Part 2.
TEXAS WORKERS' COMPENSATION COMMISSION
Chapter 110.
REQUIRED NOTICES OF COVERAGE
Subchapter A. CARRIER NOTICES
28 TAC §110.1
The Texas Workers' Compensation Commission (commission) adopts
amendments to §110.1 of this title, concerning Requirements for Notifying
the Commission of Insurance Coverage, without changes to the proposed text
published in the April 4, 2003, issue of the
Texas
Register
(28 TexReg 2880).
As required by the Government Code §2001.033(1), the commission's
reasoned justification for this rule is set out in this order which includes
the preamble, which in turn includes the rule. This preamble contains a summary
of the factual basis of the rule, a summary of comments received from interested
parties, names of those groups and associations who commented and whether
they were for or against adoption of the rule, and the reasons why the commission
disagrees with some of the comments and proposals.
Previously, the commission did not address the use of insurance binders
by rule, although they are an accepted part of insurance practice as a precursor
to issuing a policy. As a result, carriers did not have a way of notifying
the commission that a temporary binder agreement between an employer and carrier
providing workers' compensation coverage was in effect. This amendment clarifies
the issuance of a binder as constituting workers' compensation coverage and
provides that the same rules that apply to canceling a policy apply to canceling
a binder.
By Advisories 2002-07 and 2002-07B the commission has implemented the electronic
reporting of insurance coverage information by commercial insurance carriers
through designated data collection agents effective September 1, 2002. The
International Association of Industrial Accident Boards and Commissions (IAIABC)
Proof of Coverage (POC) Release 2 standard is used as the reporting medium.
The commission has received requests from several carriers to report workers'
compensation insurance coverage represented by binders using the IAIABC POC
binder transaction to meet the reporting requirements of §110.1. The
amended section more clearly states how binders are used in the Texas workers'
compensation system and clarify the requirements for reporting workers' compensation
insurance coverage to the commission.
Adopted §110.1 adds new subsection (a), which clarifies that a binder
constitutes an approved insurance policy as referenced in Texas Labor Code §401.011(44)(A),
and new subsection (b), which defines the term, "insurance coverage information"
as used in the rule. The amendments re-designate the remaining subsections
as (c) through (l) accordingly. Amended subsection (e) clarifies that the
requirements of that subsection apply to employers who do not have workers'
compensation insurance coverage.
Language is added to subsection (h)(2), requiring an insurance carrier
to notify the commission if it cancels a binder before it issues a policy.
Although no changes were proposed or made to subsection (i), it should be
noted that the adopted changes to the rule make this subsection applicable
to situations in which a binder is canceled prior to the issuance of a policy.
That is, workers' compensation insurance coverage, including coverage that
becomes effective pursuant to the issuance of a binder, remains in effect
until the later of the circumstances enumerated in current subsection (i).
Other amendments were made for clarity and for consistency in terminology.
Comments supporting the proposed amendment to §110.1 were received
from the Insurance Council of Texas. Comments opposing the proposed amendments
to §110.1 were received from the Texas Association of Responsible Nonsubscribers.
Summaries of the comments and commission responses are as follows:
COMMENT: Commenter stated general support of the rule as proposed as it
responded to requests from the insurers to have the commission accept the
reporting of workers' compensation insurance coverage as represented by binders
using the IAIABC POC binder transaction.
RESPONSE: The commission concurs.
COMMENT: Commenter took exception to the statement in the proposal preamble
that the proposed changes benefit all system participants in providing more
complete and accurate information regarding the existence of workers' compensation
coverage for Texas employers. Commenter did not believe that the proposed
changes would benefit nonsubscribing employers.
RESPONSE: The commission disagrees. The amendment does benefit system participants
in the way described. Nonsubscribing employers have opted out of the workers'
compensation system and are not considered system participants.
COMMENT: Commenter disagreed that the proposed amendment either improves
clarity or consistency as it relates to coverage reports provided by nonsubscribing
employers, and specifically found that the terminology of "insurance coverage
information" in §110.1(e) would be confusing to nonsubscribing employers
since many nonsubscribing employers provide various other types of insurance.
RESPONSE: The commission disagrees. The amendments to §110.1(a) clarify
the effect of a workers' compensation insurance binder. This clarification
is helpful to those who need to confirm workers' compensation coverage. In
addition, new subsection (b) defines "insurance coverage information" as information
regarding whether or not an employer has workers' compensation insurance coverage
and subsection (e) clearly states that it is applicable to employers who do
not have workers' compensation insurance coverage. Therefore, this information
should not cause confusion regarding other types of insurance coverage.
The amendments are adopted pursuant to Texas Labor Code §401.024,
which allows the commission to collect coverage information by electronic
transmission; Texas Labor Code §402.042, which authorizes the Executive
Director to prescribe the form, manner, and procedure for transmission of
information to the commission; Texas Labor Code §402.061, which authorizes
the commission to adopt rules necessary to administer the Texas Workers' Compensation
Act (Act); Texas Labor Code Chapter 406, Subchapter A, which addresses workers'
compensation coverage election and security procedures, including Texas Labor
Code §406.006, which requires insurance carriers to report employer coverage
and claim administration contact information to the commission; Texas Labor
Code §406.008, which requires insurance carriers to report changes they
initiate to employer coverage to the commission; and Texas Labor Code §406.009,
which requires the commission to collect and maintain coverage information;
monitor and enforce the compliance of the timely submission of coverage information
and authorizes the commission to adopt rules as necessary to enforce the provisions
of Texas Labor Code Chapter 406, Subchapter A.
The amendments are adopted pursuant to Texas Labor Code §§401.024,
402.042, 402.061, Chapter 406, Subchapter A, including, §§406.006,
406.008, and 406.009.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on May 16, 2003.
TRD-200303038
Susan Cory
General Counsel
Texas Workers' Compensation Commission
Effective date: June 5, 2003
Proposal publication date: April 4, 2003
For further information, please call: (512) 804-4287
28 TAC §124.2
The Texas Workers' Compensation Commission (the commission)
adopts amendments to §124.2, concerning Carrier Reporting and Notification
Requirements, with changes to the proposed text published in the April 4,
2003, issue of the
Texas Register
(28 TexReg
2882).
As required by the Government Code §2001.033(1), the commission's
reasoned justification for this rule is set out in this order, which includes
the preamble, which in turn includes the rule. This preamble contains a summary
of the factual basis of the rule, a summary of comments received from interested
parties, names of those groups and associations who commented and whether
they were for or against adoption of the rule, and the reasons why the commission
disagrees with some of the comments and proposals.
Changes made to the proposed rule are in response to public comment received
in writing and are described in the summary of comments and responses section
of this preamble.
Changes in the proposed text are found in §124.2(c)(1) and §124.2(n).
In order to properly execute its responsibilities under the Texas Labor
Code, the commission must associate reported workers' compensation claims
with the coverage information reported by the insurance carrier (as defined
in Texas Labor Code §401.011(27)) under §110.1 of this title (related
to Requirements for Notifying the Commission of Insurance Coverage). To facilitate
this process and allow for its automation, the commission amends §124.2(c)(1)
to require that specific items of coverage information (the insurance carrier's
Federal Employer Identification Number (FEIN), the employer's policy number
and the policy period) be reported by the insurance carrier in conjunction
with the information from the Employer's First Report of Injury and that this
information be identical with that reported under §110.1 for the employer
associated with the claim.
Section 124.2(c)(4) has been amended to require that the items of coverage
information specified in §124.2(c)(1) be reported to the commission through
a "Change" transaction if they are not available when the First Report of
Injury is submitted.
The provisions for reporting the required coverage information are already
incorporated in the International Association of Industrial Accident Boards
and Commissions (IAIABC) Electronic Data Interface First Report of Injury
currently in use by the commission pursuant to subsection (b) of the rule.
No changes to the current First Report of Injury record layout are required
by the amended rule.
Analysis of the commission's database indicates that of the first reports
of injury submitted by EDI, all of them contain the carrier's FEIN (mandatory
field), approximately 86 percent contain the policy number, and approximately
70 percent contain the policy period information. However, of the first reports
of injury containing the policy number, in only 58 percent of the cases does
the policy number match the policy number reported through the coverage reporting
system. This rule change emphasizes the importance of consistent reporting
of these key data elements which will enable the automated association of
claim and coverage information in the commission's new automation system (TXCOMP).
All participants in the workers' compensation system interact with the
insurance carrier (as defined in Texas Labor Code §401.011(27)) or the
third party representing the insurance carrier for various claim administration
functions such as coverage verification, claim adjustment, medical billing
and preauthorization. The commission is continuously asked for this contact
information but does not currently collect or maintain it in a standardized
or accessible form. New §124.2(n) requires each insurance carrier to
provide to the commission, through its Austin representative, the contact
information for all workers' compensation claim service administration functions
performed by the insurance carrier either directly or through third parties.
The insurance carrier may provide this information either by creating and
maintaining a single World Wide Web (Web) page containing this information
and furnishing the Uniform Resource Locator (URL) of that Web page to the
commission through its Austin representative or by having the Austin representative
make an online submission of the contact information that the commission will
make available to the public. This second option represents a change from
the rule as proposed, which only provided the Web page option.
The commission envisions that the input of the URL or contact information
will be performed by the carrier's Austin representative through their ability
to log onto the commission's new information system (TXCOMP) and update specific
information on the carrier's data record. Having the information provided
as data greatly enhances the commission's ability to use the information and
make it available to the other workers' compensation system participants.
Use of the Web page option will allow a carrier significant flexibility in
how the required information is organized and presented. While the functional
areas specified in the proposed amendment must be addressed, the contact points
may be grouped if that best suits the carrier's business model. If the carrier
chooses, it may provide a single point of contact that can either provide
the information required or direct the requester to the appropriate source.
Amended §124.2(c)(1) requires that certain coverage information (insurance
carrier FEIN, policy number and policy period) be reported by the insurance
carrier in conjunction with the information from the Employer's First Report
of Injury and that this information be identical with that reported under §110.1
for the employer associated with the claim.
Amended §124.2(c)(4) requires that the coverage information required
by §124.2(c)(1) be reported through a Change transaction if it is not
available when the First Report of Injury is submitted to the commission.
New §124.2(n) states the requirement for each insurance carrier to
provide to the commission, contact information for the claim service functions
of coverage verification, claim adjustment, medical billing, pharmacy billing
(if different from medical billing), and preauthorization request processing.
Telephone and facsimile numbers, mailing address, and company and/or department
e-mail address information for each function shall be provided. Communications
and staffing provided by the carrier in response to this subsection shall
conform to the requirements of §102.4 of this title (regarding, General
Rules for Non-Commission Communications). Each insurance carrier will provide
to the commission, through its Austin representative, the contact information
for these functions either by creating and maintaining a single World Wide
Web (Web) page containing this information and furnishing the Uniform Resource
Locator (URL) of that Web page to the commission through its Austin representative
or by having the Austin representative make an online submission of the contact
information that the commission will make available to the public. It is anticipated
that an insurance carrier's Austin representative will provide the URL for
its Web page or submit the contact information to the commission through their
access to the commission's automation system (TXCOMP).
Comments generally supporting the proposed amendments were received from
Texas Mutual Insurance Company. Comments generally opposing the proposed amendments
were received from Alliance of American Insurers, American Insurance Association,
and The St. Paul Companies, Inc. Comments generally supporting some of the
proposed amendments and generally opposing others were received from Insurance
Council of Texas.
In addition to supporting or opposing various portions of the rule, commenters
made suggestions for improvements to the rules or asked for clarification
on certain points. Such comments containing recommendations were received
from the following groups: The St. Paul Companies, Inc., Texas Mutual Insurance
Company, Alliance of American Insurers, Insurance Council of Texas and American
Insurance Association.
Summaries of the comments and commission responses are as follows:
Section 124.2(c)(1)
COMMENT: Commenter supported the proposed amendment of subsection (c)(1)
of §124.2.
RESPONSE: The commission concurs.
COMMENT: Commenter did not object to the data reporting requirements in
amended subsection (c)(1), but found the proposed language confusing and suggested
that the language be modified to clarify that the policy information to be
reported was that of the insured not the insurance company.
RESPONSE: The commission agrees that the proposed language would be improved
by differentiating between the FEIN, associated with the carrier, and the
policy number, policy effective date and policy expiration date associated
with the insured employer. Subsection (c)(1) has been changed to clarify this
distinction.
COMMENT: Commenter objected to the requirement that a carrier report the
carrier FEIN, policy number, policy effective date and policy expiration date
on the first report of injury and further objected to the requirement to report
the carrier FEIN, characterizing this as a new burden being placed on the
carrier, as this information is already provided through the coverage reporting
system. Commenter felt that this requirement would not improve the benefit
delivery system in any manner. The commenter recommended deletion of the first
report of injury data elements from the final rule.
RESPONSE: The commission disagrees. No new information is required to be
reported by this rule change. The commission already requires reporting of
the carrier's FEIN and the policy information in the first report of injury
under the current rule. As discussed earlier in this preamble, only on 58
percent of the first reports of injury received by the commission does the
policy number match with a policy number on coverage information provided
by the carrier pursuant to §110.1 of this title (regarding Requirements
for Notifying the Commission of Insurance Coverage). This amendment simply
requires consistency of reporting information between the first report of
injury and the coverage information required under §110.1. This consistency
of reporting will enable the commission to more efficiently link claims information
and coverage information, thereby facilitating better and more efficient customer
service by the commission to all system participants
COMMENT: Commenter requested clarification as to whether or not omission
of the specified data elements would cause the First Report of Injury to be
rejected.
RESPONSE: The carrier FEIN is, and has been for many years, a mandatory
data element. Its omission causes the First Report of Injury to be rejected.
The policy number, policy effective date and policy expiration date are not
mandatory fields and their omission does not cause the First Report of Injury
to be rejected.
Section 124.2(n)
COMMENT: The commenter stated that the concept of the commission providing
insurance company contact information to system participants was a good idea,
although they disagreed with the manner in which the commission proposed to
make the information available.
RESPONSE: The commission agrees that improvement of the exchange of claim
administration contact information is needed and has provided some new ways
to facilitate that exchange. The concerns expressed by the commenter are addressed
in responses which follow.
COMMENT: Commenters challenged the commission's statutory authority to
require a carrier to create a claims handling contact Web page.
RESPONSE: Section 406.006 of the Texas Labor Code requires insurance carriers
to file notice of coverage and claim administration contact information with
the commission and authorized the commission to adopt rules that establish
the specific information required. Section 406.010 of the Texas Labor Code
authorizes the commission by rule to specify the requirements for insurance
carrier designation of persons to provide claims service. Section 401.024
of the Texas Labor Code provides that the commission may by rule require the
use of an electronic transmission for specified information. "Electronic transmission"
means the transmission of information by facsimile, electronic mail, electronic
data interchange, or any other similar method. The use of an Internet-based
electronic transmission via a Web page is a similar method to the methods
listed. Electronic mail is similarly Internet based. Although the commission
has the authority to require the use of a Web page as a method of providing
claim administration contact information, the amended rule also establishes
a method of providing this information without developing a Web page.
COMMENT: Commenter believes the proposed amendments are unnecessary and
questioned the need for a specified method of providing carrier claim administrative
contact information, contending that the information was available from other
numerous, readily available sources such as toll free telephone numbers, general
websites, telephone directories, and from the employer.
RESPONSE: The commission disagrees. The commission receives approximately
500 telephone calls per day from workers' compensation system participants,
predominately health care providers, requesting contact information for the
carrier. The commission does not have this information available in an organized,
automated form and has depended on individual customer service employees having
personal reference lists. After the commission implemented its online coverage
look-up system on the state Web portal (TexasOnline), over sixty percent of
the comments received from users of that system asked for the addition of
the carrier contact information. This amendment will support the commission's
implementation of an enhanced version of the online coverage system that will
provide the claim administration contact information.
COMMENT: Commenters contended that developing and maintaining a Web page
would add significant cost for the carrier that would be passed on to the
employer as higher premiums.
RESPONSE: The commission disagrees. The Web page necessary to convey the
claim administration contact information requires a simple, content only page
with no functionality. Development and maintenance costs should be minimal.
However, to address the concerns of the commenters, the commission has added
an optional method of providing the claim administration contact information
that, while not offering the flexibility of the Web page option, will be at
no cost to the carrier.
COMMENT: Commenter recommended changing the language in §124.2(n)(1)(A)
to read "Policy issuance and effective dates of policy", and expressed concern
that the term, "Coverage verification questions," would raise the possibility
that the contact person is to make determinations regarding the compensability
of the claim.
RESPONSE: The Commission agrees and has added the language suggested by
the commenter as a parenthetical explanation of the term, "coverage verification."
Also, for clarity, the word "questions" was omitted from §124.2(n)(1)(A).
COMMENT: Commenter recommended a 12-month phase-in period for the requirements
of §124.2(n).
RESPONSE: The commission agrees that some phase-in period is appropriate,
however disagrees that the period should be 12 months. The commission has
adopted the amendments with an effective date of November 1, 2003. This will
allow carriers a sufficient time to prepare to meet the requirements.
COMMENT: Commenter expressed concern that the organizational layout and
contact information would provide insight on how a carrier conducts business,
delivers services and which providers it uses for those services. The commenter
stated that this information was an asset that the carrier guarded because
it differentiates one carrier from another.
RESPONSE: The commission agrees in part. The provider information is not
an issue with all carriers because many of them provide these services in-house
or through well-known associations. However, to address these concerns for
other carriers, the organizational layout information has been removed because
this information may reflect the insurance carrier's business practices.
COMMENT: Commenter stated that no other state has such a requirement.
RESPONSE: The commission is not reluctant to be a leader in providing what
is clearly a much-needed service to a large portion of the Texas workers'
compensation community. The need for improved communication of this contact
information is clear and the commission believes that the addition of the
no cost method of submitting the information, added in response to carrier
concerns is an innovation other states may want to consider.
COMMENT: Commenter expressed concern that this initiative by Texas might
lead to similar requirements by other states, resulting in a carrier having
to maintain multiple Web pages to meet each state's requirements. Another
commenter suggested that the rule specifically state that carriers do not
need to provide electronic information on a country-wide basis.
RESPONSE: The commission disagrees. The adopted amendments respond to a
specific need of the Texas workers' compensation system. Claim administration
contact information necessary for claims in the Texas workers' compensation
system is all that is addressed by this rule. In the United States, workers'
compensation is a state program and state requirements inherently differ.
The alternative process now provided by the current proposal should minimize
the financial impact on the carrier by providing a no cost method of complying
without being required to develop and maintain a Web page.
COMMENT: Commenter expressed a concern that the system proposed in the
amended rule would expose confidential claim information to compromise.
RESPONSE: The commission disagrees. There is no claim-specific information
required to be provided and no security exposure beyond that a carrier may
have through its own Web based systems.
COMMENT: Commenter expressed concern that insurance carrier employee personal
information would be accessible through the system, possibly exposing these
employees to unwarranted or threatening contacts.
RESPONSE: The commission disagrees. There is no requirement in the adopted
amendment that the contact information contain personal employee information.
No individual names are required. Telephone numbers and e-mail addresses should
be functional rather than personal.
COMMENT: Commenter provided general opposition to the rule as it might
delay service to the injured worker or health care provider if multiple calls
were required or the claim had not previously been reported. The commenter
also felt that the proposed amendment could be interpreted to require a very
complex organizational structure that, in the extreme, could extend down to
policy specific information. Commenter recommended that the carrier be allowed
to provide a point of contact in the carrier's claim department that could
either directly respond to the inquiry or properly direct the caller to someone
who could help them and proposed modified language that allowed for a single
point of contact.
RESPONSE: The commission agrees that a single point of contact may be preferable,
depending on the carrier's organizational structure and method of handling
the various claim service administrative functions. The language of the rule
has been modified in subsection (n)(1) accordingly to remove the direction
on how the information should be organized, thus allowing the carrier flexibility
in how this will be done. While contact points for the five functions listed
in the proposed amendment are required, if the carrier wishes, all five, or
any combination of functions, could be referred to a single contact.
COMMENT: Commenter felt that the five-day requirement to update the contact
information, found in subsection (n)(3), was unreasonable and should be extended
to twenty calendar days.
RESPONSE: The commission agrees that the five-day requirement proposed
may not provide enough time to update contact information. However, the claim
administration contact information is useless if it is not current and correct.
The proposed rule has been modified to require that the claim administration
contact information or URL address be updated within ten working days of a
change. The term, "business day," is changed to "working day" for consistency
with §102.3(b) of this title (regarding Computation of Time).
COMMENT: Commenter supported the commission's proposed flexibility in the
organization of the contact information page and recommended the addition
of a §124.2(n)(1)(F) to read: "Other administrative functions reflecting
an insurance carrier's business practices." The commenter recommended that
the carrier be allowed to include other contact information on the contact
page for use by other insurance functions such as insurance agents to check
on the status of a quote and policyholders to call regarding their premium
audit.
RESPONSE: The commission disagrees that this text should be added. The
rule states the required information that the carrier must make available.
While the carrier is not prohibited from providing additional contact information
on the contact page, the required information must be prominently presented.
The focus of the page is to provide contact information for claim administration
functions as regulated by the commission.
COMMENT: Commenter suggested as an alternative to the commission's proposed
Web page method of providing the claim administration contact information
that the commission require each carrier to submit their contact information
to the commission as a MS Word document which the commission would compile
into a directory, convert to a single Adobe PDF file and make available for
download from the commission's Web site.
RESPONSE: The commission disagrees. The commenter's suggested method would
require commission action to request the information and to request updates.
This would delay the dissemination of the information. Requiring the entity
that has the information readily available and knows when it changes enter
it directly creates a much more efficient and accurate system.
COMMENT: Commenter requested clarification as to whether the required contact
information only applied to contacts concerning Texas workers' compensation
claims.
RESPONSE: The commenter's understanding is correct that the requirement
only requires contact information regarding entities that handle Texas workers'
compensation coverage or claims.
COMMENT: Commenter requested clarification as to whether or not the commission
would require the contact information page to be accessible from the carrier's
Web site in addition to the commission's Web site.
RESPONSE: The commission intends to make the carrier's contact Web page
accessible through the commission's Web site. The carrier is not required
to make this same Web page accessible through their own Web site, although
the commission would encourage the carrier to provide complete claim service
procedure and contact information available to all workers' compensation participants
through the broadly accessible medium of the Web.
The amendments are adopted pursuant to the Texas Labor Code §401.011(27),
which defines an insurance carrier; Texas Labor Code §401.024, which
authorizes the commission to require by rule the use of an electronic transmission
of information; Texas Labor Code §402.042, which authorizes the Executive
Director to prescribe the form, manner, and procedure for transmission of
information to the Commission; Texas Labor Code §402.061, which authorizes
the commission to adopt rules necessary to administer the Act; Texas Labor
Code §406.006, which requires insurance carriers to report employer coverage
and claim administration contact information to the commission; Texas Labor
Code §406.010, which requires insurance carriers to provide claims service
and to designate sufficient numbers of persons to provide claims service and
requires the commission by rule to specify the requirements for such designation;
and Texas Labor Code, §409.005, which requires the insurance carrier
to file the report of injury on behalf of the policyholder.
The amendments are adopted pursuant to the Texas Labor Code, §§401.011(27),
401.024, 402.061, 406.006, 406.010, and 409.005.
§124.2.Carrier Reporting and Notification Requirements.
(a)
An insurance carrier shall notify the Commission and the
claimant of actions taken on, or events occurring in a claim as required by
this title.
(b)
The Commission shall prescribe the form, format, and manner
of required electronic submissions through publications such as advisory(ies),
instructions, specifications, the Texas Electronic Data Interchange Implementation
Guide, and trading partner agreements. Trading partners will be responsible
for obtaining a copy of the International Association of Industrial Accident
Boards and Commissions (IAIABC) Electronic Data Interchange Implementation
Guide.
(c)
The carrier shall electronically file, as that term is
used in §102.5(e) of this title (relating to General Rules for Written
Communication To and From the Commission), with the Commission:
(1)
the information from the original Employer's First Report
of Injury; the insurance carrier's Federal Employer Identification Number
(FEIN); and the policy number, policy effective date, and policy expiration
date reported under §110.1 of this title (relating to Requirements for
Notifying the Commission of Insurance Coverage) for the employer associated
with the claim, not later than the seventh day after the later of:
(A)
receipt of a required report where there is lost time from
work or an occupational disease; or
(B)
notification of lost time if the employer made the Employer's
First Report of Injury prior to the employee experiencing absence from work
as a result of the injury;
(2)
any correction of Commission-identified errors in a previously
accepted electronic record as provided in §102.5(e) of this title (Correction);
(3)
information regarding a compensable death with no beneficiary
(Compensable Death No Beneficiaries/Payees) not later than the tenth day after
determining that an employee whose injury resulted in death had no legal beneficiary;
and
(4)
a change in an electronic record initiated by carrier (Change),
the coverage information required by paragraph (1) of this subsection if not
available when the First Report of Injury was submitted to the commission
and any change in a claimant or employer mailing address within 7 days of
receipt of the new address.
(d)
The carrier shall notify the Commission and the claimant
of a denial of a claim (Denial) based on non-compensability or lack of coverage
in accordance with this section and as otherwise provided by this title.
(e)
The carrier shall notify the Commission and the claimant
of the following:
(1)
first payment of indemnity benefits on a claim (Initial
Payment) within 10 days of making the first payment;
(2)
change in the net benefit payment amount caused by a change
in the employee's post-injury earnings (Reduced earnings) within ten days
of making the first payment reflecting the change;
(3)
change in the net benefit payment amount that was not caused
by a change in employee's post-injury earnings, this includes but is not limited
to subrogation, attorney fees, advances, and contribution (Change in Benefit
Amount) within 10 days of making the first payment reflecting the change;
(4)
change from one income benefit type to another or to death
benefits (Change in Benefit Type) within 10 days of making the first payment
reflecting the change;
(5)
resumption of payment of income or death benefits (Reinstatement
of Benefits) within 10 days of making the first payment;
(6)
termination or suspension of income or death benefits (Suspension)
within 10 days of making the last payment for the benefits.
(7)
employer continuation of salary equal to or exceeding the
employee's Average Weekly Wage as defined by this title (Full Salary) within:
(A)
seven days of receipt of the Employer's First Report of
Injury or a Supplemental Report of Injury (if the report included information
that salary would be continued) if the carrier has not initiated temporary
income benefits; or
(B)
ten days of making the last payment of temporary income
benefits due to the employer's continuation of full salary.
(f)
Notification to the claimant as required by subsections
(d) and (e) of this section requires the carrier to use plain language notices
with language and content prescribed by the Commission. These notices shall
provide a full and complete statement describing the carrier's action and
its reason(s) for such action. The statement must contain sufficient claim-specific
substantive information to enable the employee/legal beneficiary to understand
the carrier's position or action taken on the claim. A generic statement that
simply states the carrier's position with phrases such as "employee returned
to work," "adjusted for light duty," "liability is in question," "compensability
in dispute," "under investigation," or other similar phrases with no further
description of the factual basis for the action taken does not satisfy the
requirements of this section.
(g)
Notification to the Commission as required by subsections
(c), (d) and (e) of this section requires the carrier to use electronic filing,
as that term is used in §102.5(e) of this title. In addition to the electronic
filing requirements of this subsection, when a carrier notifies the Commission
of a denial as required by subsection (d) of this section, it must provide
the Commission a written copy of the notice provided to the claimant under
subsection (f) of this section. The notification requirements of this section
are not considered completed until the copy of the notice provided to the
claimant is received by the Commission.
(h)
Notification to the Commission and the claimant of a dispute
of disability, extent of injury, or eligibility of a claimant to receive death
benefits shall be made as otherwise prescribed by this title and requires
the carrier to use plain language notices with language and content prescribed
by the Commission. These notices shall provide a full and complete statement
describing the carrier's action and its reason(s) for such action. The statement
must contain sufficient claim-specific substantive information to enable the
employee/legal beneficiary to understand the carrier's position or action
taken on the claim. A generic statement that simply states the carrier's position
with phrases such as "no medical evidence to support disability," "not part
of compensable injury," "liability is in question," "under investigation,"
"eligibility questioned" or other similar phrases with no further description
of the factual basis for the action taken does not satisfy the requirements
of this section.
(i)
The Commission shall send an acknowledgment to the transmitting
trading partner detailing whether an electronically submitted record was accepted,
accepted with errors, or rejected. The acknowledgment shall be provided directly
to the trading partner submitting the transmission, not through the Austin
representative box identified in §102.5 of this title. If the record
was accepted with errors in conditional elements, the carrier must correct
the errors in accordance with §102.5 of this title.
(j)
Except as otherwise provided by this title, carriers shall
not provide notices to the Commission that explain that:
(1)
benefits will be paid as they accrue;
(2)
a wage statement has been requested;
(3)
temporary income benefits are not due because there is
no lost time;
(4)
the carrier is disputing some or all medical treatment
as not reasonable or necessary;
(5)
compensability is not denied but the carrier disputes the
existence of disability (if there are no indications of lost time or disability
and the employee is not claiming disability); or
(6)
future medical benefits are disputed (notices of which
shall not be provided to anyone in the system).
(k)
Written requests for a waiver of the electronic filing
requirement for the Employer's First Report of Injury may be submitted to
the Commission's executive director or his/her designee for consideration.
Waivers must be requested at least annually and the requests must include,
a justification for the waiver, the volume of the carrier's claims and total
premium amounts, current automation capabilities, Electronic Data Interchange
(EDI) programming status, and a specific target date to implement EDI. Waivers
require written approval from the executive director and shall be granted
at the discretion of and for the time frame noted by the Executive Director
or his/her designee.
(l)
If specifically directed by the Commission, such as through
Commission advisory or the Texas Electronic Data Interchange Guide, the carrier
may provide the information required in subsection (c), (d), or (e) of this
section to the Commission in hardcopy/paper format.
(m)
Notifications to the claimant and the claimant's representative
shall be filed by facsimile or electronic transmission unless the recipient
does not have the means to receive such a transmission in which case the notifications
shall be personally delivered or sent by mail.
(n)
On or after November 1, 2003, each insurance carrier shall
provide to the commission, through its Austin representative in the form and
manner prescribed by the commission, the contact information for all workers'
compensation claim service administration functions performed by the insurance
carrier either directly or through third parties.
(1)
The contact information for each function shall include
mailing address, telephone number, facsimile number, and e-mail address as
appropriate. This contact information may be provided either in the form of
a single World Wide Web (Web) Uniform Resource Locator (URL) for a Web page
created and maintained by the carrier that contains the required information
or through an online submission to the commission.
(A)
Coverage verification (policy issuance and effective dates
of policy);
(B)
Claim adjustment;
(C)
Medical billing;
(D)
Pharmacy billing (if different from medical billing); and
(E)
Preauthorization.
(2)
If the Web page option is used the page shall contain the
date on which it was last updated and an e-mail address or other contact information
to which a user may report problems or inaccuracies.
(3)
The insurance carrier shall update the contact information
and/or Web URL within ten working days after any such change is made.
This agency hereby certifies that the adoption has been
reviewed by legal counsel and found to be a valid exercise of the agency's
legal authority.
Filed with the Office of
the Secretary of State on May 16, 2003.
TRD-200303041
Susan Cory
General Counsel
Texas Workers' Compensation Commission
Effective date: June 5, 2003
Proposal publication date: April 4, 2003
For further information, please call: (512) 804-4287
28 TAC §124.7
The Texas Workers' Compensation Commission (the commission)
adopts an amendment to §124.7, concerning Initial Payment of Temporary
Income Benefits, without changes to the proposed text published in the March
14, 2003, issue of the
Texas Register
(28
TexReg 2245).
As required by the Government Code §2001.033(1), the commission's
reasoned justification for this rule is set out in this order, which includes
the preamble, which in turn includes the rule. This preamble contains a summary
of the factual basis of the rule, a summary of comments received from interested
parties, names of those groups and associations who commented and whether
they were for or against adoption of the rule, and, if applicable, the reasons
why the commission disagrees with any comment or proposal.
No changes were made to the rule as proposed.
Section 124.6 was repealed as part of an earlier rule action which adopted §124.2
(Carrier Reporting and Notification Requirements) and §124.3 (Investigation
of an Injury and Notice of Denial/Dispute). As a result, the reference to §124.6
contained in §124.7(c) is inaccurate. This amendment removes that incorrect
reference.
Comments supporting the proposed amendment were received from the Insurance
Council of Texas.
Summaries of the comments and commission responses are as follows:
COMMENT: Commenter stated that the deletion of a reference to a rule that
has been repealed will prevent system participants from becoming confused
about the applicability of the repealed rule. The commenter supports the commission's
efforts to "clean up" rules by deleting language and rule references that
are no longer applicable or relevant.
RESPONSE: The commission agrees.
The amendment is adopted pursuant to the Texas Labor Code, §401.024,
which provides the commission the authority to require use of facsimile or
other electronic means to transmit information in the system; Texas Labor
Code, §402.042, which authorizes the Executive Director to enter orders
as authorized by the statute as well as to prescribe the form, manner, and
procedure for transmission of information to the commission; Texas Labor Code, §402.061,
which authorizes the commission to adopt rules necessary to administer the
Act; Texas Labor Code, §406.010, which authorizes the commission to adopt
rules regarding claims service; Texas Labor Code, §408.027, which sets
out the timeframe and procedures for payment of medical bills; Texas Labor
Code, §408.081, which provides that, except as otherwise provided, benefits
are to be paid weekly as and when they accrue; Texas Labor Code, §408.082
and §408.101, which define the accrual date for benefits; Texas Labor
Code, §409.021, which requires carriers to timely initiate or dispute
compensation; and Texas Labor Code, §409.022, which requires a notice
of refusal to specify the carrier's grounds for disputing a claim.
The amendment is adopted pursuant to the Texas Labor Code, §§401.024,
402.042, 402.061, 406.010, 408.027, 408.081, 408.082,408.101, 409.021, and
409.022.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on May 16, 2003.
TRD-200303039
Susan Cory
General Counsel
Texas Workers' Compensation Commission
Effective date: June 5, 2003
Proposal publication date: March 14, 2003
For further information, please call: (512) 804-4287
28 TAC §126.11
The Texas Workers' Compensation Commission (the commission)
adopts amendments to §126.11, concerning the Extension of the Date of
Maximum Medical Improvement for Spinal Surgery without changes to the proposed
text published in the April 4, 2003, issue of the
Texas Register
(28 TexReg 2885).
As required by the Government Code §2001.033(1), the commission's
reasoned justification for this rule is set out in this order which includes
the preamble, which in turn includes the rule. This preamble contains a summary
of the factual basis of the rule, a summary of comments received from interested
parties, names of those groups and associations who commented and whether
they were for or against adoption of the rule, and the reasons why the commission
disagrees with some of the comments and proposals.
No changes were made to the proposed rule in response to public comment
received in writing and no public hearing was requested or held.
Section 408.026 of the Texas Workers' Compensation Act (the Act) was revised
by the 77th Texas Legislature, 2001, to delete the spinal surgery second opinion
process and instead establish carrier liability for medical costs related
to non-emergency spinal surgery through the preauthorization process as provided
by §413.014 (relating to Preauthorization Requirements; Concurrent Review
and Certification of Health Care). Section 413.014 directs that all non-emergency
spinal surgery procedures require preauthorization approval prior to surgery,
and concurrent review approval for the continuation of treatment beyond previously
approved treatment.
The statutory revision is applicable only to health care services requested
or provided on or after the effective date of rules adopted by the commission.
This necessitated a transitory period during which pending requests continued
to be processed under the second opinion process of §133.206 and new
requests were handled under the preauthorization process in. Following the
2001 Legislative session, the commission amended §133.206 to reflect
that it applied only to health care provided or requested prior to January
1, 2002. All of those requests have been finalized and therefore, §133.206
is no longer needed and has been repealed.
Amended §126.11 replaces the rule language that references approval
for non-emergency spinal surgery through the spinal surgery second opinion
process with the appropriate references to the preauthorization process in §134.600
(relating to Preauthorization Requirements; Concurrent Review and Certification
of Health Care).
The language is further amended to delete the reference to §134.1001
(relating to the Spine Treatment Guideline), abolished effective January 1,
2002 by House Bill 2600, 77th Texas Legislature.
Adopted subsection (a) replaces language that references the spinal surgery
second opinion section of the commission with language that connects an approval
for spinal surgery to the preauthorization process. The language of subsection
(a) is further revised to reflect the approval notification source as the
insurance carrier (carrier) as provided in the preauthorization process, rather
than the commission.
Amended subsection (f)(3) deletes the reference to §134.1001 (the
abolished Spine Treatment Guideline).
Amended subsection (j) replaces the language of "concurrence finding" with
"preauthorized approval."
Comments supporting the proposed amendment to §126.11 were received
from the Insurance Council of Texas.
A summary of the comment and commission response is as follows:
COMMENT: Commenter expressed support of the amendment to §126.11 as
a necessary "rule clean-up" to avoid confusion and misinformation.
RESPONSE: The commission agrees.
The amendment is adopted pursuant to the Texas Labor Code, §402.061,
which authorizes the Commission to adopt rules necessary to administer the
Act; the Texas Labor Code, §402.072, which mandates that only the Commission
can impose sanctions which deprive a person of the right to practice before
the Commission, receive remuneration in the workers' compensation system,
or revoke a license, certification or permit required for practice in the
system; the Texas Labor Code, §408.022, which requires an employee receiving
treatment under the workers' compensation system to choose a doctor from a
list of doctors approved by the Commission and establishes the extent of an
employee's option to select an alternate doctor; the Texas Labor Code §408.026,
(as amended by HB-2600, 2001 Texas Legislature) that requires the preauthorization
of non-emergency spinal surgery; the Texas Labor Code Chapter 410, which provides
procedures for the adjudication of disputes; the Texas Labor Code §413.014
(as amended by HB-2600, 2001 Texas Legislature) that requires the commission
to specify by rule, except for treatments and services required to treat a
medical emergency, which health care treatments and services require express
preauthorization and concurrent review by the carrier as well as allowing
health care providers to request precertification and allowing the carriers
to enter agreements to pay for treatments and services that do not require
preauthorization or concurrent review. This mandate also states the carrier
is not liable for the cost of the specified treatments and services unless
preauthorization is sought by the claimant or health care provider and either
obtained or ordered by the commission; the Texas Labor Code §413.031,
which provides a process for dispute resolution for disputes involving medical
services; the Texas Labor Code, §415.034, which allows a party charged
with an administrative violation or the Executive Director of the Commission
to request a hearing with the State Office of Administrative Hearings; and
the Texas Government Code, §2003.021(c), which requires the State Office
of Administrative Hearings to conduct hearings under the Texas Labor Code,
Title 5, in accordance with the applicable substantive rules and policies
of the Texas Workers' Compensation Commission.
The amendment is adopted pursuant to the Texas Labor Code, §§402.061,
402.072, 408.022, 408.026, Chapter 410, §§413.014, 413.031, 415.034,
and the Texas Government Code, §2003.021(c).
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on May 16, 2003.
TRD-200303040
Susan Cory
General Counsel
Texas Workers' Compensation Commission
Effective date: June 5, 2003
Proposal publication date: April 4, 2003
For further information, please call: (512) 804-4287
The Texas Workers' Compensation Commission (the commission) adopts
amendments to §133.2, concerning Sharing Medical Reports and Test Results
and the simultaneous repeal of §133.206, concerning Spinal Surgery Second
Opinion Process. Section 133.2 is adopted with a minor change to the proposed
text as published in the April 4, 2003, issue of the
Texas Register
(28 TexReg 2888). Section 133.206 is adopted without
changes to the proposal and will not be republished.
As required by the Government Code §2001.033(1), the commission's
reasoned justification for this rule is set out in this order, which includes
the preamble, which in turn includes the rule. This preamble contains a summary
of the factual basis of the rule, a summary of comments received from interested
parties, names of those groups and associations who commented and whether
they were for or against adoption of the rule, and the reasons why the commission
disagrees with some of the comments and proposals.
No changes were made to the proposed rule in response to public comment
received in writing and no public hearing was requested or held. One change
was made to §133.2(a) as proposed as a result of staff review.
Section 408.026 of the Texas Workers' Compensation Act (the Act) was revised
by the 77th Texas Legislature, 2001, to delete the spinal surgery second opinion
process and instead establish carrier liability for medical costs related
to non-emergency spinal surgery through the preauthorization process as provided
by §413.014 (relating to Preauthorization Requirements; Concurrent Review
and Certification of Health Care). Section 413.014 directs that all non-emergency
spinal surgery procedures require preauthorization approval prior to surgery,
and concurrent review approval for the continuation of treatment beyond previously
approved treatment.
Adopted amendments to §133.2(a) remove language that referenced a
doctor "performing a second opinion on spinal surgery" to reflect the changes
in the Act regarding Spinal Surgery approval procedure and adds a "referral
doctor" to the list of doctors to whom the treating doctor is required to
forward copies of reports, radiographic films, and test results. In addition,
the word "and" has been changed to "or" to clarify that the treating doctor
is required to forward medical records to the appropriate doctor per the request.
The repeal of §133.206 reflects the statutory deletion of the spinal
surgery second opinion process from the Texas workers' compensation system.
The statutory revision is applicable only to health care services requested
or provided on or after the effective date of rules adopted by the commission.
This necessitated a transitory period during which pending requests continued
to be processed under the second opinion process of §133.206 and new
requests were handled under the preauthorization process in. Following the
2001 Legislative session, the commission amended §133.206 to reflect
that it applied only to health care provided or requested prior to January
1, 2002. All of those requests have been finalized and therefore, §133.206
is no longer needed and has been repealed.
Comments supporting in part and opposing in part the proposed amendment
to §133.2 and supporting the repeal of §133.206 were received from
the Insurance Council of Texas.
Summaries of the comments and commission responses are as follows:
COMMENT: Commenter expressed support for the repeal of §133.206.
RESPONSE: The commission agrees.
COMMENT: Commenter agreed with the proposed removal of language in §133.2
concerning a doctor providing a second opinion for spinal surgery.
RESPONSE: The commission agrees.
COMMENT: Commenter expressed concern that the amendment of §133.2
could make it difficult for insurers to receive the information they need
to make informed decisions regarding preauthorization and to deny unnecessary
spinal surgeries, as well as to perform meaningful preauthorization peer reviews.
Commenter recommended the addition of language to §133.2 to allow the
insurer or insurer's utilization review company performing preauthorization
and concurrent review to receive a full set of records, including radiographic
and other diagnostic films, from the treating doctor within 10 days of the
date the treating doctor receives the written request from the insurer or
insurer's utilization review agent.
RESPONSE: The commission disagrees with the proposed language inclusion
in §133.2. Because there is no longer a second opinion process for spinal
surgery, the suggested addition to the preauthorization process is appropriately
considered in the context of §134.600, Preauthorization, Concurrent Review
and Voluntary Certification of Health Care, rather than in §133.2 or §133.206
which are the subject of this rule action.
The amendment is adopted pursuant to the Texas Labor Code, §402.061,
which authorizes the Commission to adopt rules necessary to administer the
Act; the Texas Labor Code, §402.072, which mandates that only the Commission
can impose sanctions which deprive a person of the right to practice before
the Commission, receive remuneration in the workers' compensation system,
or revoke a license, certification or permit required for practice in the
system; the Texas Labor Code, §408.022, which requires an employee receiving
treatment under the workers' compensation system to choose a doctor from a
list of doctors approved by the Commission and establishes the extent of an
employee's option to select an alternate doctor; the Texas Labor Code §408.026,
(as amended by HB-2600, 2001 Texas Legislature) that requires the preauthorization
of non-emergency spinal surgery; the Texas Labor Code Chapter 410, which provides
procedures for the adjudication of disputes; the Texas Labor Code §413.014
(as amended by HB-2600, 2001 Texas Legislature) that requires the commission
to specify by rule, except for treatments and services required to treat a
medical emergency, which health care treatments and services require express
preauthorization and concurrent review by the carrier as well as allowing
health care providers to request precertification and allowing the carriers
to enter agreements to pay for treatments and services that do not require
preauthorization or concurrent review. This mandate also states the carrier
is not liable for the cost of the specified treatments and services unless
preauthorization is sought by the claimant or health care provider and either
obtained or ordered by the commission; the Texas Labor Code §413.031,
which provides a process for dispute resolution for disputes involving medical
services; the Texas Labor Code, §415.034, which allows a party charged
with an administrative violation or the Executive Director of the Commission
to request a hearing with the State Office of Administrative Hearings; and
the Texas Government Code, §2003.021(c), which requires the State Office
of Administrative Hearings to conduct hearings under the Texas Labor Code,
Title 5, in accordance with the applicable substantive rules and policies
of the Texas Workers' Compensation Commission.
Subchapter A. GENERAL RULES FOR REQUIRED REPORTS
28 TAC §133.2
The amendment is adopted pursuant to the Texas Labor Code, §402.061, §402.072, §408.022, §408.026,
Chapter 410, §413.014 §413.031, §415.034, and the Texas Government
Code, §2003.021(c).
§133.2.Sharing Medical Reports and Test Results.
(a)
The treating doctor within 10 days of receipt of a written
request shall forward to a referral doctor, consulting doctor, designated
doctor, or a doctor that is examining the claimant under a medical examination
order, copies of reports required in any rules in this part, radiographic
films, and test results, to prevent unnecessary duplication of tests and examinations.
An attending emergency doctor or facility will send copies of medical reports
and other information to the treating doctor upon request.
(b)
When the claimant changes treating doctors, the subsequent
treating doctor will contact, in writing, the previous doctor or, if unable
to contact the previous doctor, will contact the carrier to obtain copies
of all required written medical reports pertinent to the injury and test results
submitted to the carrier. The written request will include a signed waiver
from the claimant releasing the claimant's medical records to the subsequent
treating doctor. The previous doctor will send all information to the subsequent
doctor within 10 days of receipt of the written request.
(c)
The previous treating doctor shall charge the carrier no
more than the fair and reasonable cost as specified in §133.106(f) of
this title (relating to Fair and Reasonable Fees for Required Reports and
Records) for copies of required reports and test results when the copies are
forwarded to the subsequent treating doctor. The carrier shall reimburse the
reasonable copying charge for records provided to designated doctors, or a
doctor performing a required medical examination.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on May 16, 2003.
TRD-200303042
Susan Cory
General Counsel
Texas Workers' Compensation Commission
Effective date: June 5, 2003
Proposal publication date: April 4, 2003
For further information, please call: (512) 804-4287
28 TAC §133.206
The repeal is adopted pursuant to the Texas Labor Code, §402.061,
which authorizes the Commission to adopt rules necessary to administer the
Act; the Texas Labor Code, §402.072, which mandates that only the Commission
can impose sanctions which deprive a person of the right to practice before
the Commission, receive remuneration in the workers' compensation system,
or revoke a license, certification or permit required for practice in the
system; the Texas Labor Code, §408.022, which requires an employee receiving
treatment under the workers' compensation system to choose a doctor from a
list of doctors approved by the Commission and establishes the extent of an
employee's option to select an alternate doctor; the Texas Labor Code, §408.026,
(as amended by HB-2600, 2001 Texas Legislature) that requires the preauthorization
of non-emergency spinal surgery; the Texas Labor Code, Chapter 410, which
provides procedures for the adjudication of disputes; the Texas Labor Code, §413.014
(as amended by HB-2600, 2001 Texas Legislature) that requires the commission
to specify by rule, except for treatments and services required to treat a
medical emergency, which health care treatments and services require express
preauthorization and concurrent review by the carrier as well as allowing
health care providers to request precertification and allowing the carriers
to enter agreements to pay for treatments and services that do not require
preauthorization or concurrent review. This mandate also states the carrier
is not liable for the cost of the specified treatments and services unless
preauthorization is sought by the claimant or health care provider and either
obtained or ordered by the commission; the Texas Labor Code, §413.031,
which provides a process for dispute resolution for disputes involving medical
services; the Texas Labor Code, §415.034, which allows a party charged
with an administrative violation or the Executive Director of the Commission
to request a hearing with the State Office of Administrative Hearings; and
the Texas Government Code, §2003.021(c), which requires the State Office
of Administrative Hearings to conduct hearings under the Texas Labor Code,
Title 5, in accordance with the applicable substantive rules and policies
of the Texas Workers' Compensation Commission.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on May 16, 2003.
TRD-200303043
Susan Cory
General Counsel
Texas Workers' Compensation Commission
Effective date: June 5, 2003
Proposal publication date: April 4, 2003
For further information, please call: (512) 804-4287
28 TAC §165.6
The Texas Workers' Compensation Commission (the commission)
adopts an amendment to §165.6, concerning the Follow-up Inspection of
the Policyholder's Premises by the Division without changes to the proposed
text published in the April 4, 2003, issue of the
Texas Register
(28 TexReg 2890) and will not be republished. The amendment
corrects the reference to an article of the Texas Insurance Code.
As required by the Government Code, §2001.033(1), the commission's
reasoned justification for this rule is set out in this order which includes
the preamble, which in turn includes the rule. This preamble contains a summary
of the factual basis of the rule, a summary of comments received from interested
parties, names of those groups and associations who commented and whether
they were for or against adoption of the rule, and the reasons why the commission
disagrees with some of the comments and proposals.
No changes were made to the rule as proposed in response to public comment
received in writing and no public hearing was requested or held.
During a review of §165.6, it was noted that the reference to the
Texas Insurance Code in subsection (a) was incorrect. The rule cites Texas
Insurance Code, Article 5.76, §10(d) as the article requiring policyholders
to obtain a safety consultation. The article cited should be Article 5.76-3, §8(c).
This amendment removes the inaccurate reference and replaces it with the proper
one.
Comments supporting the proposed amendment to §165.6 were received
from the Insurance Council of Texas.
A summary of the comment and commission response is as follows:
COMMENT: Commenter expressed support of the amendment to §165.6 as
a necessary "rule clean-up" to avoid confusion and misinformation.
RESPONSE: The commission agrees.
The amendment is adopted pursuant to Texas Labor Code, §402.061,
which authorizes the Commission to adopt rules necessary to administer the
Act; Texas Labor Code, Chapter 415, which sets out prohibited acts, penalties,
and procedures for administrative violations; and Texas Insurance Code, §5.76-3,
which authorizes and sets out the provisions for the Texas Mutual Insurance
Company.
The amendment is adopted pursuant to Texas Labor Code, §402.061, Texas
Labor Code, Chapter 415, and Texas Insurance Code, §5.76-3.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on May 16, 2003.
TRD-200303044
Susan Cory
General Counsel
Texas Workers' Compensation Commission
Effective date: June 5, 2003
Proposal publication date: April 4, 2003
For further information, please call: (512) 804-4287
Subchapter B. MEDICAL BENEFIT REGULATION
Chapter 124.
CARRIERS: REQUIRED NOTICES AND MODE OF PAYMENT
Chapter 126.
GENERAL PROVISIONS APPLICABLE TO ALL BENEFITS
Chapter 133.
GENERAL MEDICAL PROVISIONS
Subchapter C. SECOND OPINION FOR SPINAL SURGERY
Chapter 165.
REJECTED RISK: INJURY PREVENTION SERVICES
Chapter 180.
MONITORING AND ENFORCEMENT