Texas Register, Volume 28, Number 14, Pages 2821-2988, April 4, 2003 Page: 2,884
2821-2988 p. ; 28 cm.View a full description of this periodical.
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rule as proposed, in whole or in part, may wish to comment to
that effect.
The amendments are proposed under the Texas Labor Code,
401.011(27) which defines an insurance carrier, Texas Labor
Code, 402.042, which authorizes the Executive Director to pre-
scribe the form, manner, and procedure for transmission of infor-
mation to the Commission; Texas Labor Code, 402.061, which
authorizes the commission to adopt rules necessary to adminis-
ter the Act; Texas Labor Code, 406.006, which requires insur-
ance carriers to report employer coverage and claim adminis-
tration contact information to the commission; and Texas Labor
Code, 409.005, which requires the insurance carrier to file the
report of injury on behalf of the policyholder.
No other code, statute, or article is affected by this rule action.
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 Inter-
national 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 Commu-
nication To and From the Commission), with the Commission:
(1) the information from the original Employer's First Re-
port of Injury and the insurance carrier's Federal Employer Identifica-
tion Number (FEIN), policy number, policy effective date and policy
expiration date reported under 110.1, of this title (relating to Require-
ments 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 pre-
viously 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 subsection (c) (1)
of this section if not available when the First Report of Injury was
submitted to the commission [as needed] 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 contri-
bution (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 (Re-
instatement 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 bene-
fits.
(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 in-
formation 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 no-
tices with language and content prescribed by the Commission. These
notices shall provide a full and complete statement describing the car-
rier's action and its reason(s) for such action. The statement must con-
tain sufficient claim-specific substantive information to enable the em-
ployee/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 descrip-
tion of the factual basis for the action taken does not satisfy the require-
ments 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 elec-
tronic 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 re-
quirements 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 dis-
pute of disability, extent of injury, or eligibility of a claimant to receive
death benefits shall be made as otherwise prescribed by this title and re-
quires the carrier to use plain language notices with language and con-
tent 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-specific28 TexReg 2884 April 4, 2003 Texas Register
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Texas. Secretary of State. Texas Register, Volume 28, Number 14, Pages 2821-2988, April 4, 2003, periodical, April 4, 2003; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth101027/m1/63/: accessed June 6, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.