Texas Workers' Compensation

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§ 126.9. Choice of Treating Doctor and Liability for Payment

(a) The injured employee is entitled to the employee’s initial choice of treating doctor from the list of doctors approved by the Texas Workers’ Compensation Commission. As of January 1, 1993, any change in treating doctor after the initial choice requires approval from the commission. The term “doctor,” as used in this section, has the meaning defined in Texas Civil Statutes, Article 8308-1.03(17).

(b) The commission shall include, with the information mailed to the employee as required by the Act, § 5.09, the requirements related to the selection of a treating doctor from the commission-approved doctor list and to changing treating doctors as described in this section.

(c) The first doctor who provides health care to an injured employee shall be known as the injured employee’s initial choice of treating doctor. The following do not constitute an initial choice of treating doctor:

(1) a doctor salaried by the employer;

(2) a doctor recommended by the carrier or employer, unless the injured employee continues, without good cause as determined by the commission, to receive treatment from the doctor for a period of more than 60 days; or

(3) any doctor providing emergency care unless the injured employee receives treatment from the doctor for other than follow-up care related to the emergency treatment.

(d) If an injured employee wants to change treating doctors, other than exceptions as described in Texas Civil Statutes, Article 8308-4.64, or removal of the doctor from the list, the employee shall submit to the field office handling the claim, reasons why the current treating doctor is unacceptable. Unless medical necessity exists for an immediate change, the submission shall be in writing on a form prescribed by the commission. If the need for an immediate change exists, then the injured employee may notify the field office by telephone. Injured employees who change doctors because the doctor is removed from the list or for one of the exceptions listed in Texas Civil Statutes, Article 8308-4.64, shall immediately notify the commission of the change in the form and format prescribed by the commission.

(e) Reasons for approving a change in treating doctor include, but are not limited to:

(1) the reasons listed in Texas Civil Statutes, Article 8308-4.63(d); and

(2) the selected doctor chooses not to be responsible for coordinating injured employee’s health care as described in § 133.3 of this title (relating to Responsibilities of Treating Doctor).

(f) The commission shall issue an order approving or denying a change of doctor request. This order shall be issued within 10 days after receiving the request and, if a change is approved, shall include an order for the insurance carrier to pay for treatment provided by the approved doctor unless superseded by a subsequent order.

(g) With good cause, the injured employee or carrier may dispute the order regarding a change to an alternate treating doctor within 10 days after receiving the order. That dispute will be handled through the dispute resolution process described in Chapters 140-143 of this title (relating to Dispute Resolution/General Provisions, Benefit Review Conference, Benefit Contested Case Hearing, and Review by the Appeals Panel).

(h) The commission may, after holding a benefit contested case hearing as provided by Chapter 142 of this title (relating to Benefit Contested Case Hearing), relieve the carrier of liability for health care furnished by a doctor or health care provider at the doctor’s direction if:

(1) the doctor chosen by the employee is not on the list at the time the medical treatments or services are rendered; or

(2) the employee failed to comply with commission rules regarding a change in treating doctor.

(i) If the carrier is relieved of liability for the costs of health care, the employee may be billed for medical treatments or services provided the health care provider billing the employee had no knowledge of the violation by the employee at the time the medical treatments or services were rendered.

(j) The commission shall relieve the carrier of liability by an order which identifies the health care provider(s) and expressly states the time period for which the carrier is relieved of liability and whether the health care provider may submit the bill to the employee for those treatments or services. Provided, however, that a doctor removed from the list may not seek reimbursement under workers’ compensation for treatments or services rendered.

The provisions of this § 126.9 adopted to be effective July 1, 1993, 18 TexReg 3755.

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At a Glance:

Title:

§ 126.9. Choice of Treating Doctor and Liability for Payment

Title:

Title 28. Insurance

Status:

Current

Usage:

New Law Rule

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