Section 127.10 - General Procedures for Designated Doctor Examinations(a) Authorization to receive documents. The designated doctor is authorized under Labor Code § 408.0041(c) to receive the injured employee's confidential medical records and analyses of the injured employee's medical condition, functional abilities, and return-to-work opportunities without a signed release from the injured employee to help resolve a dispute under this subchapter. The following requirements apply to the designated doctor's receipt of medical records and analyses: (1) The treating doctor and insurance carrier must provide the designated doctor copies of all the injured employee's medical records in their possession relating to the medical condition to be evaluated by the designated doctor.(A) For subsequent examinations with the same designated doctor, the treating doctor and insurance carrier must provide only those medical records not previously sent.(B) The cost of copying must be reimbursed in accordance with § 134.120 of this title (relating to Reimbursement for Medical Documentation).(2) The treating doctor and insurance carrier may also send the designated doctor an analysis of the injured employee's medical condition, functional abilities, and return-to-work opportunities. (A) The analysis sent by any party may only cover the injured employee's medical condition, functional abilities, and return-to-work opportunities as provided in Labor Code § 408.0041. The analysis may include supporting information, such as videotaped activities of the injured employee and marked copies of medical records.(B) If the insurance carrier sends an analysis to the designated doctor, the insurance carrier must send a copy to the treating doctor, the injured employee, and the injured employee's representative, if any.(C) If the treating doctor sends an analysis to the designated doctor, the treating doctor must send a copy to the insurance carrier, the injured employee, and the injured employee's representative, if any.(3) The treating doctor and insurance carrier must ensure that the designated doctor receives the required records and analyses (if any) no later than three working days before the date of the designated doctor examination.(A) If the designated doctor has not received the medical records or any part of them at least three working days before the examination, the designated doctor must report this violation to the division within one working day of not timely receiving the records.(B) Once notified, the division will take action necessary to ensure that the designated doctor receives the records.(C) If the designated doctor does not receive the medical records within one working day of the examination or does not have sufficient time to review the late medical records before the examination, the designated doctor must reschedule the examination to occur no later than 21 days after receiving the records.(b) Requirement to review information. Before examining an injured employee, the designated doctor must review the injured employee's medical records, including any analysis of the injured employee's medical condition, functional abilities, and return to work opportunities that the insurance carrier and treating doctor provide in accordance with subsection (a) of this section, and any materials the division submits to the doctor.(1) The designated doctor must also review the injured employee's medical condition, history, and any medical records the injured employee provides and must perform a complete physical examination of the injured employee.(2) The designated doctor must give the medical records reviewed the weight the designated doctor determines to be appropriate.(c) Additional testing and referrals. The designated doctor must perform additional testing when necessary to resolve the issue in question. The designated doctor must also refer an injured employee to other health care providers when the referral is necessary to resolve the issue in question, and the designated doctor is not qualified to fully resolve it. (1) Any additional testing or referrals required for the evaluation are not subject to preauthorization requirements.(2) Payment for additional testing or referrals that the designated doctor has determined are necessary under this subsection must not be denied prospectively or retrospectively, regardless of any potential disagreements about medical necessity, extent of injury, or compensability.(3) Any additional testing or referrals required for the evaluation are subject to the requirements of § 180.24 of this title (relating to Financial Disclosure).(4) Any additional testing or referrals required for the evaluation of an injured employee under a certified workers' compensation network under Insurance Code Chapter 1305 or a political subdivision under Labor Code § 504.053(b): (A) are not required to use a provider in the same network as the injured employee; and(B) are not subject to the network or out-of-network restrictions in Insurance Code § 1305.101 (relating to Providing or Arranging for Health Care).(5) Any additional testing or referral examination and the designated doctor's report must be completed within 15 working days of the designated doctor's physical examination of the injured employee unless the designated doctor receives division approval for additional time before the 15 working days expire.(6) If the injured employee fails or refuses to attend the designated doctor's requested additional testing or referral examination within 15 working days or within the additional time the division approved, the designated doctor must complete the report based on the designated doctor's examination of the injured employee, the medical records received, and other information available to the doctor and indicate the injured employee's failure or refusal to attend the testing or referral examination in the report.(d) MMI and impairment ratings. Any evaluation relating to either MMI, an impairment rating, or both, must be conducted in accordance with § 130.1 of this title (relating to Certification of Maximum Medical Improvement and Evaluation of Permanent Impairment). For examinations conducted under this subsection on or after June 5, 2023, the designated doctor may provide multiple certifications of MMI and impairment ratings only when directed by the division.(e) Reports on MMI and impairment ratings. A designated doctor who determines the injured employee has reached MMI, assigns an impairment rating, or determines the injured employee has not reached MMI, must complete and file a report as required by § 130.1 and § 130.3 of this title (relating to Certification of Maximum Medical Improvement and Evaluation of Permanent Impairment by a Doctor Other than the Treating Doctor). (1) If the designated doctor provides multiple certifications of MMI and impairment ratings, the designated doctor must file a Report of Medical Evaluation under § 130.1(d) of this title for each assigned impairment rating and a designated doctor examination data report under § 127.220 of this title (relating to the Designated Doctor Reports) for the doctor's extent of injury determination.(2) The designated doctor must submit only one narrative report required by § 130.1(d)(1)(B) of this title on all assigned impairment ratings and extent of injury findings.(3) All designated doctor narrative reports submitted under this subsection must comply with the requirements of § 127.220(a) of this title (relating to Designated Doctor Reports).(f) Reports on return to work. A designated doctor who examines an injured employee for any question relating to return to work must complete a Work Status Report that complies with § 129.5 of this title (relating to Work Status Reports) and a narrative report that complies with the requirements of § 127.220(a) of this title. The designated doctor must file the work status report and the narrative report together within seven working days of the date the designated doctor examines the injured employee.(1) The designated doctor must file the reports with the treating doctor, the division, and the insurance carrier by fax or electronic transmission.(2) The designated doctor must file the reports with the injured employee and the injured employee's representative (if any) by fax or electronic transmission if the designated doctor has a fax number or email for the recipient.(3) If the designated doctor has no fax number or email for a recipient, the designated doctor must send them the reports by other verifiable means.(g) Report on other issues. A designated doctor who resolves questions on issues other than those listed in subsections (d), (e), and (f) of this section must file a designated doctor examination data report that complies with § 127.220(c) of this title and a narrative report that complies with § 127.220(a) of this title within seven working days of the date the designated doctor examines the injured employee.(1) The designated doctor must file these reports with the treating doctor, the division, and the insurance carrier by fax or electronic transmission.(2) The designated doctor must provide these reports to the injured employee and the injured employee's representative (if any) by fax or electronic transmission if the designated doctor has a fax number or email for the recipient.(3) If no fax number or email is provided for the recipient, the designated doctor must send the reports by other verifiable means.(h) Presumptive weight. The designated doctor's report is given presumptive weight on the issue or issues the designated doctor was properly appointed to address, unless the preponderance of the evidence is to the contrary.(i) Payment of benefits during dispute. The insurance carrier must pay all benefits, including medical benefits, in accordance with the designated doctor's report for the issue or issues in dispute.(1) If the designated doctor provides multiple certifications of MMI and impairment ratings, the insurance carrier must pay benefits based on the conditions to which the designated doctor determines the compensable injury extends.(2) For medical benefits, the insurance carrier has 21 days from receipt of the designated doctor's report to reprocess all medical bills previously denied for reasons inconsistent with the designated doctor's findings. By the end of this period, insurance carriers must pay these medical bills in accordance with the Labor Code and Chapters 133 and 134 of this title.(3) The insurance carrier must pay all other benefits no later than five days after receiving the report.(j) Record retention. The designated doctor must maintain accurate records for, at a minimum, five years from the anniversary date of the date of the designated doctor's last examination of the injured employee.(1) This requirement does not reduce or replace any other record retention requirements imposed on a designated doctor by an appropriate licensing board.(2) These records must include the injured employee's medical records, any analysis the insurance carrier or treating doctor submits (including supporting information), reports the designated doctor generates as a result of the examination, and narratives the insurance carrier and treating doctor provide, to reflect: (A) the date and time of any designated doctor appointments scheduled with an injured employee;(B) the circumstances for a cancellation, no-show, or other situation where the examination did not occur as initially scheduled or rescheduled, and if applicable, documentation of the agreement to reschedule the examination and the notice that the doctor provided to the division, the injured employee's treating doctor, and the insurance carrier within 24 hours of rescheduling an appointment;(C) the date of the examination;(D) the date the designated doctor received medical records from the treating doctor or any other person;(E) the date the designated doctor submitted the reports described in subsections (d), (e), and (f) of this section to all required parties and documentation that these reports were submitted to the division, treating doctor, and insurance carrier by fax or electronic transmission and to other required parties by verifiable means;(F) if applicable, the names of any referral health care providers the designated doctor used, the dates of referral health care provider appointments, and the reason the designated doctor referred them; and(G) if applicable, the date the doctor contacted the division for assistance in getting medical records from the insurance carrier or treating doctor.(k) Dispute resolution. Parties may dispute any entitlement to benefits affected by a designated doctor's report through the dispute resolution processes outlined in Chapters 140-144 and 147 of this title (relating to dispute resolution processes, proceedings, and procedures).28 Tex. Admin. Code § 127.10
The provisions of this §127.10 adopted to be effective February 1, 2011, 35 TexReg 11324; amended to be effective September 1, 2012, 37 TexReg 5422; Amended by Texas Register, Volume 43, Number 43, October 26, 2018, TexReg 7166, eff. 11/4/2018; Amended by Texas Register, Volume 48, Number 16, April 21, 2023, TexReg 2128, eff. 4/30/2023