Outline
The Texas DWC022 form plays a crucial role in the workers' compensation process, specifically concerning Required Medical Examinations (RMEs). This form is utilized by insurance carriers to request an examination of an injured employee by a doctor of their choice. It serves two primary purposes: to evaluate the determinations made by a Designated Doctor and to assess the appropriateness of the health care received by the injured employee. Key information required on the form includes details about the employee, employer, and insurance carrier, as well as specifics regarding the examination, such as the doctor's name and appointment time. The form also includes sections for both the insurance carrier and the injured employee to certify their agreement or disagreement with the examination request. Understanding the nuances of the DWC022 is essential for both employees and insurance representatives, as compliance with the requirements outlined can significantly impact the outcome of a workers' compensation claim.
Sample - Texas Dwc022 Form
Texas Department of Insurance
Division of Workers’ Compensation
7551 Metro Center Drive, Suite 100 •
(800)
DWC022
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formulario o acerca de su reclamación, |
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llame al ajustador de su aseguradora al |
DWC Claim # |
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Casilla 15 de la Sección III. |
Carrier Claim # |
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Required Medical Examination (RME) - Request for Agreement / Request for Order
I. EMPLOYEE/EMPLOYEE’S ATTORNEY INFORMATION
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Employee's Name (First, Middle, Last) |
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2. Employee’s Social Security Number |
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Employee’s Address (Street or PO Box, City State Zip) |
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Employee’s Telephone Number |
5. Alternate Telephone Number (if available) |
6. Date of Injury (mm/dd/yyyy) |
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7. Attorney/Representative’s Name (if applicable) |
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8. Attorney/Representative’s Address (Street or PO Box, City State Zip) |
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II. EMPLOYER INFORMATION (at the time of the injury)
9. Employer’s Name |
10. Employer’s Address (Street or PO Box, City State Zip) |
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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 |
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14. Adjuster’s |
15. Adjuster’s Telephone Number |
16. Adjuster’s Fax Number |
17. Adjuster’s License Number |
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ext. |
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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 |
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21. RME Doctor's Telephone Number |
22. Examination Location (Street, City State Zip) |
23. Date and Time of Appointment |
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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.
Yes
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 |
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 |
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.
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Signature of Adjuster or Authorized Insurance Carrier Representative |
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Printed Name of Adjuster or Authorized Insurance Carrier Representative |
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33. Title of Adjuster or Authorized Insurance Carrier Representative
34. Date of Signature
DWC022 Rev. 07/11 |
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DWC022 |
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REQUEST FOR RME: APPROPRIATENESS OF HEALTH CARE RECEIVED (Complete Sections VII and VIII) |
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VII. EXAMINATION INFORMATION |
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Examining RME Doctor's Name |
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36. RME Doctor’s Mailing Address (Street or PO Box, City State Zip) |
37. RME Doctor’s License Number |
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RME Doctor's Telephone Number |
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39. Examination Location (Street, City State Zip) |
40. Date and Time of Appointment |
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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?
Yes
No If yes, provide the name of the 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
If yes, provide the name of the health care plan.
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.
Yes
No
VIII. INSURANCE CARRIER CERTIFICATION
47.I hereby certify the following:
•This request is complete and accurate.
•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
Sent to injured employee/attorney on (mm/dd/yyyy) |
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and no reply received as of (mm/dd/yyyy) |
•The insurance carrier will pay reasonable expenses incident to the examination of the injured employee.
•The selected doctor does not have a disqualifying association.
•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.
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
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
53. Signature of Injured Employee or Injured Employee’s Attorney/Representative
For
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
DWC022 Rev. 07/11 |
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DWC022
Information for the Injured Employee
For what purposes may a Required Medical Examination be requested?
DWC
•Request for Order (Evaluation of Designated Doctor Determination): If you have been examined by a Designated Doctor, the insurance carrier may ask
•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
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
What will
Within 7 days of receiving the insurance carrier’s request for an RME,
If
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
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
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
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.
•Fax the request to
DWC022 Rev. 07/11 |
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Form Information
| Fact Name | Details |
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| Form Purpose | The DWC022 form is used to request a Required Medical Examination (RME) to assess an injured employee's medical condition and treatment appropriateness. |
| Governing Law | This form is governed by the Texas Labor Code, specifically §408.004 and §504.053. |
| Submission Deadline | Employees have 15 days from receiving the request to respond regarding their agreement to attend the examination. |
| Examination Frequency | An RME for appropriateness of health care can occur no more than once every 180 days, while evaluations of Designated Doctor determinations may happen more frequently. |
| Travel Distance | If the employee's address and the examination location are over 75 miles apart, an explanation is required in the form. |
| Insurance Carrier Certification | The insurance carrier must certify that the request is complete, accurate, and that the selected doctor has no disqualifying associations. |
| Rescheduling | If unable to attend, the employee must contact the doctor's office at least 24 hours in advance to reschedule, with a new appointment occurring within 7 days. |
| Travel Reimbursement | Employees can request travel reimbursement using DWC-Form 048, available through the Texas Department of Insurance website. |
Detailed Guide for Filling Out Texas Dwc022
Completing the Texas DWC022 form is an important step in the process of requesting a Required Medical Examination (RME). This form gathers essential information about the employee, employer, insurance carrier, and the medical examination itself. Follow these steps to ensure that you fill out the form accurately and completely.
- Start with Section I: Employee/Employee’s Attorney Information. Fill in the employee's full name, Social Security number, address, and telephone numbers. Include the date of injury and the attorney's name and address if applicable.
- Move to Section II: Employer Information. Provide the employer's name and address at the time of the injury.
- In Section III: Insurance Carrier Information, fill out the insurance carrier's name, address, adjuster's name, email, telephone number, fax number, and license number.
- Proceed to Section IV: Examination Information. Enter the examining RME doctor's name, mailing address, license number, telephone number, examination location, and the date and time of the appointment. Indicate if the claim involves a Certified Health Care Network or a political subdivision and explain any travel requirement over 75 miles.
- In Section V: Purpose of Examination, list the Designated Doctor's name, date of examination, and check all applicable issues to be addressed in the requested RME.
- Complete Section VI: Insurance Carrier Certification by certifying the accuracy of the request and signing the form. Include the printed name, title, and date of the signature.
- If applicable, fill out Section VII: Examination Information for the Appropriateness of Health Care Received. Provide the same details as in Section IV for the second RME doctor.
- In Section VIII: Insurance Carrier Certification, certify the agreement status of the injured employee regarding the examination and provide the necessary signatures and dates.
- Finally, if applicable, complete Section IX: Injured Employee Agreement/Non-Agreement. Indicate whether the injured employee agrees or disagrees to attend the examination, and ensure the signature and printed name are included.
Once you have filled out the form, review it carefully to ensure all sections are complete and accurate. After that, submit the form to the appropriate parties as instructed. Keeping a copy for your records is also a good practice.
Obtain Answers on Texas Dwc022
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What is the Texas DWC022 form?
The Texas DWC022 form is a document used in the workers' compensation process in Texas. It is specifically a request for a Required Medical Examination (RME) by the insurance carrier. This examination can address issues related to the evaluation of a designated doctor’s determination or assess the appropriateness of health care received by an injured employee.
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When is the DWC022 form required?
The form is necessary when an insurance carrier wants to request an RME for an injured employee. This can occur in two main scenarios: to evaluate a designated doctor's findings or to determine if the health care received was appropriate. The request must be submitted to the Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC).
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What information do I need to provide on the form?
The DWC022 form requires various details, including:
- Employee's name, social security number, address, and contact information
- Employer's name and address at the time of the injury
- Insurance carrier's details, including the adjuster's name and contact information
- Examination information, such as the name and address of the examining doctor
- Specific issues to be addressed in the examination
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How often can a Required Medical Examination be performed?
An RME to assess the appropriateness of health care received can only occur once every 180 days. However, examinations related to a designated doctor’s determination can be more frequent. After receiving Supplemental Income Benefits for eight quarters, an RME regarding the ability to return to work may be conducted no more than once a year.
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What happens after I submit the DWC022 form?
Once TDI-DWC receives the insurance carrier’s request for an RME, they will review it within seven days. If approved, TDI-DWC will issue an order requiring the injured employee to attend the examination. If the request is denied, the employee will not be required to attend.
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Can I reschedule my RME appointment?
If you cannot attend the RME, you must contact the doctor's office to reschedule at least 24 hours in advance. The new appointment must take place within seven days of the original date, unless you and the doctor agree on a different date, which should not exceed 30 days from the original appointment.
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What should I do if I have questions about travel reimbursement?
If you have questions regarding travel reimbursement or need to request accommodations under the Americans with Disabilities Act (ADA), you can contact TDI-DWC at (800) 252-7031. To request travel reimbursement, you will need to fill out the DWC-Form 048, which is available on the TDI website.
Common mistakes
Filling out the Texas DWC022 form can be a daunting task, and mistakes can lead to delays or complications in the workers' compensation process. One common error is providing incorrect personal information. This includes the employee's name, Social Security number, or address. Even a small typo can cause significant issues, so it's crucial to double-check these details for accuracy.
Another frequent mistake involves failing to complete all necessary sections of the form. Each section serves a specific purpose, and incomplete information can result in the form being returned or rejected. It is essential to read the instructions carefully and ensure that every applicable section is filled out completely.
Many individuals also overlook the importance of signatures. The form requires signatures from both the insurance carrier representative and the injured employee or their attorney. Missing a signature can delay the process and may require resubmission. Always confirm that all required signatures are present before submitting the form.
Additionally, people sometimes neglect to provide explanations when required. For instance, if the employee's address and the examination location are more than 75 miles apart, an explanation is necessary. Failing to include this information can lead to confusion and may hinder the processing of the request.
Finally, some individuals misinterpret the purpose of the form. Understanding whether the request is for a Required Medical Examination (RME) regarding a designated doctor or the appropriateness of health care received is vital. Misunderstanding the purpose can lead to filling out the wrong sections or providing irrelevant information, complicating the process further.
Documents used along the form
The Texas DWC022 form is an important document in the workers' compensation process, specifically for requesting a Required Medical Examination (RME). Along with this form, there are several other documents that may be commonly used. Each of these documents serves a unique purpose in the claims process, helping to ensure that all necessary information is collected and reviewed.
- DWC Form-073: This form is used to assess an employee's ability to return to work after an injury. It provides critical information on the employee's medical status and is often required in conjunction with the RME to evaluate the employee's recovery and readiness to resume work duties.
- DWC Form-048: This form is a Request for Travel Reimbursement. Injured employees may use it to seek reimbursement for travel expenses incurred while attending required medical examinations. It is essential for ensuring that employees are not financially burdened by travel costs related to their medical evaluations.
- DWC Form-041: This is the Employee's Notice of Injury or Occupational Disease. It serves to formally notify the employer and the insurance carrier about the injury or illness. This document is crucial for establishing the timeline and details surrounding the claim, which can affect the RME process.
- DWC Form-006: This form is used for the Initial Report of Injury. It provides a comprehensive overview of the injury, including details about the incident and the nature of the injury. This report is often referenced during the RME process to understand the context of the employee's medical examination.
Understanding these documents can help injured employees navigate the workers' compensation process more effectively. Each form plays a role in ensuring that the employee receives appropriate medical evaluation and support throughout their recovery journey.
Similar forms
The Texas DWC022 form serves specific purposes related to workers' compensation claims. Several other documents share similarities with the DWC022 form in terms of their function and the information they require. Below is a list of these similar documents:
- DWC Form-073: This form is used to assess the ability of an injured employee to return to work. Like the DWC022, it gathers information about the employee's medical condition and work capabilities.
- DWC Form-048: This document requests reimbursement for travel expenses related to medical examinations. It shares the DWC022's focus on medical evaluations and the logistics surrounding them.
- DWC Form-031: This is a request for a designated doctor examination. Similar to the DWC022, it involves the evaluation of an employee's medical condition and is used to determine benefits.
- DWC Form-041: This form is used for notifying the Texas Department of Insurance about a dispute regarding medical benefits. It parallels the DWC022 in its focus on medical evaluations and claims processing.
- DWC Form-010: This document serves as a notification of an injured employee's rights. It shares the DWC022's emphasis on ensuring that employees are informed about their medical evaluations and related processes.
- DWC Form-007: This form is for reporting an injury to the Texas Department of Insurance. It requires similar information about the employee and the circumstances of the injury, akin to the DWC022.
- DWC Form-006: This document is used for filing a claim for income benefits. Like the DWC022, it focuses on the employee's injury and medical evaluation to determine eligibility for benefits.
- DWC Form-005: This form is a request for a change of treating doctor. It involves similar processes and information as the DWC022, particularly regarding medical evaluations.
- DWC Form-004: This is a request for a preauthorization of medical treatment. It parallels the DWC022 in that it deals with medical assessments and the necessity of certain treatments.
Dos and Don'ts
When filling out the Texas DWC022 form, there are several important things to keep in mind. Here’s a list of what you should and shouldn't do:
- Do provide accurate information about the employee, including their name and Social Security number.
- Do include the correct date of injury in the designated section.
- Do ensure that all contact details for the insurance adjuster are complete and correct.
- Do check if the examination location is more than 75 miles from the employee's address and provide an explanation if it is.
- Do sign and date the form to certify its accuracy.
- Don't leave any required fields blank; incomplete forms may delay the process.
- Don't forget to keep a copy of the completed form for your records.
- Don't submit the form without verifying that all information is accurate.
- Don't ignore the deadlines for returning the form, especially regarding the injured employee's agreement.
- Don't provide false information, as this can lead to penalties.
Misconceptions
- Misconception 1: The DWC022 form is only for employees who have already been denied benefits.
- Misconception 2: Completing the DWC022 form guarantees that an RME will be scheduled.
- Misconception 3: Employees have unlimited time to respond to the request for an RME.
- Misconception 4: The insurance carrier can request an RME at any time without restrictions.
- Misconception 5: An employee can choose any doctor for the RME.
- Misconception 6: If an employee disagrees with the RME, they are not required to attend.
- Misconception 7: The DWC022 form is not necessary if the employee has a treating physician.
- Misconception 8: Travel expenses for the RME are never covered.
This is not true. The DWC022 form is used for various purposes, including requesting a Required Medical Examination (RME) to evaluate medical benefits or the appropriateness of care received, regardless of whether benefits have been denied.
Submitting the form does not automatically mean an examination will take place. The Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) reviews the request and decides whether to approve or deny it.
Employees actually have 15 days from the date they receive the request to complete the agreement section of the form and return it to the insurance carrier. Timely responses are crucial.
There are specific guidelines regarding how often an RME can be performed. For instance, an RME to determine the appropriateness of health care cannot occur more than once every 180 days.
The RME must be conducted by a doctor selected by the insurance carrier. Employees may not have the flexibility to choose their own doctor for this examination.
If an employee does not agree to attend the RME, the insurance carrier can still request TDI-DWC to issue an order requiring attendance. Noncompliance could lead to penalties.
Even if an employee has a treating physician, the DWC022 form may still be required for specific examinations related to the workers' compensation claim, especially if the insurance carrier needs further evaluation.
In fact, the insurance carrier is required to pay reasonable expenses related to the examination. Employees should inquire about travel reimbursement using the appropriate forms.
Key takeaways
The Texas DWC022 form is essential for requesting a Required Medical Examination (RME) to assess either the appropriateness of medical care received or to evaluate a Designated Doctor’s determination.
It is crucial to fill out all sections accurately. Missing information can delay the process and lead to complications in your workers' compensation claim.
Employees have a limited time frame of 15 days to respond to the request for agreement to attend the examination. Keeping a copy of the completed form for personal records is advisable.
If an employee cannot attend the scheduled examination, they must contact the doctor's office at least 24 hours in advance to reschedule, ensuring it is done within the specified time limits.