Texas Workers' Compensation Claims Handling Manual, rev. 1.4 · Meridian Claims Services (synthetic demo TPA) · analyzed against Texas workers' compensation requirements (live mode)
When an employer client reports a lost-time injury, confirm the Employer's First Report of Injury (DWC Form-001) has been filed with us as carrier representative. Our standard requires the employer's report within 15 days of the employee's first missed day beyond the date of injury. Log the report date in the claim system and follow up on late filings.
The manual requires the employer's report 'within 15 days of the employee's first missed day beyond the date of injury,' but REG-TX-01 (28 TAC § 120.2) mandates that the employer file DWC Form-001 'not later than the 8th day after the employee's absence from work for more than one day due to injury.' The internal 15-day deadline is longer than the regulatory 8-day deadline, creating a weaker standard and non-compliance.
Revise the internal standard to require the employer to file DWC Form-001 not later than the 8th day after the employee's absence from work for more than one day due to injury, consistent with 28 TAC § 120.2.
Upon receipt of written notice of injury, the adjuster must either initiate benefit payments or issue a written notice of refusal with stated grounds to the Division and the employee within 30 days of the notice. Document the action taken and the mailing date in the activity log.
The manual sets a 30-day deadline for the adjuster to either initiate benefit payments or issue a written refusal notice to the Division and the employee. REG-TX-02 (Tex. Lab. Code § 409.021(a)) requires this action be taken 'not later than the 15th day after receiving written notice of an injury.' The manual's 30-day period is double the statutory maximum, representing a weaker standard and a clear deadline contradiction.
Change the deadline from 'within 30 days of the notice' to 'not later than the 15th day after receiving written notice of an injury' to comply with Tex. Lab. Code § 409.021(a).
The carrier's right to contest compensability lapses if not exercised on or before the 90th day after written notice of injury, except on newly discovered evidence that could not reasonably have been obtained earlier. Calendar the contest deadline at intake and escalate at day 45 if the investigation is incomplete.
The manual states the carrier's right to contest compensability lapses if not exercised 'on or before the 90th day after written notice of injury,' but REG-TX-03 (Tex. Lab. Code § 409.021(c)) requires the carrier to contest compensability 'on or before the 60th day after receiving written notice of the injury.' This is a specific deadline contradiction (90 days versus 60 days). The 'newly discovered evidence' exception in the manual paraphrases the regulation's exception and does not conflict.
Change the compensability contest deadline from the 90th day to the 60th day after written notice of injury to conform to Tex. Lab. Code § 409.021(c). The internal escalation at day 45 may be retained as a stricter internal control.
No income benefits are payable for the first week of disability under any circumstances. Begin income benefit payments with the second week of disability and continue on the weekly schedule. Waiting-week amounts are never paid retroactively.
The manual states that 'No income benefits are payable for the first week of disability under any circumstances' and that 'Waiting-week amounts are never paid retroactively.' However, REG-TX-05 (Tex. Lab. Code § 408.082) provides: 'Income benefits may not be paid for the first week of disability unless the disability lasts for two weeks or longer, in which case compensation for the first week accrues and is payable.' The manual's absolute prohibition contradicts the regulatory requirement to pay the waiting week when the disability lasts two weeks or longer.
Revise the section to state that income benefits are not paid for the first week of disability unless the disability lasts for two weeks or longer, in which case compensation for the first week accrues and is payable. Remove the 'under any circumstances' and 'never paid retroactively' language.
Process complete medical bills promptly. Final action — payment, reduction, denial, or audit determination — must be taken within 60 days of receipt of a complete bill. Bills pended for audit must carry a documented audit plan and follow the audit timeline.
The manual states that final action must be taken 'within 60 days of receipt of a complete bill,' but REG-TX-07 (28 TAC § 133.240) requires the insurance carrier to take final action — pay, reduce, deny, or determine to audit — on a complete medical bill 'not later than the 45th day after receipt of the bill.' The 60-day deadline contradicts the 45-day regulatory deadline.
Revise the manual to require final action within 45 days (not 60 days) after receipt of a complete medical bill to align with 28 TAC § 133.240.
| Citation | Requirement | What it requires |
|---|---|---|
| 28 TAC § 134.600 | Preauthorization requirements | Specified non-emergency health care — including inpatient hospital admissions, spinal surgery, and physical/occupational therapy beyond the initial evaluation-and-treatment allowance — requires preauthorization from the carrier before the service is provided. |
| Tex. Lab. Code § 409.003 | Employee claim filing deadline | The employee must file a claim for compensation with the division not later than one year after the date the injury occurred, or within one year of when the employee knew or should have known an occupational disease was work-related. |