The Texas DWC022 form, issued by the Texas Department of Insurance Division of Workers' Compensation, is a specialized document designed to facilitate requests for a Required Medical Examination (RME). This form serves as a communication bridge between insurance carriers and injured employees, ensuring the latter undergo medical examinations by a doctor chosen by the insurance carrier, either to evaluate the determination of a designated doctor or to verify the appropriateness of received healthcare. To streamline the process of addressing workers' compensation claims, understanding how to accurately complete and submit this form is crucial.
Click the button below to learn more about filling out the Texas DWC022 form effectively.
In the realm of workers' compensation in Texas, the DWC022 form plays a pivotal role, serving as a channel through which insurance carriers can request a Required Medical Examination (RME) for an injured employee. This examination could be crucial in several scenarios, including evaluating a Designated Doctor's determination or investigating the appropriateness of the health care received by an injured worker. The form facilitates communication between the employee (or their attorney), the employer at the time of the injury, and the insurance carrier handling the workers' compensation claim. It outlines detailed requirements for both requesting an RME and certifying the need for such an examination. By encompassing sections that cover everything from personal information about the injured employee to specific examination details and insurance carrier certification, the DWC022 form underscores the need for a consensual and orderly approach to addressing disputes related to workers' compensation claims. Moreover, it sets out guidelines for the frequency of RMEs and the procedural steps following TDI-DWC's approval or denial of the request, emphasizing the rights and responsibilities of all parties involved.
Texas Department of Insurance
Division of Workers’ Compensation
7551 Metro Center Drive, Suite 100 • MS-94 Austin, TX 78744-1645
(800) 252-7031 phone • (512) 804-4378 fax
DWC022
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Complete if known:
formulario o acerca de su reclamación,
llame al ajustador de su aseguradora al
DWC Claim #
número de teléfono que aparece en la
Casilla 15 de la Sección III.
Carrier Claim #
Required Medical Examination (RME) - Request for Agreement / Request for Order
I. EMPLOYEE/EMPLOYEE’S ATTORNEY INFORMATION
1.
Employee's Name (First, Middle, Last)
2. Employee’s Social Security Number
3.
Employee’s Address (Street or PO Box, City State Zip)
4.
Employee’s Telephone Number
5. Alternate Telephone Number (if available)
6. Date of Injury (mm/dd/yyyy)
(
)
7. Attorney/Representative’s Name (if applicable)
8. Attorney/Representative’s Address (Street or PO Box, City State Zip)
II. EMPLOYER INFORMATION (at the time of the injury)
9. Employer’s Name
10. Employer’s Address (Street or PO Box, City State Zip)
III. INSURANCE CARRIER INFORMATION
11. Insurance Carrier's Name
12. Insurance Carrier's Address (Street or PO Box, City State Zip)
13. Adjuster’s Name
14. Adjuster’s E-mail
15. Adjuster’s Telephone Number
16. Adjuster’s Fax Number
17. Adjuster’s License Number
ext.
REQUEST FOR RME: EVALUATION OF DESIGNATED DOCTOR DETERMINATION (Complete Sections IV, V and VI)
IV. EXAMINATION INFORMATION
18. Examining RME Doctor's Name
19. RME Doctor’s Mailing Address (Street or PO Box, City State Zip)
20. RME Doctor’s License Number
21. RME Doctor's Telephone Number
22. Examination Location (Street, City State Zip)
23. Date and Time of Appointment
24. Does the claim involve medical benefits provided through a Certified Health Care Network?
Yes
No If yes, provide the name of the network.
25.Does the claim involve medical benefits provided through a political subdivision pursuant to §504.053(b)(2) of the Texas Labor Code, relating to directly contracting with health care providers or contracting through a health benefits pool? Yes No
If yes, provide the name of the health care plan.
26.Are the employee’s address (Box 3) and the examination location (Box 22) more than 75 miles apart? If yes, explain why the employee is being required to travel more than 75 miles for the examination.
No
V. PURPOSE OF EXAMINATION
27. Designated Doctor’s Name
28. Date of Designated Doctor examination
29. Issues in the Designated Doctor’s report to be addressed in requested RME. Check all that apply:
Maximum Medical Improvement
Ability to return to work (DWC Form-073)
Impairment Rating
Ability to return to work after the second anniversary of entitlement to
Extent of compensable injury
supplemental income benefits (Texas Labor Code §408.151)
Whether disability is a direct result of work-related injury
Other (explain)
VI. INSURANCE CARRIER CERTIFICATION
30.I hereby certify the following:
•This request is complete and accurate.
•The insurance carrier will pay reasonable expenses incident to the examination of the injured employee.
•The selected doctor does not have a disqualifying association.
•If the claim involves medical benefits provided through a political subdivision pursuant to §504.053(b) of the Texas Labor Code, this RME is necessary to resolve an issue relating to the entitlement to or amount of income benefits as required by §504.053(c)(1) of the Texas Labor Code.
•I am authorized to act on behalf of the insurance carrier.
I understand that misrepresenting a workers’ compensation claim may result in enforcement action including administrative penalties and fines.
31.
Signature of Adjuster or Authorized Insurance Carrier Representative
For TDI-DWC Use Only
32.
Printed Name of Adjuster or Authorized Insurance Carrier Representative
33. Title of Adjuster or Authorized Insurance Carrier Representative
34. Date of Signature
DWC022 Rev. 07/11
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REQUEST FOR RME: APPROPRIATENESS OF HEALTH CARE RECEIVED (Complete Sections VII and VIII)
VII. EXAMINATION INFORMATION
35.
Examining RME Doctor's Name
36. RME Doctor’s Mailing Address (Street or PO Box, City State Zip)
37. RME Doctor’s License Number
38.
RME Doctor's Telephone Number
39. Examination Location (Street, City State Zip)
40. Date and Time of Appointment
41. Date of Prior Examination
42. Prior Examining Doctor's Name
43. If different doctors are named in Boxes 35 and 42, explain the reason for requesting a different doctor.
44. Does the claim involve medical benefits provided through a Certified Health Care Network?
45.Does the claim involve medical benefits provided through a political subdivision pursuant to §504.053(b)(2) of the Texas Labor Code, relating to directly contracting with health care providers or contracting through a health benefits pool? Yes No
46.Are the employee’s address (Box 3) and the examination location (Box 39) more than 75 miles apart? If yes, explain why the employee is being required to travel more than 75 miles for the examination.
VIII. INSURANCE CARRIER CERTIFICATION
47.I hereby certify the following:
•I have obtained the injured employee’s agreement or attempted to obtain the injured employee’s agreement for an examination under Texas Labor Code §408.004 (Appropriateness of Health Care Examination) as follows:
Check ONLY ONE box below as applicable and provide date(s) as indicated for that box:
Injured employee/attorney notified insurance carrier of agreement to attend examination by carrier’s doctor on (mm/dd/yyyy) Injured employee/attorney notified insurance carrier of non-agreement to attend examination by carrier’s doctor on (mm/dd/yyyy)
Sent to injured employee/attorney on (mm/dd/yyyy)
and no reply received as of (mm/dd/yyyy)
48. Signature of Adjuster or Authorized Insurance Carrier Representative
49. Date of Signature
50. Printed Name of Adjuster or Authorized Insurance Carrier Representative
51. Title of Person Signing
IX. INJURED EMPLOYEE AGREEMENT/NON-AGREEMENT
52. Complete this section and return a copy of this form to the insurance carrier ONLY if Section VII above has been completed.
I agree
I do not agree - to attend the requested examination to determine whether health care I have received was appropriate.
NOTE: If you agree, you must attend the examination at the time and location scheduled. If you do not agree, the insurance carrier will submit the request to TDI-DWC for review. If TDI-DWC approves the request, you will be issued an order to attend the examination.
53. Signature of Injured Employee or Injured Employee’s Attorney/Representative
54.Printed Name of Injured Employee or Injured Employee’s Attorney/Representative
55.Date of Signature
NOTE: With few exceptions, upon your request, you are entitled to be informed about information TDI-DWC collects about you; receive and review the information (Government Code, §§552.021 and 552.023); and have TDI-DWC correct information that is incorrect (Government Code, §559.004).
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Information for the Injured Employee
For what purposes may a Required Medical Examination be requested?
DWC Form-022 Required Medical Examination - Request for Agreement / Request for Order is an insurance carrier’s request for you to be examined by a doctor of the insurance carrier’s choice. This examination is called a Required Medical Examination, or RME.
•Request for Order (Evaluation of Designated Doctor Determination): If you have been examined by a Designated Doctor, the insurance carrier may ask TDI-DWC to order you to attend an RME to address the same issue(s) the Designated Doctor addressed.
•Request for Agreement/Order (Appropriateness of Health Care Received): The insurance carrier may use the form to request your agreement to attend an RME to determine whether health care you have received was appropriate. You have 15 days from the date the carrier sent the request to you to complete Section IX. INJURED EMPLOYEE AGREEMENT/NON-AGREEMENT and return the form to the insurance carrier. You should keep a copy for your records. If you do not agree to attend the RME, the insurance carrier may ask TDI-DWC to order you to attend.
Exception for Network Claims: If you received medical benefits through a certified workers’ compensation health care network, the insurance carrier is not permitted to request an RME on the appropriateness of health care received.
Exception for Certain Political Subdivision Claims: If you received medical benefits through a political subdivision pursuant to §504.053(b)(2) of the Texas Labor Code, relating to directly contracting with health care providers or contracting through a health benefits pool, the insurance carrier is not permitted to request an RME unless the RME is necessary to resolve a question relating to the entitlement to or amount of income benefits.
How often can a Required Medical Examination be performed?
An RME to determine appropriateness of health care received may not be performed more than once every 180 days. Examinations to evaluate a Designated Doctor determination may be performed more frequently. After you have received Supplemental Income Benefits for eight quarters, an RME to evaluate a Designated Doctor determination regarding your ability to return-to-work may be performed no more than once per year.
What will TDI-DWC do?
Within 7 days of receiving the insurance carrier’s request for an RME, TDI-DWC will approve or deny the request.
If TDI-DWC approves the insurance carrier’s request or you agree to attend the RME, TDI-DWC will issue an order requiring you to attend.
NOTE: If the request is approved, your failure to attend the scheduled RME may be considered an administrative violation and may result in suspension of temporary income benefits, if applicable. You may request that your treating doctor attend the RME.
If TDI-DWC denies the insurance carrier’s request, you will receive a copy of the denial order. In that case you will not be required to attend the RME.
Can the RME appointment be rescheduled?
If you cannot attend an RME, you must contact the doctor’s office to reschedule the examination at least 24 hours in advance. The rescheduled appointment must be no later than 7 days after the original appointment unless you and the doctor agree on a different date that is no later than 30 days after the original appointment.
Questions / Information Regarding Travel Reimbursement
If you have questions regarding this form, need to request an accommodation under Title II of the Americans with Disabilities Act (ADA), or need information about reimbursement of travel expenses, contact TDI-DWC by calling (800) 252-7031. To request travel reimbursement, you must use the DWC-Form 048 Request for Travel Reimbursement which is available at http://www.tdi.texas.gov/forms/formlisting.html.
Instructions for the Insurance Carrier
RME regarding Evaluation of Designated Doctor Determination
•After completing Sections I, II, and III, complete Sections IV, V and VI regarding an Evaluation of Designated Doctor Determination RME.
•Check the applicable box(es) in Section V, Box 29 to describe the reason(s) for the examination.
•Fax the request to TDI-DWC at (512) 804-4378.
RME regarding Appropriateness of Health Care Received
•After completing Sections I, II, and III, complete Section VII regarding an Appropriateness of Health Care Received RME.
•Attempt to obtain agreement by sending the form to the injured employee and the injured employee’s attorney or representative, if any.
•Upon obtaining the employee’s answer in writing or by telephone or after 15 days with no response, complete Section VIII. In this section you must indicate whether the injured employee agreed, refused to agree, or failed to respond to the request.
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Filling out the Texas DWC022 form is an essential process for those involved in a workers’ compensation case, specifically when a Required Medical Examination (RME) must be conducted. This documentation is vital for ensuring that all details about the employee, employer, and insurance carrier are correctly recorded, and it serves as a formal request to either agree upon or order an RME. These examinations can be crucial for various reasons, including the evaluation of a designated doctor's determination or to ascertain the appropriateness of healthcare received. The following steps will guide you through filling out the form accurately.
After completing the form, ensure that all provided information is accurate and comprehensive. The completed form should be faxed to the Texas Department of Insurance, Division of Workers’ Compensation as directed. It’s crucial to keep a copy of the form for your records. Timely and accurate completion of the DWC022 form is a step towards resolving the workers' compensation claim effectively.
The DWC022 form serves as a formal request by an insurance carrier for a Required Medical Examination (RME) of an injured employee in Texas. This examination can be requested to evaluate a Designated Doctor's determination related to a worker's compensation claim or to assess whether the health care received by the injured worker was appropriate. The ultimate aim is to ensure that the examination or treatment recommendations are in line with the state's regulations and standards.
Only insurance carriers can request an RME by submitting the DWC022 form to the Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC). The form requires detailed information about the employee, employer, insurance carrier, and specifics about the requested medical examination.
The DWC022 form is divided into several sections, requesting detailed information such as:
Yes, an injured employee can refuse to attend the RME. However, they must indicate their non-agreement on the DWC022 form. Following such refusal, the insurance carrier may request TDI-DWC to issue an order for the employee to attend the examination. Failure to comply with this order could result in the suspension of temporary income benefits, if applicable.
An RME aimed at evaluating the appropriateness of received health care can only be performed once every 180 days. However, RMEs to evaluate a Designated Doctor's determination may occur more frequently under certain conditions, including evaluations related to the ability to return to work after receiving supplemental income benefits for eight quarters.
Upon approval of the DWC022 request by TDI-DWC, an order will be issued requiring the injured employee to attend the RME. Not attending this scheduled examination could be deemed an administrative violation, possibly leading to repercussions such as the suspension of temporary income benefits, where applicable.
If an injured employee cannot attend the scheduled RME, they must contact the doctor's office at least 24 hours in advance to reschedule the appointment. The rescheduled date must be within 7 days of the original date, unless an alternate date within 30 days is agreed upon by both parties.
If the distance between the employee's address and the examination location exceeds 75 miles, the insurance carrier must explain the necessity for the travel on the DWC022 form. Injured employees entitled to attend an RME are eligible for travel expense reimbursement, which requires a separate form (DWC-Form 048).
The insurance carrier completes the DWC022 form and submits it to TDI-DWC. For Examination of Designated Doctor Determination requests, specific sections of the form must be completed and faxed to TDI-DWC. For Appropriateness of Health Care Received, additional steps to obtain the injured employee's agreement are required before submission.
Filling out the Texas DWC022 form can be a complex process. Here are ten common mistakes that people often make:
By avoiding these common mistakes, you can ensure a smoother, more efficient processing of your DWC022 form submission.
When dealing with workers' compensation claims in Texas, necessary documentation extends beyond the Texas Department of Insurance Division of Workers' Compensation DWC022 form, which is central to requesting a Required Medical Examination (RME). Understanding the suite of forms and documents that typically accompany or follow the DWC022 form can provide a more comprehensive picture of the processes involved in managing a claim effectively. These documents serve various facets of the claims process, from initial injury reporting through to the resolution of disputes regarding medical benefits or impairment ratings.
Together, these documents form a network of support in managing workers' compensation claims, ensuring thorough documentation and adherence to procedural requirements for all parties involved. In navigating the complexities of workers' compensation, these forms ensure transparency, facilitate communication between parties, and help drive fair outcomes in benefit determinations and medical evaluations.
The DWC Form-073, used for reporting an employee's ability to return to work, shares similarities with the DWC022 in its role within the Texas workers' compensation system. Both forms facilitate communication between injured employees, healthcare providers, employers, and insurance carriers. The DWC Form-073 specifically collects information regarding an injured employee’s functional ability to return to work, which may be considered alongside or subsequent to the RME examination findings documented in the DWC022 form regarding the employee's current medical condition and work capability.
The DWC Form-048, designed for requesting travel reimbursement for medical appointments and examinations related to a workers’ compensation claim, complements the DWC022 form’s function. The DWC022 may require an employee to travel for a Required Medical Examination (RME), and the DWC Form-048 would be the necessary follow-up document for the employee to seek reimbursement for such travel. This relationship underscores the integrated process within workers' compensation procedures, focusing on both the assessment and the logistical needs of injured employees.
Similar to the DWC022, the PLN-11 form pertains to the certified network plan notification in Texas workers' compensation cases. While the DWC022 queries about the involvement of medical benefits through a certified network, the PLN-11 form is used by the insurance carrier to notify injured employees about the network's plan and requirements. This document is essential for understanding an injured worker's rights and responsibilities within a specific healthcare network, which directly impacts how procedures like those outlined in the DWC022 are implemented.
The Texas Labor Code §408.0041 Authorization for Release of Medical Information operates in tandem with the concepts addressed in the DWC022 form. Since the DWC022 involves requesting medical examinations and potentially disputing previous medical findings, the need for accessing and sharing an employee's medical records is implicit in these processes. The authorization form is vital for ensuring that such medical information can be legally shared among the parties involved in a workers' compensation claim, respecting the employee's privacy rights while facilitating the claim's adjudication.
The DWC Form-069, the Employer's Wage Statement, while it appears to be primarily concerned with income data, surprisingly intersects with the DWC022's domain concerning the evaluation of income benefits after an RME. Understanding an injured employee's earning capacity before and after an injury is crucial in determining entitlement to or the amount of income benefits, which can be influenced by the outcomes of examinations requested through the DWC022 form.
Lastly, the Request to Schedule, Reschedule, or Cancel a Benefit Review Conference (BRC) Form, although not specific to medical examinations, aligns with the DWC022 form in terms of procedural mechanisms within the workers' compensation system. Both documents are tools for advancing a dispute to the next level of resolution. While the DWC022 form can initiate a reassessment of medical evaluations, the BRC form facilitates dispute resolution through a more formal dialogue, potentially involving issues identified through the RME process.
When filling out the Texas DWC022 form, it's crucial to follow specific guidelines to ensure the process is handled correctly and efficiently. Here are essential do's and don'ts to consider:
Following these guidelines ensures a smoother process for all parties involved and helps in a more efficient resolution of your claim.
Addressing misconceptions about the Texas DWC022 form can guide both injured workers and their representatives through the complexities of workers' compensation claims in Texas. Below are eight common misconceptions and clarifications to set the record straight.
Understanding these clarifications ensures that all parties engaged in a workers' compensation claim in Texas are well-informed and capable of navigating the process with a clear understanding of their responsibilities and rights. It emphasizes the importance of accurate information and compliance with the established procedures.
Filling out and using the Texas DWC022 form is an essential process in the management of workers' compensation claims in Texas. Here are eight key takeaways to understand when dealing with this form:
Clearly, navigating the DWC022 form requires attention to detail and an understanding of the broader workers' compensation system in Texas. Ensuring that each step is completed correctly can help support the injured employee's recovery journey and streamline the insurance carrier's process of addressing and resolving claims.
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