Outline
The Texas DWC049 form plays a crucial role in the workers' compensation process, specifically for those seeking to schedule a Medical Contested Case Hearing (MCCH). This form is essential for individuals looking to appeal decisions related to medical necessity or medical fee disputes. It requires specific details, including the DWC claim number, the insurance carrier's information, and the injured employee's personal details. The form also allows the requester to indicate if they need expedited processing or special accommodations. Importantly, it outlines the responsibilities of the parties involved, such as the requirement for the non-prevailing party in a SOAH appeal to reimburse costs. The form must be submitted within strict deadlines following a Benefit Review Conference or an Independent Review Organization decision. Failure to provide complete information can delay the resolution of disputes. Understanding the nuances of the DWC049 form is vital for ensuring that the rights of injured employees are upheld and that they receive the medical care and compensation they deserve.
Sample - Texas Dwc049 Form
DWC049
Complete if known:
DWC Claim #
Carrier Claim #
Request to Schedule a Medical Contested Case Hearing (MCCH)
Type (or print in black ink) each item on this form
I. REQUEST SPECIFICATIONS
1. Check the appropriate box to indicate the type of medical contested case hearing you are requesting:
Appeal of an Independent Review Organization (IRO) Medical Necessity Decision to the
Appeal of Medical Fee Dispute Decision to State Office of Administrative Hearings (SOAH). Enter the date the Benefit Review Conference ended (mm/dd/yyyy)
IMPORTANT NOTE: In an appeal to SOAH, the
2.Check the appropriate box(es) for services you are requesting, if any:
Expedited MCCH (specify reason*)
Special Accommodations (specify)
*Does not include claim involving a first responder. See Section III, Box 10 regarding expedited first responder claims.
II. INJURED EMPLOYEE CLAIM INFORMATION
3. Employee’s Name (Last, First, Middle) |
4. Date of Injury (mm/dd/yyyy) |
5.Employee’s Physical Address (Street, City, State, Zip Code)
6.Insurance Carrier’s Name
7.Employer’s Business Name (at the time of the injury)
8.Employer’s Business Address (Street or PO Box, City, State, Zip Code)
For
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DWC049
III. REQUESTER INFORMATION
9. Check the appropriate box:
Injured Employee |
Health Care Provider |
Subclaimant |
Pharmacy Processing Agent |
Insurance Carrier |
Attorney for__________ |
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10. Provide the following information:
Is the injured employee a first responder, as defined in Texas Labor Code §504.055, who sustained a serious bodily
injury*? |
Yes |
No |
If yes,
• Medical Fee Dispute: MCCH will be expedited only if the requester is the injured employee.
• Medical Necessity Dispute: MCCH will be expedited regardless of requester type.
*bodily injury that creates a substantial risk of death or that causes death, serious permanent disfigurement, or protracted loss or impairment of the function of any bodily member or organ
11. If injured employee is checked in Box 9, is the employee assisted by the Office of Injured Employee
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Counsel (OIEC)? |
Yes |
No |
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12. |
Requester's Mailing Address (Street or PO Box, City, State, Zip Code) |
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13. |
Requester’s Printed Name/Title |
14. |
Phone Number |
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15. |
Requester’s Signature |
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16. |
Date of Signature (mm/dd/yyyy) |
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NOTE: With few exceptions, upon your request, you are entitled to be informed about the information
Employee’s Name: DWC Claim Number:
For
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DWC049
Frequently Asked Questions
Request to Schedule Medical Contested Case Hearing (MCCH)
Where will the MCCH be held?
•Medical Fee Dispute: The State Office of Administrative Hearings (SOAH) will schedule the hearing at the SOAH offices in Travis County.
•Medical Necessity Dispute: The Texas Department of Insurance, Division of Workers’ Compensation
What type of special accommodations will be provided?
The
Who determines whether an MCCH is expedited?
If an expedited MCCH is requested in Section I, Box 2, the
If Yes is checked in Section III, Box 10 to indicate that the injured employee is a first responder, the
•Medical Fee Dispute: MCCH will be expedited only if the requester is the injured employee.
•Medical Necessity Dispute: MCCH will be expedited regardless of requester type.
What is the deadline for filing the DWC
•Medical Fee Dispute: You must submit the form to the
•Medical Necessity Dispute: You must submit the form to the
Where do I send the DWC
The completed form, including a copy of the IRO decision (if applicable), must be faxed to (512)
Texas Department of Insurance Division of Workers’ Compensation
7551 Metro Center Drive, Suite 100 •
Is any of the requested information optional?
No, provide all requested information. An MCCH will only be scheduled if the form is complete. An incomplete form may delay resolution of your dispute.
Am I required to attend the MCCH?
If you do not attend, the MCCH may be held without you. Failure to attend an MCCH could result in a recommendation of a penalty or fine unless you can show good cause for your absence. An injured employee should attend any proceeding related to a dispute about his or her claim, even if the injured employee did not request the proceeding.
Who do I contact if I have questions about requesting an MCCH?
Contact the
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Form Information
| Fact Name | Details |
|---|---|
| Purpose | The DWC049 form is used to request a Medical Contested Case Hearing (MCCH) in Texas. |
| Types of Appeals | It allows for appeals related to medical necessity decisions and medical fee disputes. |
| Filing Deadline | The form must be submitted within 20 days after the Benefit Review Conference ends or after receiving the IRO decision. |
| First Responder Expedited Requests | MCCHs for first responders with serious bodily injuries may be expedited, depending on the requester's status. |
| Reimbursement Requirement | If the non-prevailing party appeals to SOAH, they must reimburse TDI-DWC for associated costs. |
| Submission Method | Completed forms can be faxed to (512) 804-4011 or mailed to the TDI-DWC office in Austin. |
| Governing Law | This form is governed by the Texas Labor Code, specifically sections related to workers' compensation disputes. |
Detailed Guide for Filling Out Texas Dwc049
Filling out the Texas DWC049 form is an essential step in requesting a Medical Contested Case Hearing (MCCH). Once completed, this form should be submitted to the Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) to initiate your request. It's important to ensure that all sections are filled out accurately to avoid delays in processing.
- Begin by filling in the DWC Claim # and Carrier Claim # at the top of the form.
- In Section I, check the appropriate box to specify the type of medical contested case hearing you are requesting. Attach a copy of the Independent Review Organization (IRO) decision if applicable.
- If you are requesting any services, check the relevant box(es) for expedited MCCH or special accommodations, providing a reason if necessary.
- In Section II, provide the injured employee's full name (Last, First, Middle) and the date of injury in the specified format (mm/dd/yyyy).
- Fill in the injured employee's physical address, including street, city, state, and zip code.
- Enter the name of the insurance carrier and the employer's business name at the time of the injury.
- Provide the employer's business address, including street or PO Box, city, state, and zip code.
- In Section III, check the appropriate box to indicate whether you are the injured employee, health care provider, subclaimant, pharmacy processing agent, insurance carrier, or attorney.
- Answer the question regarding whether the injured employee is a first responder who sustained a serious bodily injury. If yes, proceed to the next question.
- If the injured employee is checked in Box 9, indicate whether they are assisted by the Office of Injured Employee Counsel (OIEC).
- Provide the requester's mailing address, including street or PO Box, city, state, and zip code.
- Print the requester's name and title in the designated area.
- Include a phone number where the requester can be reached.
- Sign and date the form in the specified fields.
After completing the form, ensure that it is sent to the TDI-DWC by faxing it to (512) 804-4011 or mailing it to the address provided. Remember, all requested information is mandatory for processing, and an incomplete form may lead to delays.
Obtain Answers on Texas Dwc049
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What is the purpose of the Texas DWC049 form?
The Texas DWC049 form is used to request a Medical Contested Case Hearing (MCCH). This form allows individuals to appeal decisions related to medical necessity or medical fee disputes. It is essential for anyone involved in a workers' compensation claim in Texas to understand how to properly fill out and submit this form.
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What types of hearings can I request using the DWC049 form?
You can request two main types of hearings:
- Appeal of an Independent Review Organization (IRO) Medical Necessity Decision to the Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC).
- Appeal of Medical Fee Dispute Decision to the State Office of Administrative Hearings (SOAH).
It is important to attach the relevant decision when submitting your request.
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What happens if I do not attend the MCCH?
If you fail to attend the MCCH, the hearing may proceed without you. This absence could lead to a recommendation for a penalty or fine unless you can demonstrate good cause for not attending. It is strongly advised that injured employees attend any hearings related to their claims, even if they did not initiate the request.
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How do I know if my MCCH request will be expedited?
The TDI-DWC will determine whether your request for an expedited MCCH is appropriate. If the injured employee is a first responder, certain conditions apply:
- For medical fee disputes, the MCCH will be expedited only if the injured employee is the requester.
- For medical necessity disputes, the MCCH will be expedited regardless of who requests it.
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Where should I send the completed DWC049 form?
You can send the completed form via fax or mail. The fax number is (512) 804-4011. If you choose to mail it, send it to:
Texas Department of Insurance
Division of Workers’ Compensation
7551 Metro Center Drive, Suite 100 • MS-35
Austin, TX 78744-1645Ensure that you include any necessary attachments, such as a copy of the IRO decision, if applicable.
Common mistakes
Filling out the Texas DWC049 form can be a straightforward process, but there are common mistakes that people often make. One significant error is failing to check the appropriate box for the type of medical contested case hearing. It’s crucial to clearly indicate whether you are appealing a Medical Necessity Decision or a Medical Fee Dispute Decision. Skipping this step can lead to delays in processing your request, as the Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) needs this information to proceed.
Another frequent mistake involves providing incomplete or inaccurate personal information. It is essential to include the injured employee's full name, date of injury, and contact details. Omitting any of this information can result in the rejection of your form. Remember, an incomplete form may delay the resolution of your dispute, so double-checking this section is vital.
Additionally, many individuals overlook the requirement to attach necessary documentation, such as the Independent Review Organization (IRO) decision when appealing a Medical Necessity Decision. Failing to include these documents can hinder the progress of your case. Always ensure that you have all supporting materials ready before submitting the form.
Lastly, another common error is neglecting to sign and date the form. The signature is not just a formality; it confirms that the information provided is accurate and that you are formally requesting the hearing. Without a signature, the form may be deemed invalid, causing unnecessary delays in your case. Always make it a point to review the entire form before submission to ensure all requirements are met.
Documents used along the form
The Texas DWC049 form is an essential document for requesting a Medical Contested Case Hearing (MCCH) related to workers' compensation disputes. Several other forms and documents are commonly used in conjunction with the DWC049 to ensure a comprehensive approach to the hearing process. Below is a list of these documents, each serving a specific purpose in the context of workers' compensation claims.
- DWC Form-045: This form is used to request a Benefit Review Conference (BRC). It serves as a preliminary step before escalating to a contested case hearing. The BRC allows parties to discuss the issues and potentially reach an agreement without further legal action.
- DWC Form-053: The Employee's Claim for Compensation form is essential for initiating a workers' compensation claim. It collects necessary information about the injury and the employee, ensuring that all relevant details are documented from the start.
- DWC Form-006: This is the Notice of Disputed Issue form. It is filed by the insurance carrier to indicate that they contest the validity of a claim or specific benefits. This form is crucial for formally notifying the injured employee of the dispute.
- DWC Form-041: The Request for Medical Examination form is used when a party seeks an independent medical examination. This examination can provide additional evidence and insight into the medical aspects of the claim, which may be critical during the hearing.
Understanding these forms and their functions can significantly impact the outcome of a workers' compensation dispute. Properly completing and submitting these documents ensures that all parties are informed and prepared for the hearing process.
Similar forms
The Texas DWC049 form is a crucial document for requesting a Medical Contested Case Hearing (MCCH) related to workers' compensation claims. Several other documents serve similar purposes in the realm of workers' compensation and medical disputes. Here’s a look at five of them:
- DWC Form 045: This form is used to request a Benefit Review Conference (BRC). Like the DWC049, it is part of the process for resolving disputes over workers' compensation claims. Both forms require detailed information about the injured employee and the nature of the dispute.
- DWC Form 006: This form is utilized for filing a Claim for Compensation for Death or Injury. Similar to the DWC049, it initiates a formal process for addressing claims, but focuses specifically on cases involving fatalities or serious injuries.
- DWC Form 041: This document is used to request a hearing to contest a decision made by the Division of Workers' Compensation. It shares the same objective as the DWC049, allowing parties to challenge decisions regarding benefits or medical necessity.
- DWC Form 073: This form is designed for submitting a request for a Medical Fee Dispute Resolution. Both forms deal with disputes related to medical services, but the DWC073 specifically addresses issues regarding payment for medical treatment.
- DWC Form 051: This form is used to notify the Division of Workers' Compensation about a change in the status of a claim. Like the DWC049, it is essential for maintaining accurate records and ensuring that all parties are informed about the current status of a claim.
Dos and Don'ts
When filling out the Texas DWC049 form, there are several important dos and don'ts to keep in mind. Following these guidelines can help ensure that your submission is complete and processed efficiently.
- Do check the appropriate boxes clearly. Indicate the type of medical contested case hearing you are requesting by marking the correct options. This will help avoid confusion and ensure your request is directed to the right department.
- Do provide all requested information. Fill out each section completely, including the injured employee's name, date of injury, and contact details. An incomplete form may delay the resolution of your dispute.
- Do attach any necessary documentation. If you're appealing an Independent Review Organization (IRO) decision, make sure to include a copy of that decision with your form.
- Do keep a copy of the completed form for your records. This can be helpful for future reference or if any issues arise regarding your submission.
- Don't use pencil or any ink color other than black. The form must be filled out in black ink to ensure readability and proper processing.
- Don't leave any fields blank. Every section of the form is required, so ensure that you fill in all information accurately.
- Don't forget to sign and date the form. Your signature is necessary to validate the request, and missing this can lead to delays.
- Don't submit the form after the deadline. For medical fee disputes, the form must be submitted within 20 days after the Benefit Review Conference ends. Be mindful of these timelines to avoid complications.
Misconceptions
Misconceptions about the Texas DWC049 form can lead to confusion and delays in the medical contested case hearing process. Here are four common misconceptions:
- The DWC049 form is optional. Many people believe that submitting this form is not necessary. In reality, all requested information must be provided. An incomplete form will delay the scheduling of the hearing.
- Only injured employees can request a hearing. Some think that only the injured employee has the right to file this form. However, health care providers, attorneys, and other authorized representatives can also submit the DWC049 on behalf of the injured employee.
- The MCCH will be scheduled automatically. There is a misconception that simply filling out the form guarantees a hearing. The Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) must review the submission first. If the form is incomplete or incorrect, it may not be scheduled.
- Attendance at the MCCH is optional. Some individuals believe they do not need to attend the hearing. This is false. If a party fails to attend, the hearing may proceed without them, and this could lead to penalties or fines unless a valid reason for absence is provided.
Understanding these points can help ensure that the process moves forward smoothly. It is crucial to approach the DWC049 form with care and attention to detail.
Key takeaways
Filling out and using the Texas DWC049 form can be a critical step for individuals navigating medical contested case hearings. Here are some key takeaways to keep in mind:
- Understand the Purpose: The DWC049 form is used to request a Medical Contested Case Hearing (MCCH) related to disputes over medical necessity or medical fees.
- Identify the Type of Hearing: Clearly indicate whether you are appealing a decision made by an Independent Review Organization (IRO) or a medical fee dispute decision. Each type has specific requirements.
- Complete All Sections: Ensure that every section of the form is filled out accurately. Incomplete forms may lead to delays in scheduling your hearing.
- Submit Timely: Be aware of deadlines. The form must be submitted within 20 days of the Benefit Review Conference conclusion or the IRO decision date.
- Provide Necessary Attachments: If applicable, attach a copy of the IRO decision when submitting the form for an appeal.
- Consider Special Accommodations: If you or your request falls under the Americans with Disabilities Act (ADA), indicate any necessary accommodations on the form.
- Attend the Hearing: Your presence at the MCCH is crucial. If you do not attend, the hearing may proceed without you, potentially impacting the outcome of your case.
By following these guidelines, individuals can better navigate the complexities of the Texas DWC049 form and ensure their requests are properly considered.