(a) An insurance carrier shall notify the division and the claimant of actions taken on or events occurring in a claim as required by this title.
(b) The division 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 insurance carrier shall electronically file, as that term is used in §102.5(e) of this title (concerning General Rules for Written Communications to and from the Commission), with the division:
(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 (concerning Insurance Carrier Requirements for Notifying the Division) 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 division-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 10th 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 the insurance 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 division and any change in a claimant or employer mailing address within seven days of receipt of the new address.
(d) The insurance carrier shall notify the division 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 insurance carrier shall notify the division 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), and the notice must be made within 10 days of making the first payment which reflects 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; or
(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 insurance carrier has not initiated temporary income benefits; or
(B) 10 days of making the last payment of temporary income benefits due to the employer’s continuation of full salary.
(f) If an insurance carrier receives a written notice of injury for a disease or illness identified by Texas Government Code, Chapter 607, Subchapter B (relating to Diseases or Illnesses Suffered by Firefighters, Peace Officers, or Emergency Medical Technicians), the insurance carrier shall take one of the following actions no later than the 15th day following receipt of the notice of injury:
(1) initiate benefits as required by the Workers’ Compensation Act and the division’s rules;
(2) file a notice of denial as described in this section; or
(3) provide the claimant and the division with notice as required under Labor Code §409.021(a-3) (Notice of Continuing Investigation) for a claim for benefits received on or after June 10, 2019.
(g) When applying subsection (f) of this section and Government Code, Chapter 607, Subchapter B, a “claim for benefits” means the first written notice of injury as provided in §124.1 of this title (concerning Notice of Injury).
(h) The insurance carrier shall issue a Notice of Continuing Investigation as a plain language notice in the form and manner prescribed by the division. The notification requirements of this section are not considered complete until a copy of the notice provided to the claimant is received by the division.
(1) A Notice of Continuing Investigation shall include the following:
(A) a statement describing all steps taken by the insurance carrier to investigate the disease or illness before the notice was given;
(B) a list of any claim-specific evidence, releases, or documentation the insurance carrier reasonably believes is both relevant and necessary to complete its investigation; and
(C) contact information for the adjuster, including the adjuster’s email address, facsimile number, and telephone number.
(2) An insurance carrier shall provide a reasonable amount of time for a claimant to respond to the notice.
(3) The notice may not include a request for additional diagnostic testing, mental health records, generic requests (such as “the claimant’s medical records”), or requests for records that are not directly related to either the disease or illness or eligibility for application of a statutory presumption.
(4) Notwithstanding the issuance of a Notice of Continuing Investigation, an insurance carrier must continue taking reasonable steps to acquire claim-specific information necessary to complete its investigation of the claim.
(i) Notification to the claimant as required by subsections (d) – (h) of this section requires the insurance carrier to use plain language notices in the form and manner prescribed by the division. These notices shall provide a full and complete statement describing the insurance carrier’s action and rationale. The statement must contain sufficient claim-specific substantive information to enable the claimant to understand the insurance carrier’s position or action taken on the claim. A generic statement that simply states the insurance 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.
(j) In addition to the denial notice requirements in subsection (i), if the insurance carrier receives a written notice of injury for a disease or illness identified by Texas Government Code, Chapter 607, Subchapter B (relating to Diseases or Illnesses Suffered by Firefighters, Peace Officers, or Emergency Medical Technicians), the denial must also include the following:
(1) If the insurance carrier asserts that a statutory presumption does not apply, a statement explaining why and describing the claim-specific information that the insurance carrier reviewed.
(2) Alternatively, based upon its investigation, if the insurance carrier concludes that a statutory presumption applies, but that a notice of denial will be issued, a statement explaining why and describing the claim-specific information reviewed prior to issuance of the notice, that supports a reasonable belief that risk factors, accidents, hazards, or other causes not associated with their employment were a substantial factor in bringing about the injured employee’s disease or illness, without which the disease or illness would not have occurred.
(3) If the insurance carrier provided a timely Notice of Continuing Investigation as permitted by law, the denial notice must also include a statement describing whether the claimant provided a timely response to the notice.
(k) Notification to the division as required by subsections (c) – (h) of this section requires the insurance carrier to use electronic filing, as that term is used in §102.5(e) of this title (concerning General Rules for Written Communications to and from the Commission).
(1) In addition to the electronic filing requirements of this subsection, when an insurance carrier notifies the division of a denial as required by this section, it must provide the division a written copy of the notice provided to the claimant as described under subsections (i) – (j) of this section, as applicable.
(2) The notification requirements of this section are not considered completed until the copy of the notice provided to the claimant is received by the division.
(l) Notification to the division 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 insurance carrier to use plain language notices in the form and manner prescribed by the division. These notices shall provide a full and complete statement describing the insurance carrier’s action and its reason(s) for such action. The statement must contain sufficient claim-specific substantive information to enable the claimant to understand the insurance carrier’s position or action taken on the claim. A generic statement that simply states the insurance 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.
(m) The division 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 insurance carrier must correct the errors in accordance with §102.5 of this title.
(n) Except as otherwise provided by this title, insurance carriers shall not provide notices to the division 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 insurance carrier is disputing some or all medical treatment as not reasonable or necessary;
(5) compensability is not denied but the insurance 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).
(o) Written requests for a waiver of the electronic filing requirement for the Employer’s First Report of Injury may be submitted to the commissioner or their designee for consideration. Waivers must be requested at least annually, and the requests must include a justification for the waiver, the volume of the insurance 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 and shall be granted at the discretion of and for the time frame noted by the commissioner or their designee.
(p) If specifically directed by the division, such as through division advisory or the Texas Electronic Data Interchange Guide, the insurance carrier may provide the information required in subsections (c) – (g) of this section to the division in hardcopy or paper format.
(q) 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.
(r) Each insurance carrier shall provide to the division, through its Austin representative in the form and manner prescribed by the division, 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 email address as appropriate. This contact information may be provided either in the form of a single Uniform Resource Locator (URL) for a web page created and maintained by the insurance carrier that contains the required information or through an online submission to the division.
(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
(2) If the web page option is used the page shall contain the date on which it was last updated and an email address or other contact information to which a user may report problems or inaccuracies.
(3) The insurance carrier shall update the contact information or URL within 10 working days after any such change is made.
(s) All notices to a claimant required under this section must be stated in plain language and in no less than 12-point font. This subsection applies to notices sent on or after April 1, 2020.
The provisions of this §124.2 adopted to be effective August 29, 1999, 24 TexReg 6503; amended to be effective June 5, 2003, 28 TexReg 4285; amended to be effective January 12, 2020, 45 TexReg 348