The Texas DWC022 form is a document used by insurance carriers to request a Required Medical Examination (RME) for employees who have filed a workers' compensation claim. This form serves two primary purposes: to evaluate a designated doctor's determination or to assess the appropriateness of health care received by the injured employee. Understanding this form is crucial for ensuring compliance with Texas workers' compensation regulations.
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The Texas DWC022 form plays a critical role in the workers' compensation process, particularly concerning Required Medical Examinations (RMEs). This form serves as a request from insurance carriers for injured employees to undergo evaluations by designated doctors. It encompasses two primary purposes: the evaluation of a designated doctor's determination and the appropriateness of healthcare received. Essential information is collected, including the employee's details, employer information, and specifics about the insurance carrier. The form also outlines the examination details, such as the name and contact information of the examining doctor, the examination location, and the date and time of the appointment. Additionally, it ensures that the insurance carrier certifies the accuracy of the request and confirms that the selected doctor does not have any disqualifying associations. Employees must respond to the request within a specified timeframe, indicating their agreement or disagreement to attend the examination. Understanding the nuances of this form can significantly impact the outcome of a workers' compensation claim, providing clarity and direction for both employees and insurance carriers.
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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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 a straightforward process, but it requires attention to detail. After completing the form, it’s essential to submit it to the appropriate insurance carrier promptly. They will then process your request, which may lead to a required medical examination based on the information provided.
The Texas DWC022 form is a document used in the workers’ compensation system. It serves as a request for a Required Medical Examination (RME) by the insurance carrier. This examination is conducted by a doctor chosen by the insurance carrier to assess the injured employee’s medical condition and determine whether the healthcare they received was appropriate or to evaluate issues related to a Designated Doctor's determination.
The DWC022 form must be completed by the insurance carrier when they wish to request a medical examination for an injured employee. This includes providing detailed information about the employee, employer, and the insurance carrier, as well as specifics about the examination being requested.
The form requires various details, including:
An RME to determine the appropriateness of healthcare received can be requested no more than once every 180 days. However, evaluations related to a Designated Doctor determination can occur more frequently. After receiving Supplemental Income Benefits for eight quarters, an RME regarding the ability to return to work may only be requested once per year.
Once the DWC022 form is submitted, the Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) will review the request. They will either approve or deny it within seven days. If approved, an order requiring the employee to attend the RME will be issued. If denied, the employee will not be required to attend the examination.
If an employee cannot attend the scheduled RME, they should contact the doctor’s office to reschedule at least 24 hours in advance. The new appointment must occur no later than seven days after the original date, unless a different date is mutually agreed upon, which should be within 30 days.
If you have questions or need assistance regarding the DWC022 form, you can reach out to the TDI-DWC by calling (800) 252-7031. They can provide information about the form, help with travel reimbursement inquiries, or assist with any accommodations you may need under the Americans with Disabilities Act (ADA).
Failing to provide the correct employee’s name in Section I. Ensure the name matches official documents.
Omitting the social security number. This number is crucial for identification and processing.
Not including a valid telephone number for the employee. This can delay communication regarding the claim.
Incorrectly filling out the date of injury. Use the correct format (mm/dd/yyyy) to avoid confusion.
Neglecting to provide the insurance carrier's name and address in Section III. This information is vital for processing.
Forgetting to sign the form. The signature of the adjuster or authorized representative is required for validation.
Not checking the appropriate boxes in Section V regarding the issues to be addressed. This can lead to incomplete evaluations.
Failing to explain why the examination location is over 75 miles from the employee's address when applicable. This is necessary for justification.
Submitting the form without keeping a copy for personal records. Always retain a copy for future reference.
The Texas DWC022 form is an important document used in the workers' compensation process, particularly for requesting a Required Medical Examination (RME). Along with this form, several other documents may be utilized to ensure proper handling of claims. Here’s a brief overview of some commonly used forms and documents that accompany the DWC022.
Each of these forms plays a vital role in the workers' compensation process in Texas. Understanding their purpose can help injured employees navigate their claims more effectively and ensure they receive the benefits to which they are entitled.
The Texas DWC022 form is similar to the DWC Form-073, which is used to assess an employee's ability to return to work. Both forms require detailed information about the employee, the employer, and the insurance carrier. The DWC Form-073 specifically focuses on the employee's work capabilities after an injury, while the DWC022 seeks to determine the appropriateness of medical examinations and treatments. Both forms serve essential roles in the workers' compensation process, ensuring that injured employees receive the necessary evaluations to support their recovery and return to work.
Another document comparable to the DWC022 is the DWC Form-048, which is the Request for Travel Reimbursement. This form is used when an injured employee needs to request reimbursement for travel expenses related to attending medical examinations. Similar to the DWC022, it requires specific details about the employee and the circumstances surrounding the examination. Both forms aim to facilitate the workers' compensation process, ensuring that employees can access necessary medical evaluations without financial burden.
The DWC Form-005, known as the Employee’s Claim for Compensation, also shares similarities with the DWC022. Both forms are integral to initiating claims within the Texas workers' compensation system. While the DWC Form-005 focuses on the employee's claim details and the nature of their injury, the DWC022 is concerned with the medical examination process. Each form plays a vital role in documenting and processing claims, ensuring that injured employees receive appropriate care and compensation.
Another related document is the DWC Form-007, which is the Notice of Injury or Illness. This form is used by employers to report an employee's injury to the insurance carrier. Like the DWC022, it requires detailed information about the employee and the incident. Both forms are crucial in the early stages of a workers' compensation claim, helping to establish the necessary groundwork for subsequent evaluations and treatments.
The DWC Form-011, which serves as the Employee’s Notice of Refusal of Medical Treatment, is also similar to the DWC022. This form is used when an employee refuses medical treatment recommended after an injury. Both documents require information about the employee's injury and the circumstances surrounding medical evaluations. They ensure that the employee's choices regarding their treatment are documented, which is essential for the workers' compensation process.
The DWC Form-006, known as the Employee’s Request for Medical Examination, is another document akin to the DWC022. This form is utilized by employees who wish to request a medical examination to assess their condition. Both forms involve the examination process, though the DWC022 is specifically for insurance carrier requests. They both emphasize the importance of medical evaluations in the workers' compensation system and help facilitate communication between employees and insurance carriers.
Similar to the DWC022, the DWC Form-012, which is the Request for Additional Income Benefits, plays a role in the workers' compensation process. This form is used when an employee seeks additional benefits due to ongoing disability. While the DWC022 focuses on medical evaluations, both forms require detailed information about the employee's situation and are crucial for determining the appropriate level of support for the injured worker.
The DWC Form-020, which is the Employee’s Report of Injury, is also comparable to the DWC022. This form is used by employees to report their injuries to their employers and insurance carriers. Both forms require comprehensive information about the injury and its impact on the employee's ability to work. They are essential in ensuring that all parties involved have a clear understanding of the situation, which is vital for the claims process.
Lastly, the DWC Form-019, known as the Employer’s Report of Injury, is similar to the DWC022 in that it documents the injury from the employer's perspective. This form is used to report the injury to the insurance carrier and provides essential details about the incident. Both forms work together to ensure that the workers' compensation system has a complete picture of the injury, which is crucial for processing claims and ensuring that employees receive the care they need.
When filling out the Texas DWC022 form, careful attention to detail is essential. Here are five important dos and don’ts to keep in mind:
This form is used for both agreements and non-agreements. If an employee does not agree, the insurance carrier can still request an order from TDI-DWC.
Filing this form is a necessary step for the insurance carrier to request a Required Medical Examination. It is not optional if they want to proceed with the examination process.
There are specific timeframes for how often an RME can be requested. For example, an RME for appropriateness of care cannot be performed more than once every 180 days.
Failure to attend a scheduled RME can lead to administrative penalties, including the suspension of benefits. It's important to communicate any issues with attendance.
There are specific conditions under which an RME can be requested. For instance, if medical benefits were provided through a certified health care network, an RME regarding appropriateness of care cannot be requested.
Employees are entitled to reimbursement for reasonable travel expenses related to the RME. However, they must complete the appropriate forms to request this reimbursement.
This form applies broadly to any workers' compensation claims that require a Required Medical Examination, regardless of the injury type.
The RME doctor can be different from the treating doctor. In fact, the insurance carrier may choose a doctor of their choice for the examination.
Filling out the Texas DWC022 form is an important step in the workers' compensation process. Here are some key takeaways to keep in mind:
Being informed about these key points can help ensure a smoother process when dealing with the Texas DWC022 form. If you have any questions, do not hesitate to reach out for assistance.