policies effective for claims attributable to COVID-19 with accident dates on and after December 1, 2019.

5. Item U-1401 has been available for public inspection in SERFF and at TDI since the filing date.

6. The filing, including exhibits, is incorporated by reference into this order.

7. On April 21, 2020, TDI published notice of the filing on the TDI website at www.tdi.texas.gov/rules/2020/nccimanual.html and distributed notice of the filing to electronic news subscribers.

8. TDI received one written comment on the filing by the May 21, 2020, deadline. The comment was from the Office of Injured Employee Counsel and supports the proposed amendments to the Statistical Plan.

9. TDI made no changes to the proposed amendments.

Conclusions of Law

1. TDI has jurisdiction over this matter under Insurance Code Article 5.96 and §§ 2051.002, 2051.201, 2052.002, 2053.002, 2053.011, 2053.051, 2053.052, 2053.053 and 36.001.

2. TDI gave notice in compliance with Commissioner's Order No. 3142.

3. The amendments to the NCCI Statistical Plan are consistent with Insurance Code Article 5.96 and Chapters 2051, 2052, and 2053.

4. Applying the changes in Item U-1401 for new and renewal policies effective for claims attributable to COVID-19 with accident dates on and after December 1, 2019, is reasonable.

Order

It is ordered that NCCI's filing, Item U-1401—Nature and Cause of Injury Codes for COVID19 (Coronavirus) Claims is approved. The changes in Item U-1401 apply for new and renewal policies effective for claims attributable to COVID-19 with accident dates on and after December 1, 2019.

DWC Issues Data Call Relating to Impact of COVID-19

DWC has issued a mandatory data call for certain information related to COVID-19 injuries reported to selected insurance carriers on or after December 1, 2019.

This data call is designed to provide DWC with immediate access to information necessary to determine the impact of COVID-19 injuries on the Texas workers’ compensation system.

DWC directs all selected insurance carriers and insurance carrier groups to provide summary data using the COVID-19 data callreporting forms and instructions. Each selected insurance carrier or group is required to provideonedata submission per insurance carrier or group.

Insurance carriers and groups must submit the requested data to DWC through the insurance carrier Austin representative’s Secure File Transfer Protocol box no later than 5 p.m., Central time on August 17, 2020. This submission should include all COVID-19 exposures and injuries reported and payments made on these injuries through June 30, 2020. See the schedule attached to this bulletin for subsequent submission deadlines. Subsequent data call submissions are cumulative.

Insurance carriers should maintain injury level data for the injuries reported in this data call and may be asked to submit that data to DWC in the future.

For questions about this bulletin, please contact the Workers’ Compensation Research and Evaluation Group atWCResearch@tdi.texas.gov.

COVID-19 Data Call Submission Deadlines

The National Council on Compensation Insurance (NCCI) filed Item U-1401- Nature and Cause of Injury Codes for COVID-19 (Coronavirus) Claims.

The filing proposes that the changes in Item U-1401 apply to new and renewal policies effective for claims attributable to COVID-19 with accident dates on and after December 1, 2019

New claims reporting codes for COVID-19

DWC encourages workers’ compensation insurance carriers to begin using the new International Association of Industrial Accident Boards and Commissions codes for electronic data interchange (EDI) claims reports: “cause of injury” code 83 – Pandemic and “nature of injury” code 83 – COVID-19 on April 1, 2020. The codes should be used for COVID-19 injuries occurring on or after December 1, 2019. DWC has updated its claims EDI collection systems to accept these new code values.

Filing fees and payments

If a DWC filing requires a payment by check, such as DWC Form-155, Request for Record Check or DWC Form-156, Prospective Employment Authorization and Certification, you may submit it without payment.

Signatures and sworn statements, affidavits, and notarization

You may submit filings and consent orders with electronic signatures and without sworn statements, affidavits, or notarization until further notice. This includes: • DWC Form-153, Request for Copies of Confidential Claimant Information; • DWC Form-155, Request for Record Check; and • DWC Form-156, Prospective Employment Authorization and Certification. In addition, until further notice, DWC will also accept these forms by fax, without the need to mail the original form. Fax these forms to 512-804-4146.

First Report of Injury

When reporting a claim, DWC requests that carriers clearly specify if a claim involves COVID19. This can be done in the incident description field on the first report of injury. This will help DWC monitor the impact of this event.

Reporting of Claim by Employer  120.2

The employer must report each death and occupational disease for which they have received notice of injury or knowledge to their insurance carrier. Employers must also report any injuries that result in more than 1 day of absence from work. As used here, the term "knowledge" includes receipt of written or oral information regarding diagnosis of an occupational disease, or the diagnosis of an occupational disease through direct examination or testing by a doctor employed by the employer.

The report of injury or illness is to be filed with the insurance carrier no later than the 8th day after having received notice of or having knowledge of an occupational disease or death, or not later than the 8th day after the employee's absence from work for more than one day due to a work-related injury. The report is considered filed when delivered personally, mailed, reported via tele-claim, electronically submitted, or sent by fax.

The employer will provide a written copy of the report and a written copy of the Notice of Injured Employee Rights and Responsibilities in English or Spanish or other language common to employee.

The employer must maintain a record of the date the copy of the report of injury and the date the notice of rights were provided to the employee. The employer must also maintain a record of the date the report of injury is filed with the insurance carrier.

If the insurance carrier has not received the report, the employer has the burden of proving that the report was filed within the required time frame. The employer has the burden of proving that good cause exists if the employer failed to timely file or provide the report.

The Division establishes the form, format, and manner of the Employer's First Report of Injury or Illness. The form filed with the Division by the insurance carrier thereafter is the DWC-005.

A party who fails to comply with this section may be found to have committed an administrative violation.

Physician Selection  408.022

Except in the case of emergency, the Division will require an injured employee to receive medical treatment from a doctor approved by the Commissioner. A doctor may perform only those procedures that are within the scope of the practice for which the doctor is licensed. The employee is entitled to the employee's initial choice of a doctor from the Division's approved provider list. The state also maintains a list of doctors who are not permitted to treat workers' compensation claims. Both of these can be found on the TDI's site. 

If the worker's employer has a formal network in place only network providers may be selected as their elected physician related to the workers' compensation claim. The employer should distribute copies of the network provider list, if applicable, upon receipt of notice or knowledge of an alleged work-related injury. If there is no network in place the worker may select a physician of their choosing to be their elected provider related to their claim. 

If an employee is dissatisfied with the initial choice of a doctor--either selected from an employer network or of the employee's choosing--the employee may attempt to secure a change of physician. If there is a network in place, the employee should notify the network administrator of their dissatisfaction and desire to select anew. The network may have options for the worker to consider moving forward. If there is no network in place, the employee will need to contact the Division to request a change of providers. This can be requested with a completed Employee's Request to Change Treating Doctors (DWC-053, English; DWC-053S, Spanish). A change of doctor may not be granted solely to secure a new impairment rating or medical report. 

The following are not considered selections of new or alternate doctors:

• A referral made by the doctor chosen by the employee if the referral is medically reasonable and necessary;
• The receipt of services ancillary to surgery;
• The obtaining of a second or subsequent opinion only on the appropriateness of the diagnosis or treatment;
• The selection of a doctor because the original doctor:
  • Dies;
  • Retires; or
  • Becomes unavailable or unable to provide medical care to the employee; or
• A change of doctors required because of a change of residence by the employee.