Texas Register, Volume 28, Number 14, Pages 2821-2988, April 4, 2003 Page: 2,885
2821-2988 p. ; 28 cm.View a full description of this periodical.
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substantive information to enable the employee/legal beneficiary to un-
derstand 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 compens-
able 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 disabil-
ity 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 re-
quirement for the Employer's First Report of Injury may be submitted
to the Commission's executive director or his/her designee for consid-
eration. 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.
(1) 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 represen-
tative 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) Each insurance carrier shall provide to the commission,
through its Austin representative in the form and manner prescribed by
the commission, a single World Wide Web (Web) Uniform Resource
Locator (URL) for a Web page that contains the contact information
for all workers' compensation claim service administration functions
performed by the insurance carrier either directly or through third par-
ties.
(1) The contact information for each function shall include
mailing address, telephone number, facsimile number, and email ad-
dress as appropriate. The list of contacts shall include the followingclaim administration functions and shall be organized to reflect the in-
surance carrier's business practices (geographically, functionally, by
specific insured, or combination of these):
(A) Coverage verification questions;
(B) Claim adjustment;
(C) Medical billing;
(D) Pharmacy billing (if different from medical billing);
and
(E) Preauthorization.
(2) The Web 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 Web page content
within five business days after any such change is made. In addition, the
insurance carrier shall provide to the commission, through its Austin
representative in the form and manner prescribed by the commission,
any new or changed URL for its Web page within five business days
after any such change is made.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal author-
ity to adopt.
Filed with the Office of the Secretary of State on March 24, 2003.
TRD-200301886
Susan Cory
General Counsel
Texas Workers' Compensation Commission
Earliest possible date of adoption: May 4, 2003
For further information, please call: (512) 804-4287
CHAPTER 126. GENERAL PROVISIONS
APPLICABLE TO ALL BENEFITS
28 TAC 126.11
The Texas Workers' Compensation Commission (the commis-
sion) proposes amendments to 126.11, concerning the Exten-
sion of the Date of Maximum Medical Improvement for Spinal
Surgery.
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 establish carrier
liability for medical costs related to non-emergency spinal
surgery only as provided by 413.014 (relating to Preautho-
rization 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 continu-
ation of treatment beyond previously approved treatment.
The amendments to 126.11 are proposed to replace 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; Concur-
rent Review and Certification of Health Care).PROPOSED RULES April 4, 2003 28 TexReg 2885
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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/m1/64/: accessed May 26, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.