The following words and terms, when used in this chapter, shall have the following meanings.

1. (1) Accident Prevention Services Inspection--An inspection under Chapter 166 under this title (relating to Workers' Health and Safety Accident Prevention Services) that focuses on insurance carrier's duties to provide accident prevention services under Labor Code Chapter 411, Subchapter E and division rules.
2. (2) Act--The Texas Workers' Compensation Act, Labor Code, Title 5, Subtitle A.
3. (3) Administrative violation--A violation, failure to comply with, or refusal to comply with the Act, or a rule order, or decision of the commissioner. This term is synonymous with the terms "violation" or "violate."
4. (4) Agent--A person with whom a system participant utilizes or contracts with for the purpose of providing claims service or fulfilling duties under Labor Code, Title 5 and rules. The system participant who utilizes or contracts with the agent may also be responsible for the administrative violations of that agent.
5. (5) Appropriate credentials--The certification(s), education, training, and experience to provide the health care that an injured employee is receiving or is requesting to receive.
6. (6) Audit Violations--Violations discovered through a census or statistical sampling of the alleged violator.
7. (7) Commissioner--The commissioner of workers' compensation.
8. (8) Complaint--A written submission to the division alleging a violation of the Act or rules by a system participant.
9. (9) Compliance Audit (also Performance Review)--An audit of compliance with one or more duties under the Act and rules other than monitoring or review activities involving the Medical Advisor or the Medical Quality Review Panel. These audits are conducted using a census or statistical sampling to ensure that the findings of the audit are representative of overall performance in the area being audited.
10. (10) Controlled substances--"Controlled substance" as defined by the Texas Controlled Substances Act (Health and Safety Code, Chapter 481) or its successor and the Federal Controlled Substances Act (21 USCS §801 et seq.) or its successor.

11. (11) Conviction or convicted--

    1. (A) A system participant is considered to have been convicted when:

       1. (i) a judgment of conviction has been entered against the system participant in a federal, state, or local court;
       2. (ii) the system participant has been found guilty in a federal, state, or local court;
       3. (iii) the system participant has entered a plea of guilty or nolo contendere (no contest) that has been accepted by a federal, state, or local court;
       4. (iv) the system participant has entered a first offender or other program and judgment of conviction has been withheld; or
       5. (v) the system participant has received probation or community supervision, including deferred adjudication.

    2. (B) A conviction is still a conviction until and unless overturned on appeal even if:

       1. (i) it is stayed, deferred, or probated;
       2. (ii) an appeal is pending;
       3. (iii) the judgment of conviction or other record related to the conduct is expunged; or
       4. (iv) the system participant has been discharged from probation or community supervision, including deferred adjudication.
12. (12) Department--Texas Department of Insurance.
13. (13) Division--Texas Department of Insurance, Division of Workers' Compensation.
14. (14) Emergency--As defined in §133.2 of this title (relating to Definitions).
15. (15) Frivolous--That which does not have a basis in fact or is not warranted by existing law or a good faith argument for the extension, modification, or reversal of existing law.
16. (16) Frivolous complaint--A complaint that does not have a basis in fact or is not warranted by existing law or a good faith argument for the extension, modification, or reversal of existing law.
17. (17) Immediate post-injury medical care--That health care provided on the date that the injured employee first seeks medical attention for the workers' compensation injury.
18. (18) Notice of Violation (NOV)--A notice issued to a system participant by the division when the division has found that the system participant has committed an administrative violation and the division seeks to impose a sanction in accordance with Labor Code, Title 5 or division rules.
19. (19) Peer Review--An administrative review by a health care provider performed at the insurance carrier's request without a physical examination of the injured employee.
20. (20) Performance Review--This term is synonymous with Compliance Audit, as defined in this section.
21. (21) Remuneration--Any payment or other benefit made directly or indirectly, overtly or covertly, in cash or in kind, including, but not limited to, forgiveness of debt.
22. (22) Rules-The division's rules adopted under Labor Code, Title 5.
23. (23) Sanction--A penalty or other punitive action or remedy imposed by the commissioner on an insurance carrier, representative, injured employee, employer, or health care provider, or any other person regulated by the division under the Act, for an administrative violation.
24. (24) SOAH--The State Office of Administrative Hearings.
25. (25) System Participant--A person or their agent subject to the Act or a rule, order, or decision of the commissioner.

Source Note:The provisions of this §180.1 adopted to be effective July 29, 1991, 16 TexReg 3940; amended to be effective March 14, 2002, 27 TexReg 1817; amended to be effective September 14, 2003, 28 TexReg 7711; amended to be effective January 9, 2011, 35 TexReg 11873.