1. (a) Subsequent Quarter Determination. After the commission has made a determination of entitlement or non-entitlement for supplemental income benefits for the first quarter, the insurance carrier shall make determinations for subsequent quarters consistent with the provisions contained in §130.102 of this title (relating to Eligibility for Supplemental Income Benefits; Amount). The insurance carrier shall issue a determination of entitlement or non-entitlement within 10 days after receipt of the Application for Supplemental Income Benefits for a subsequent quarter.

2. (b) Application for Supplemental Income Benefits. An injured employee claiming entitlement to supplemental income benefits for a subsequent quarter must send the carrier an Application for Supplemental Income Benefits as required under this section. With the first monthly payment of supplemental income benefits for any eligible quarter and with any carrier determination of non-entitlement, the carrier shall send the injured employee a copy of the Application for Supplemental Income Benefits and the proper address to file the subsequent application. On the Application for Supplemental Income Benefits sent by the carrier, the carrier shall fill in:

   1. (1) the number of the applicable quarter;
   2. (2) the dates of the qualifying period;
   3. (3) the dates of the quarter; and
   4. (4) the deadline for filing the application with the insurance carrier.
3. (c) Filing the Application for Supplemental Income Benefits. The employee shall file the Application for Supplemental Income Benefits and any applicable documentation with the carrier by first class mail, or personal delivery or facsimile. Except as otherwise provided in this section, the Application for Supplemental Income Benefits shall be filed no later than seven days before, and no earlier than 20 days before, the beginning of the quarter for which the injured employee is applying for supplemental income benefits. If the Application for Supplemental Income Benefits is received by the insurance carrier more than 20 days before the beginning of the quarter, the insurance carrier shall return the form to the injured employee with detailed instructions on when the form is required to be filed. Any form returned to the injured employee because the form was filed early shall not be subject to the provisions of §130.108 of this title (relating to Contesting Entitlement to Supplemental Income Benefits).
4. (d) Date-Stamp. Upon receipt, the carrier shall date-stamp all Application for Supplemental Income Benefits forms with the date the carrier received the form.
5. (e) Notice of Determination. Upon making subsequent quarter determinations, the carrier shall issue a notice of determination to the injured employee. The notice shall be mailed and shall contain all the information required in the Notice of Entitlement or Non-entitlement portion of the form TWCC-52, Application for Supplemental Income Benefits. The notice of determination of non-entitlement shall contain sufficient claim specific information to enable the employee to understand the carrier's determination. A generic statement such as "not a good faith effort", "not a direct result", or similar phrases without further explanation does not satisfy the requirements of this section.

6. (f) Accrual date. If the employee is entitled to supplemental income benefits for a subsequent quarter, the benefits begin to accrue on the later of:

   1. (1) the first day of the applicable quarter; or
   2. (2) the date the Application for Supplemental Income Benefits is received by the carrier, subject to the provisions of §130.105 of this title (relating to Failure to Timely File Application for Supplemental Income Benefits; Subsequent Quarters).

7. (g) Changes in Amount. A change in the monthly amount of supplemental income benefits from one quarter to the next does not constitute a dispute subject to §130.108 of this title (relating to Contesting Entitlement to Supplemental Income Benefits). An insurance carrier that does not contest the entitlement to supplemental income benefits for a subsequent quarter, but determines a different monthly amount is due, shall:

   1. (1) send the notice as required in §130.104(e) of this title (relating to Determination of Eligibility for Subsequent Quarters);
   2. (2) include instructions about the procedures for contesting the carrier's determination as provided by §130.108 of this title (relating to Contesting Entitlement or Amount of Supplemental Income Benefits; Attorney Fees); and
   3. (3) issue payment based on the newly calculated amount.

Source Note:The provisions of this §130.104 adopted to be effective January 31, 1999, 24 TexReg 399.