Doctors are not required to be approved or trained by the Division of Workers' Compensation (DWC) in order to provide treatment to injured employees in the Texas workers' compensation system. However, a doctor must not have been denied or removed from the former DWC Approved Doctor List (ADL), or restricted from the Texas workers' compensation system.
To treat injured employees a doctor is required to have an active medical license to practice in their jurisdiction. Also, a doctor who wishes to participate in the Texas workers' compensation system in any capacity is required to disclose to the DWC the identity of any other health care provider in which they have financial interest. For additional information, see Fast Facts: Financial Disclosure.
If an injured employee is not covered by a certified workers' compensation health care network (network) and wants to change treating doctors, the injured employee is required to submit a DWC Form-053, Employee Request to Change Treating Doctor, to the DWC for approval. An injured employee is not required to obtain prior approval from the DWC when first selecting a treating doctor. Prior approval is only required to change treating doctors. Please note that an injured employee cannot request a change of treating doctor to obtain a new impairment rating or medical report.
A doctor is prohibited from directly billing an injured employee for medical treatment. However, payment may be the responsibility of the injured employee if the DWC determines that the workers' compensation claim is not compensable or the DWC relieves the insurance carrier of payment, because the injured employee did not request a change of treating doctor.
If you are a doctor treating an injured employee covered by a certified network, you must contact the individual certified network to become an approved health care provider for that network or the injured employee must have received approval by the certified network for an out-of-network referral. View the list of certified workers' compensation networks approved by TDI.
For further assistance, health care providers and doctors can call the DWC Comp Connection for Health Care Providers at 800-252-7031 option #3.
For forms, form purpose, and instructions please use the following links:
- Health care provider/medical forms home page
- All Division of Worker's Compensation (DWC) forms
- All Texas Department of Insurance (TDI) forms
Form links:
Work Status Report (DWC Form-073)
Must be filed:
- After the initial visit
- When there is a change in work status or a substantial change in activity restrictions
- On the schedule requested through or by an insurance carrier, not to exceed one report every two weeks.
- Other situations require filing form DWC Form-073, please see the full instructions for all situations in which this form must be filed
Report of Medical Evaluation (DWC Form-069)
- Relates to Maximum Medical Improvement (MMI) and Impairment Ratings (IR).
- Please see FAQ Can I perform impairment ratings? in this section for additional information on being able to assign MMI and IR's:
- Used when submitting a claim for an injured employee
Request for a Review by an Independent Review Organization (IRO) (LHL009)
- Used in the event that a medical bill has been denied for medical necessity
- For additional information please see the IRO web-page.
Request to Schedule, Reschedule, or Cancel a Benefit Review Conference (BRC) (DWC Form-045)
Used in the event that a medical bill has been denied for a claim related reason; examples of reasons:
- Disputing:
- Condition for treatment is not a compensable injury
- Treatment is not related to the compensable injury (Extent of Injury)
- The insurance carrier is not liable for treatment
- Used in the event that a medical bill has been denied for a reimbursement reason
- NOTE: DWC Form-060 should only be filled after a bill has been:
- Correctly submitted and denied
- Correctly submitted for reconsideration and denied
- For additional information please see Medical Fee Dispute Resolution for Health Care Providers.
Request for a Medical Contested Case or SOAH Hearing (DWC Form-045A)
- Used to request the appeal of a decision on:
- Reimbursement of medical treatment (Medical fee Dispute)
- Compensability of an injury (Claims related dispute)
- Treatment related/not related to a compensable injury (Extent of Injury)
- Insurance carrier liability
For additional information on dispute resolution please see the injured Employee dispute resolution page.
To assign an impairment rating and/or certify MMI, a doctor must be authorized and approved by the Division of Workers' Compensation (DWC) to certify MMI/IR. This is accomplished by successfully completing the required training and testing. A doctor whom DWC has not certified to assign impairment ratings is only authorized to determine whether an injured employee has permanent impairment resulting from a compensable injury and, in the event that the injured employee has no permanent impairment, certify MMI.
Related question
After I complete the IR training and take the IR test, can I perform impairment ratings?
After you have completed the MMI/IR training and passed the MMI/IR test, you must notify the Office of the Medical Advisor via fax at 512-804-4207 or email at OMA@tdi.texas.gov of your intent to be authorized for MMI/IR only. Your notification should include the training and testing certificates. Upon review of the submitted request and documents, DWC will update your TXCOMP profile with the MMI and IR authorization period.
Fraud occurs when a person knowingly or intentionally conceals, misrepresents, or makes a false statement to either deny or obtain workers' compensation benefits or insurance coverage, or otherwise profit from the deceit.
For additional information on workers' compensation fraud in Texas visit the Workers' Compensation Fraud section. For general information on insurance fraud in Texas visit the Texas Department of Insurance Fraud section online.
To report suspected fraud in Texas, please call the Texas Insurance Fraud Toll-Free Hotline at 800-252-3439 or report fraud in Texas online.
The Division of Workers' Compensation (DWC) has adopted a medical fee guideline, hospital fee guideline, ambulatory surgical center fee guideline, dental fee guideline and a guideline on pharmaceutical benefits.
Information about these guidelines can be found at medical and facility fee guidelines and information.
A medical care provider may not pursue a private claim against an injured employee for all or part of the cost of the health care services provided in most cases. Actions that would indicate pursuit of a private claim include:
- Sending a bill to an injured employee when an information copy was not requested by the injured employee.
- Contact by a health care provider trying to collect money for services.
- Letters sent to the injured employee from a collection agency.
- Filing a lawsuit in court.
- Filing a claim with the injured employee's private health insurance.
A health care provider may pursue a private claim only when the work-related injury is finally adjudicated by DWC as non-compensable. Pursuing a private claim when the work-related injury has not been adjudicated by DWC as non-compensable is an administrative violation and subject to a penalty.
To become a designated doctor, you must meet all of the designated doctor requirements.
Medical Fee Dispute Resolution is a program within the Texas Division of Workers’ Compensation that helps resolve disputes about the amount of payment due for health care that is medically necessary and appropriate to treat a compensable injury.
Related questions
How do I file a medical fee dispute resolution request?
If a dispute arises over medical fees of a claim, DWC administers a medical fee dispute resolution process to resolve the issue. A health care provider can file a medical fee dispute using DWC Form-060 Medical Fee Dispute Resolution Request. The fee dispute can be filed:
Electronically:
Email: MedFeeDispute-Submission@tdi.texas.gov
Fax: 512-490-1044Secure File Transfer Protocol (SFTP), using “MFDR-DWC060 Request” as the file name.
For more information, contact DWC at eFiling-Help@tdi.texas.gov.US Postal Service mail:
Texas Department of Insurance
Division of Workers’ Compensation
PO Box 12050
Austin, Texas 78711Delivery service or in person:
Texas Department of Insurance
Division of Workers' Compensation
7551 Metro Center Drive STE 100 MS 48
Austin, TX 78744How much time do I have to file the medical fee dispute resolution request?
All requests for retrospective medical fee dispute resolution must be no later than one (1) year after the date of service(s) in dispute. See 28 Texas Administrative Code (TAC) § 133.307.
How do I appeal the medical fee dispute resolution (MFDR) decision?
For disputes filed with MFDR prior to June 1, 2012
If you do not agree with the decision issued by Medical Fee Dispute Resolution, you may request a contested case hearing before the State Office of Administrative Hearings in which the amount of reimbursement sought is greater than $2,000.00. If the amount of reimbursement sought is equal to or less than $2,000.00, you may request a contested case hearing conducted by a DWC administrative law judge. The request must be filed with DWC's chief clerk of proceedings no later than 20 days from the date you received the decision. Follow the instructions under the "Your Right to Request a Hearing" section on the decision.For disputes filed with MFDR on or after June 1, 2012
Requesting a benefit review conference (BRC):
A party seeking review of an MFDR decision must request a BRC no later than 20 days from the date the MFDR decision is received by the party. The DWC Form-045M, Request to Schedule, Reschedule, or Cancel a Benefit Review Conference to Appeal a Medical Fee Dispute Decision, is required to be submitted to the DWC to request a BRC and may be found on the forms page.Requesting arbitration or a contested case hearing (CCH) before the State of Administrative Hearings (SOAH):
If the medical fee dispute remains unresolved after a BRC, the parties may request arbitration or a CCH before the State Office of Administrative Hearings (SOAH) within 20 days after conclusion of the BRC. The DWC Form-044, Election to Engage in Arbitration, is required to be submitted to the DWC request arbitration and may be found on the forms page. The DWC Form-049, Request to Schedule a Medical Contested Case Hearing (MCCH), is required to be submitted to the DWC to request a SOAH hearing and may be found on the forms page.Requesting judicial review:
A party seeking to appeal a decision by a SOAH administrative law judge must file a lawsuit in the appropriate court pursuant to Texas Labor Code §413.031 (k-1) and Chapter 2001, Subchapter G of the Government Code. The party seeking judicial review must file suit not later than the 45th day after the date on which SOAH mailed the party the notification of the decision. The mailing date is considered to be the fifth day after the date the decision was issued by SOAH.How can I find out more about medical fee dispute resolution?
DWC has developed a detailed slide presentation to assist workers' compensation system participants in understanding the medical fee dispute resolution process. The medical fee dispute resolution basics addresses the steps to follow when filing a medical fee dispute resolution request.
This process is for health care providers, insurance carriers, and injured employees who seek further review of disputed medical care or reimbursement.
We have a page just for health care providers. You and your office can stay up to date on Texas workers' compensation specific information by subscribing to workers’ compensation health-care provider news email updates.
For recent changes and postings on the DWC website visit the What's new section and for current DWC initiatives visit DWC's home page. Also, DWC hosts and is requested to present at many seminars and educational programs throughout the year around the state of Texas. DWC is very focused on ensuring education is provided for newly adopted rules. By being added to DWC's email updates you'll get notifications and instructions on how to register for seminars and educational programs or you can visit the events & training page to learn about the opportunities available to you and your office. You may also find it useful to visit the bulletins page for clarification on rules and laws.
Resources:
- Performance Based Oversight (PBO) of health care providers and insurance carriers
- Official Disability Guidelines (ODG)*
- Texas workers compensation fee guidelines
- Preauthorization
- eBilling requirements in the Texas workers' compensation system
- DWC forms
- Rules
- Act
- Texas State Board of Medical Examiners*
* See the TDI linking policy for information about links to external websites.
Many providers in the Texas workers' compensation system have found it useful to register with Novitas Solutions, Inc.*, the Medicare contract administrator for Texas, to help them stay informed of changes made by CMS. If you choose to register with Novitas Solutions, Inc.* you will be offered an option to receive automatic notifications detailing changes to Medicare procedures and policies.
To locate other resources for updates on CMS you may consider using a web search engine*; a few suggested search phrases are:
- Updates on CMS
- CMS updates
- Updates from the Centers for Medicare and Medicaid Services
- Medicare updates
Quick links to resources:
- Medicare home page*
- Centers for Medicare & Medicaid Services (CMS) Fee Schedules*
- Novitas Solutions, Inc.*
- Medicaid fee guideline* information for dental and home health services
- Cigna Government Services* the CMS Durable Medical Equipment contract administrator for Texas
* See the TDI linking policy for information about links to external websites.
A letter of clarification (LOC) is a letter drafted by the Division of Workers' Compensation (DWC) and sent to a designated doctor requesting clarification on certain issues in a report the doctor submitted following the examination of an injured employee.
Under 28 Texas Administrative Code (TAC) §126.7(u) parties to a workers' compensation claim who want clarification of a report of a designated doctor may file a request with the DWC for a LOC.
The DWC may contact the designated doctor requesting a LOC, "if it determines that clarification is necessary to resolve an issue" regarding the report [28 TAC §126.7(u)].
Under 28 TAC §126.7 (v), disputes regarding the designated doctor's report shall be resolved through the dispute resolution process.
Related questions
How does a party request a LOC?
Parties to a workers' compensation claim can submit a request for a LOC to the DWC field office handling the claim.
When may a party submit the request of LOC?
Parties may submit a request for a LOC to the DWC at any point in the dispute resolution process [i.e., prior to a Benefit Review Conference (BRC), during a BRC or during a Contested Case Hearing (CCH)]. Historically, most requests have been submitted prior to a BRC.
Do parties have a right to an LOC?
Parties are allowed by DWC rule to request an LOC. The ultimate determination of whether a Letter of Clarification is granted rests with the DWC.
Who will approve or deny my request for letter of clarification?
Beginning September 1, 2010, all LOC requests will be approved or denied by DWC benefit review officers or DWC Benefit Contested Case administrative law judges. LOC requests received by the TDIDWC prior to a proceeding being scheduled will be approved or denied by a Benefit Review Officer. LOC requests will be approved if the reviewing officer determines that clarification is necessary to resolve an issue regarding the report pursuant to 28 TAC §126.7(u).
What happens after a request is approved?
Should the DWC determine clarification is necessary, they send a letter to the designated doctor setting out the questions to be answered. Sometimes additional medical or other information is provided for consideration. The designated doctor has five days to provide a response to the request for clarification.
When may the DWC reviewing officer order an examination?
If the reviewing officer determines that additional information is necessary to resolve an issue regarding a designated doctor's report but determines that an examination is necessary, the reviewing officer may approve the LOC request and order an examination to enable the designated doctor to adequately respond to the LOC request.
Who will schedule the DWC ordered examination?
If the DWC orders an examination, the examination will be scheduled by the DWC, through the Designated Doctor Scheduling Section (DDS). The DDS will coordinate the appointment with the designated doctor and will notify the parties of the date, time and location of the examination.
What happens if the DWC denies a request for a LOC?
If the DWC denies a request for a LOC, a denial letter will be sent to the requesting parties specifying the reasons for the denial.
What are the options if a request for LOC is denied?
If the DWC denies a request for a LOC, parties may:
(a) resubmit the request for an LOC, taking into account the reasons for the previous denial;
(b) request a Benefit Review Conference to dispute the issue for which the designated doctor was appointed and resubmit the request for an LOC at the Benefit Review Conference; or
(c) dispute the denial of a request for clarification through the DWC dispute resolution process.
Workers' compensation insurance coverage information is available on the Texas Department of Insurance website. For additional assistance, call the Division of Workers' Compensation (DWC) at 800-252-7031 and select option 6 (in Austin call 512-804-4345).