Medical Fees And Charges
SORM will pay only for those services that are determined to be reasonable and necessary and related to the injury. By statute and rule, DWC has specified 16 treatments which require pre-authorization or prior approval. Health care providers within the CompKey Plus Healthcare network have different preauthorization requirements. Without this approval, SORM may not be responsible for payment.
Employees eligible for workers compensation medical services should be instructed to inform their health care provider that the injury may be covered by workers compensation provided by the State of Texas, and to give the health care provider their SORM claim number.
Information For Employees From The Division Of Workers’ Compensation
Who is the Division of Workers’ Compensation?
The Division of Workers’ Compensation is a state agency that regulates the delivery of workers’ compensation benefits to injured employees and to eligible family members of employees killed on the job. The DWC also helps resolve disputes about claims and provides workplace safety and health services. The DWC does not pay benefits. Benefits are paid by workers’ compensation insurance companies, by employers certified by this agency to self-insure, or by self-insured governmental entities.
What is Workers’ Compensation?
Workers’ compensation is a state-regulated insurance program that typically will pay your medical bills and replace a portion of your lost wages if:
- You are injured at work or have a work-related illness and
- Your employer has workers’ compensation insurance coverage under the Texas Workers’ Compensation Act.
Workers’ compensation typically will pay for the medical treatment of your work-related injury or illness if:
- You are injured at work or have a work-related illness and
- Your employer has workers’ compensation insurance coverage under the Texas Workers’ Compensation Act.
Workers’ compensation will also replace a portion of your lost wages if:
For further assistance, call 1-800-252-7031or visit
How To File A Workers Comp Claim In Texas
If you are injured on the job or become ill because of your job, you must first tell your employer, then report your injury to the Division of Workers Compensation using DWC Form-041 . To do that, complete and submit this interactive form and send it to:
Texas Department of Insurance 7551 Metro Center Dr., Suite 100 Austin, TX 78744-1609
You may also call the division at 800-252-7031 to have a paper copy of DWC Form-041 or Form-042 mailed to you.
You are required to tell your doctor how you were hurt and whether the injury is work-related send in the appropriate form to DWC provide your current address, telephone number and employer information to DWC and the insurance carrier and inform DWC and the insurance carrier if there is a change in your employment status or wages.
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Workers’ Comp Rules & Information For Texas
Who Needs Workers’ Comp in Texas?
Texas has a highly unusual position as employers are not required to carry workers’ compensation. Texas is the only state which does not require coverage. However, there are exclusions to this rule for some employers listed below:
- Any public employer including cities, counties, state agencies and state universities
- Building and construction contractors for public employers
- Motor bus companies and motor carriers
- Combustible gas dealers including liquid propane and compressed natural gas
- Companies that operate a work furlough program for inmates
This presents several scenarios for employers. They can go bare which leaves them open to civil suits for personal injury based on common law, which can be bought by any employee or worker who is misclassified. This can result in very high awards which are not limited by statutory amounts which may result in severe economic loss to the employer. The employer is estopped from using some forms of legal defenses including contributory negligence on the part of the worker or another employee and negligence of a coworker.
A business or company may self-insure if the can meet the financial requirements. They can also self-insure under the States Insurance Fund
Does Texas Allow Workers Comp Exemptions for Owners?
Sole-Proprietors and Partners
What are the Penalties for not Having Workers’ Comp in Texas?
When Do I Get an EMR Rating in Texas?
Workers’ Comp Includes Employers Liability Insurance?
Attorney Fees For Workers Comp In Texas
Should you hire representation, the attorneys fees will be deducted from the income benefit payments the DWC orders. An attorney can charge a maximum of $200 per hour, plus expenses, on your workers compensation claim, and attorneys fees can be no more than 25% of your benefits. For help finding an attorney, you may contact the State Bar of Texas www.texasbar.com or 1-800-252-9690.
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What To Do If Your Employer Does Not Have Workers Comp Insurance
If youre injured and your employer has no coverage, you can sue the employer for negligence and the employer waives any common law defenses, Collins said.
For instance, employers cannot claim that the injured worker was negligent, that the worker assumed the risk of injuries or that the worker was injured by a co-worker as a defense. The employer can, however, bring evidence that the employee intentionally injured himself or was intoxicated when the injury occurred.
Returning To Work Policy In Texas
Under workers compensation law in Texas, employers can institute Return to Work programs so that injured workers can get back on the job quickly and safely while they heal, either with changes to their regular job or in a temporary, alternate work assignment. The theory is that this benefits both employers and employees. It is designed to reduce employers workers compensation costs and help retain skilled workers, and that employees who dont return to work once they are medically able are more likely to take longer to recover, need more treatment, become depressed and lose important job skills.
The obvious question for the employee: What happens to your workers comp benefits if you go back to work? In the case of Temporary Income Benefits, the weekly benefit check may be suspended while you are working, or reduced, depending on what actual wages you earn. If you return to work and later your doctor takes you back off work, your checks may be restored as long as you have disability and have not reached maximum medical improvement. Medical benefits continue as long as it is for reasonable and necessary injury-related treatment.
You will keep receiving TIBs if your doctor releases you to return to work with restrictions but your employer doesnt have a job that meets your medical restrictions. If your employer offers modified or alternate work in accord with your medical restrictions and you decline the offer, you may lose your TIBs.
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A Quick Guide To Workers Compensation In Texas
Texas has long prided itself as a rugged and independent republic. It carries a swagger that comes with being the largest contiguous state, the second-most populous state, the second-largest economy in the nation and home to 48 Fortune 500 companies. So, its not surprising Texas also has an independent streak when it comes to workers compensation insurance.
How To Appeal A Claim Denial
If you have a dispute concerning benefits from an injury or illness and discussing it with the insurance carriers adjuster does not solve it, you may ask for dispute resolution through the DWC. The parties are required to make efforts to resolve the dispute before seeking dispute resolution.
You are allowed to have an attorney advise and represent you throughout the process. If you dont have an attorney, the Office of Injured Employee Counsel will provide an ombudsman, a specially trained OIEC employee, who can assist you free of charge. You may request ombudsman assistance by calling 1-866-393-6432.
The process has several potential steps.
There are some claims that are very small, non-serious injuries that probably get handled expeditiously, and in cases where you have a paraplegic or something like that, theres usually no dispute, Collins said. But there are a lot of claims that fall in between those parameters that have to go through the system, and it is just frightening.
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Benefits: What Does Workers Comp Cover In Texas
Workers compensation benefits pay for reasonable, needed medical care to treat your work-related injury or illness, income to replace some of the money you lost due to that injury or illness, death benefits to help families replace some of the money lost when an employee dies because of such an injury or illness and burial benefits to offset some of an employees funeral expenses.
Choice To Opt Out: Know The Risks
Texas workers compensation law allows employers to opt out of carrying workers compensation insurance, which covers medical expenses, physical therapy expenses and lost wages for employees who get sick or injured at work. Benefits can sometimes also include compensation for economic loss and benefits payable to the dependents of workers killed on the job or in the course of employment.
While workers compensation laws in Texas require public entities to provide workers compensation insurance, coverage is voluntary for most employers, according to the states Division of Workers Compensation . The DWC also reports, about 28% of private, year-round employers do not have workers compensation, and they employ about 18% of the private workforce in Texas.
Employers that opt out are called non-subscribers and must notify employees they do not carry workers compensation insurance and file an annual notice, or DWC Form-005, with the states DWC. Employee notification is covered by posting a Notice 5 at the place of employment and informing new hires in writing that the business doesnt have workers compensation insurance coverage. Non-subscribers must also report workplace injuries to the DWC on DWC Form-007.
In addition to the safety net workers compensation can provide employees a business most important assets workers compensation insurance also provides businesses with important protections, including from costly lawsuits.
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Useful Numbers And Addresses
Injured employees can contact SORM through its toll-free number.
SORM Toll-Free Phone: 445-0006
Phone numbers for preauthorization and pharmacy providers are available by calling SORMs main number.
SORM Main Phone: 475-1440
SORM Fax: 370-9025
Suspected fraud or abuse of the workers compensation system can be reported to SORMs toll-free fraud hotline.
SORM Toll-Free Fraud Hotline: 445-0006
Fraud and Investigation Email:
Thank You For Being Our Return
The goal of workers’ comp is for injured workers to return to a productive life. You play an important role in delivering the care needed to make that possible.
As your office provides care, follow these four steps:
Treat emergencies immediately or prepare to ask a few discovery questions if the situation is not urgent. Find out if the injury is work-related by asking:
- How did the injury occur?
- Where were you at the time of injury?
If the patient indicates that it was work related, ask if their employer has workers compensation coverage or use the Texas Department of Insurance coverage verification tool.
While it’s up to insurance carriers to determine if claims are work-related, proceed with caring for the injured worker as a workers compensation patient as long as the patient indicates the injury happened at work and the employer has workers compensation coverage.
Many of our policyholders choose to participate in the WorkWell, TX network – Texas Mutuals own health care network. If the patients employer is covered by Texas Mutual, call us at 532-5246 or contact the employer to determine if they participate in the network.
Your role is to provide appropriate return-to-work focused care for injured employees. Some treatment requires pre-authorization, which you can read about below or discuss with us by calling 532-5246.
Bills for Texas Mutual should be submitted to Jopari Solutions . For more information, contact Jopari Solutions at 269-0554.
Texas Dwc Seeks Comments On Benefits Forms Changes
The Texas Department of Insurance, Division of Workers Compensation is accepting public comments on revisions to two forms:
- DWC Form-046, Request to Accelerate Impairment Income Benefits. This form is necessary to allow injured employees with a hardship a way to request an acceleration of weekly impairment income benefits.
- DWC Form-047, Request to Advance Benefits. This form is necessary to allow injured employees with a financial hardship a way to request an advance of benefits.
The revised forms are not a formal rule proposal under the Administrative Procedures Act. DWC will not treat comments as formal public comments. However, DWC will consider any substantive comment before the revised forms are adopted. The proposed forms are on the TDI website.
Notice : Employers Notice Of Workers Compensation
Texas Workers Compensation Rule 110.101 requires employers who are covered by workers compensation through a commercial insurance company to advise their employees that they are covered by workers compensation insurance coverage and that they can obtain additional information about their workers compensation rights from the Texas Department of Insurance , Division of Workers Compensation by calling its toll free number.
As required by the TDI, notices in English, Spanish and any other language common to the employers employees must be posted and:
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New Employee Notice Reference Rule 110101
This notice requirement does not apply to employers that are political subdivisions with coverage under Chapter 504 of the Texas Labor Code . A new employee who previously worked for a private employer may ask about this.
You can explain that §504.018 of the Texas Labor code requires that all public employees are covered by workers compensation. It states, in part, that Employees of a political subdivision are conclusively considered to have accepted the compensation provisions instead of common-law or statutory liability or cause of action, if any, for injuries received in the course of employment or death resulting from injuries received in the course of employment.
Since employees of a political subdivision are not eligible to opt out of the Act, the notice is not required.
Eligibility For Workers Comp In Texas
As previously noted, not all employers carry workers comp insurance. The web-based news organization Texas Tribune, in a 2014 investigative series, reported that more than 500,000 people have no occupational benefits when injured on the job. More than million Texas workers get private occupational insurance from employers, plans that arent regulated by the state. Only 41% of such plans include death benefits, the Tribune reported. Roughly 81% of Texas employers have state-regulated plans.
Employers must inform new employees in writing that they carry workers compensation insurance upon hire. The written notice must inform employees of their right to reject workers compensation coverage and retain right to sue for damages, though few choose to, Collins said.
The DWC provides a search function to find out whether a particular employer has workers compensation coverage. Likewise, some employers are required to report if they elect not to obtain workers compensation insurance coverage. For a downloadable list of non-covered employers see the . It also is possible to verify if a company is a certified self-insurer in Texas.
If you cant find the insurance coverage information you seek, call 800-252-7031 or 512-804-4345 in the Austin area for assistance.
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Quality Journalism Doesn’t Come Free
Perhaps it goes without saying but producing quality journalism isn’t cheap. At a time when newsroom resources and revenue across the country are declining, The Texas Tribune remains committed to sustaining our mission: creating a more engaged and informed Texas with every story we cover, every event we convene and every newsletter we send. As a nonprofit newsroom, we rely on members to help keep our stories free and our events open to the public. Do you value our journalism? Show us with your support.
How Does Workers’ Comp Work In Texas
The Texas Department of Insurance’s Division of Workers’ Compensation regulates the state’s workers’ compensation system and also certifies employers that want to self-insure.
Texas doesn’t require most private employers to carry workers’ compensation insurance. Employers who contract with the government are required to provide workers’ compensation coverage for each employee working on the project. Some clients may also require their contractors to have workers’ compensation insurance.
Employers who choose not to have workers’ compensation insurance, Nonsubscribers, must file an annual notice with the Texas Department of Insurance. The must also display notices of no-coverage and give written statement to each new employee hired.
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Compensation Due In Fatal Cases
Beneficiaries of a deceased employee are due weekly compensation payments equal to a percentage of the employees average weekly wages, subject to a maximum amount and a minimum amount established by the Texas Workers Compensation Act. Weekly payments to the surviving spouse are payable for life or until the spouse remarries. In the event of remarriage, a lump-sum payment equal in amount to the compensation due for a period of two years is paid. Weekly payments to a child shall continue until the age of 18 or beyond such age if the child is actually dependent , or until 25 years of age if enrolled as a full-time student in an accredited educational institution. All other beneficiaries are due weekly payments for 364 weeks.
Deadlines For Texas Workers Comp Claims
- Employees must tell their employer within 30 days of the date they were hurt. Missing this deadline might mean missing out on benefits.
- Employers must file an Employers First Report of Injury or Illness with the injured workers insurance carrier and the injured claimant within eight days after the employees absence from work or receiving notice of an occupational disease.
- Employees have one year to report the injury to the DWC.
- For occupational diseases, employees must tell their employer within 30 days of the date they first knew their injury or illness might be work-related and file a claim with DWC within one year of that date.
- Those seeking death and burial benefits must send a completed Beneficiary Claim for Death Benefits to DWC within one year following the employees date of death.
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