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§ 127.100. Designated Doctor Certification

(a) Applicability. This section applies to designated doctor applications received on or after the effective date of this section.

(b) In order to serve as a designated doctor, a doctor must be certified as a designated doctor. To be certified as a designated doctor, a doctor must:

(1) submit a complete designated doctor certification application as described by subsection (c) of this section;

(2) submit a certificate or certificates certifying that the doctor has within the past 12 months successfully completed all division required trainings and passed all division required testing on the specific duties of a designated doctor under the Act and division rules, including demonstrated proficient knowledge of the currently adopted edition of the American Medical Association Guides to the Evaluation of Permanent Impairment and the division’s adopted treatment and return-to-work guidelines;

(3) be licensed in Texas;

(4) have maintained an active practice for at least three years during the doctor’s career. For the purposes of this subsection, a doctor has an active practice if the doctor maintains or has maintained routine office hours of at least 20 hours per week for 40 weeks per year for the treatment of patients; and

(5) own or subscribe to, for the duration of the doctor’s term as a certified designated doctor, the current edition of the American Medical Association Guides to the Evaluation of Permanent Impairment adopted by the division for the assignment of impairment ratings and all return-to-work and treatment guidelines adopted by the division.

(c) A complete designated doctor certification application must be completed on the division’s required form for certification applications and must include:

(1) contact information for the doctor;

(2) information on the doctor’s education;

(3) a description of the doctor’s license(s), certifications, and professional specialty, if any;

(4) a description of the doctor’s work history and hospital or other health care provider affiliations;

(5) a description of any affiliations the doctor has with a workers’ compensation health care network certified under Chapter 1305, Insurance Code or political subdivision under Labor Code §504.053(b)(2);

(6) information regarding the doctor’s current practice locations;

(7) disclosure questions regarding the doctor’s professional background, education, training, and fitness to perform the duties of a designated doctor, including disclosure and summary of any disciplinary actions taken against the doctor by any state licensing board or other appropriate state or federal agency;

(8) the identities of any person(s) with whom the doctor has contracted to assist in performance or administration of the doctor’s designated doctor duties;

(9) an attestation that:

(A) all information provided in the application is accurate and complete to the best of the doctor’s knowledge;

(B) the doctor will inform the division of any changes to this information as required by §127.200(a)(8) of this title (relating to Duties of a Designated Doctor); and

(C) the doctor shall consent to any on-site visits, as provided by §127.200(a)(15) of this title, by the division at facilities used or intended to be used by the designated doctor to perform designated doctor examinations for the duration of the doctor’s certification.

(d) If a doctor passes a division-required test, the doctor may not retest within a twelve month period. If a doctor fails a division-required test, the doctor may not retest more than three times within a six month period.

(1) After the first or second attempt, the doctor must wait 14 days before retaking the test; or

(2) After the third attempt, the doctor must wait six months before retaking the test.

(e) The division shall notify a doctor of the commissioner’s approval or denial of the doctor’s application to be certified as a designated doctor in writing. Denials will include the reason(s) for the denial. Approvals certify a doctor for a term of two years and will include the effective date and expiration date of the certification. Approvals will also include the examination qualification criteria under §127.130 of this title (relating to Qualification Standards for Designated Doctor Examinations) that the division has assigned to the designated doctor as part of the doctor’s certification.

(f) Doctors may be denied certification as a designated doctor:

(1) if the doctor did not submit the information and documentation required by subsection (b) of this section;

(2) if the doctor did not submit a complete application for certification as required by subsection (c) of this section;

(3) for having a relevant restriction on their practice imposed by a state licensing board, certification authority, or other appropriate state or federal agency, including the division; or

(4) for other activities, events, or occurrences that the commissioner determines to warrant denial of a doctor’s application for certification as a designated doctor, including but not limited to:

(A) the quality of the doctor’s past reports as a certified designated doctor, if any;

(B) a history of complaints as a certified designated doctor, if any;

(C) excess requests for deferral from the designated doctor list as a certified designated doctor, if any;

(D) a pattern of overturned reports by the division or a court as a certified designated doctor, if any;

(E) a demonstrated lack of ability to apply or properly consider the American Medical Association Guides to the Evaluation of Permanent Impairment adopted by the division for the assignment of impairment ratings and all return-to-work and treatment guidelines adopted by the division as a certified designated doctor, if any;

(F) a demonstrated lack of ability to consistently perform designated doctor examinations in a timely manner as a certified designated doctor, if any;

(G) a demonstrated failure to identify disqualifying associations as a certified designated doctor, if any;

(H) a demonstrated lack of ability to ensure the confidentiality of injured employee medical records and claim information provided to or generated by a certified designated doctor, if any;

(I) applying for certification less than a year from denial of a previous designated doctor certification or recertification application; or

(J) any grounds that would allow the division to sanction a health care provider under the Act or division rules.

(g) Within 15 working days after receiving a denial, a doctor may file a written response with the division, which addresses the reasons given to the doctor for denial.

(1) If a written response is not received by the 15th working day after the date the doctor received the notice, the denial will be final effective the following day. No further notice will be sent.

(2) If a written response which disagrees with the denial is timely received, the division shall review the response and shall notify the doctor of the commissioner’s final decision. If the final decision is still a denial, the division’s final notice shall provide the reason(s) why the doctor’s response did not change the commissioner’s decision to deny the doctor’s application for certification as a designated doctor. The denial will be effective the day following the date the doctor receives notice of the denial unless otherwise specified in the notice.

(h) Designated doctors whose application for certification is approved but wish to dispute the examination qualification criteria under §127.130 of this title that the division assigned to the doctor may do so through the procedures described in subsection (g) of this section. Designated doctors must include in their response to the division the specific criteria they believe should be modified and documentation to justify the requested change.

(i) Designated doctors who are designated doctors on the effective date of this section shall be considered certified for the duration of the designated doctor’s current certification. Before the expiration of the designated doctor’s current certification, the designated doctor must timely apply for recertification under the applicable requirements of §127.110 of this title (relating to Designated Doctor Recertification).

(j) This section will become effective on December 6, 2018.

The provisions of this §127.100 adopted to be effective September 1, 2012, 37 TexReg 5422; amended to be effective November 4, 2018, 43 TexReg 7149.

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At a Glance:

Title:

§ 127.100. Designated Doctor Certification

Title:

Title 28. Insurance

Status:

Current

Usage:

New Law Rule

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