1. (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.
2. (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 International Association of Industrial Accident Boards and Commissions (IAIABC) Electronic Data Interchange Implementation Guide.

3. (c) The carrier shall electronically file, as that term is used in §102.5(e) of this title (relating to General Rules for Written Communication To and From the Commission), with the Commission:

   1. (1) the information from the original Employer's First Report of Injury; the insurance carrier's Federal Employer Identification Number (FEIN); and the policy number, policy effective date, and policy expiration date reported under §110.1 of this title (relating to Requirements for Notifying the Commission of Insurance Coverage) for the employer associated with the claim, not later than the seventh day after the later of:

      1. (A) receipt of a required report where there is lost time from work or an occupational disease; or
      2. (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. (2) any correction of Commission-identified errors in a previously accepted electronic record as provided in §102.5(e) of this title (Correction);
   3. (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. (4) a change in an electronic record initiated by carrier (Change), the coverage information required by paragraph (1) of this subsection if not available when the First Report of Injury was submitted to the commission and any change in a claimant or employer mailing address within 7 days of receipt of the new address.
4. (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.

5. (e) The carrier shall notify the Commission and the claimant of the following:

   1. (1) first payment of indemnity benefits on a claim (Initial Payment) within 10 days of making the first payment;
   2. (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. (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 contribution (Change in Benefit Amount) within 10 days of making the first payment reflecting the change;
   4. (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. (5) resumption of payment of income or death benefits (Reinstatement of Benefits) within 10 days of making the first payment;
   6. (6) termination or suspension of income or death benefits (Suspension) within 10 days of making the last payment for the benefits.

   7. (7) employer continuation of salary equal to or exceeding the employee's Average Weekly Wage as defined by this title (Full Salary) within:

      1. (A) seven days of receipt of the Employer's First Report of Injury or a Supplemental Report of Injury (if the report included information that salary would be continued) if the carrier has not initiated temporary income benefits; or
      2. (B) ten days of making the last payment of temporary income benefits due to the employer's continuation of full salary.
6. (f) Notification to the claimant as required by subsections (d) and (e) of this section requires the carrier to use plain language notices with language and content 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-specific substantive information to enable the employee/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 description of the factual basis for the action taken does not satisfy the requirements of this section.
7. (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 electronic 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 requirements of this section are not considered completed until the copy of the notice provided to the claimant is received by the Commission.
8. (h) Notification to the Commission and the claimant of a dispute of disability, extent of injury, or eligibility of a claimant to receive death benefits shall be made as otherwise prescribed by this title and requires the carrier to use plain language notices with language and content 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-specific substantive information to enable the employee/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 "no medical evidence to support disability," "not part of compensable 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.
9. (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.

10. (j) Except as otherwise provided by this title, carriers shall not provide notices to the Commission that explain that:

    1. (1) benefits will be paid as they accrue;
    2. (2) a wage statement has been requested;
    3. (3) temporary income benefits are not due because there is no lost time;
    4. (4) the carrier is disputing some or all medical treatment as not reasonable or necessary;
    5. (5) compensability is not denied but the carrier disputes the existence of disability (if there are no indications of lost time or disability and the employee is not claiming disability); or
    6. (6) future medical benefits are disputed (notices of which shall not be provided to anyone in the system).
11. (k) Written requests for a waiver of the electronic filing requirement for the Employer's First Report of Injury may be submitted to the Commission's executive director or his/her designee for consideration. 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.
12. (l) 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.
13. (m) Notifications to the claimant and the claimant's representative 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.

14. (n) On or after November 1, 2003, each insurance carrier shall provide to the commission, through its Austin representative in the form and manner prescribed by the commission, the contact information for all workers' compensation claim service administration functions performed by the insurance carrier either directly or through third parties.

    1. (1) The contact information for each function shall include mailing address, telephone number, facsimile number, and e-mail address as appropriate. This contact information may be provided either in the form of a single World Wide Web (Web) Uniform Resource Locator (URL) for a Web page created and maintained by the carrier that contains the required information or through an online submission to the commission.

       1. (A) Coverage verification (policy issuance and effective dates of policy);
       2. (B) Claim adjustment;
       3. (C) Medical billing;
       4. (D) Pharmacy billing (if different from medical billing); and
       5. (E) Preauthorization.
    2. (2) If the Web page option is used the page shall contain the date on which it was last updated and an e-mail address or other contact information to which a user may report problems or inaccuracies.
    3. (3) The insurance carrier shall update the contact information and/or Web URL within ten working days after any such change is made.

Source Note:The provisions of this §124.2 adopted to be effective August 29, 1999, 24 TexReg 6503; amended to be effective June 5, 2003, 28 TexReg 4285.