The Texas DWC049 form is a request to schedule a Medical Contested Case Hearing (MCCH) related to workers' compensation disputes. This form is essential for individuals seeking to appeal decisions made by Independent Review Organizations or to address medical fee disputes. Completing this form accurately is crucial for ensuring that your request is processed efficiently.
To begin the process of filling out the Texas DWC049 form, please click the button below.
When filling out the Texas DWC049 form, it's essential to be thorough and accurate. Here’s a list of what you should and shouldn’t do:
By following these guidelines, you can help ensure a smoother process for your medical contested case hearing request.
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 TDI-DWC. Attach a copy of the IRO decision.
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 non-prevailing (losing) party is required to reimburse the TDI-DWC for the costs of the services provided at SOAH. In the event of a dismissal, the party who requested the SOAH hearing is required to reimburse the TDI-DWC. These requirements do not apply to the injured employee.
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 TDI-DWC Use Only
DWC049 Rev. 11/17
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III. REQUESTER INFORMATION
9. Check the appropriate box:
Injured Employee
Health Care Provider
Subclaimant
Pharmacy Processing Agent
Insurance Carrier
Attorney for__________
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, TDI-DWC will expedite an MCCH as follows:
• 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
Counsel (OIEC)?
12.
Requester's Mailing Address (Street or PO Box, City, State, Zip Code)
13.
Requester’s Printed Name/Title
14.
Phone Number
15.
Requester’s Signature
16.
Date of Signature (mm/dd/yyyy)
NOTE: With few exceptions, upon your request, you are entitled to be informed about the information TDI-DWC collects about you; get and review the information (Government Code, §§552.021 and 552.023); and have TDI-DWC correct information that is incorrect (Government Code, §559.004). For more information, contact agencycounsel@tdi.texas.gov or you may refer to the Corrections Procedure section at www.tdi.texas.gov.
Employee’s Name: DWC Claim Number:
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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 (TDI-DWC) will schedule the MCCH at a location not more than 75 miles from the injured employee’s residence at the time of the injury or the address on this form, unless good cause exists for the selection of a different location. You may request another location, but must provide an acceptable reason to relocate the proceeding. The TDI-DWC will determine whether a change in location is appropriate. In addition, injured employees may request the MCCH be held through a telephone conference.
What type of special accommodations will be provided?
The TDI-DWC or SOAH will provide accommodations to parties who qualify under the Americans with Disabilities Act (ADA), and other reasonable accommodations at the discretion of the Administrative Law Judge.
Who determines whether an MCCH is expedited?
If an expedited MCCH is requested in Section I, Box 2, the TDI-DWC will determine whether scheduling the MCCH more quickly is appropriate.
If Yes is checked in Section III, Box 10 to indicate that the injured employee is a first responder, the TDI-DWC will expedite an MCCH as follows:
•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 Form-049?
•Medical Fee Dispute: You must submit the form to the TDI-DWC no later than the 20th day after the conclusion of the Benefit Review Conference.
•Medical Necessity Dispute: You must submit the form to the TDI-DWC no later than the 20th day after the date the Independent Review Organization (IRO) decision is sent to the appealing party.
Where do I send the DWC Form-049?
The completed form, including a copy of the IRO decision (if applicable), must be faxed to (512) 804-4011 or mailed to the address shown below.
Texas Department of Insurance Division of Workers’ Compensation
7551 Metro Center Drive, Suite 100 • MS-35 Austin, TX 78744-1645
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 TDI-DWC by calling (512) 804-4010 or 1-800-252-7031. An injured employee who is not represented by an attorney may also receive assistance by calling the Office of Injured Employee Counsel (OIEC) at 1-866-393-6432.
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When navigating the Texas workers' compensation system, several forms and documents may accompany the Texas DWC049 form, which is used to request a Medical Contested Case Hearing (MCCH). Understanding these additional documents can streamline the process and ensure that all necessary information is provided. Below is a brief overview of key forms often used in conjunction with the DWC049.
Utilizing these forms correctly can significantly impact the efficiency and outcome of your case. Ensure that all documents are filled out accurately and submitted on time to avoid unnecessary delays in the resolution process. If there are any questions about these forms or the procedures involved, reaching out to the appropriate resources is highly recommended.
Filling out the Texas DWC049 form can seem straightforward, but many people make common mistakes that can lead to delays or complications in their cases. Here are ten frequent errors to watch out for.
First, many individuals forget to check the appropriate box to indicate the type of medical contested case hearing they are requesting. This step is crucial. Without this indication, the Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) may not process the request correctly.
Another common mistake is neglecting to provide a copy of the Independent Review Organization (IRO) decision when appealing a medical necessity decision. This attachment is essential for the review process. If it’s missing, the appeal may be dismissed.
Some people do not specify the reason for an expedited MCCH request. This omission can lead to confusion and may result in the request being denied. Always include a clear reason to support your request for expedited handling.
In the section for the injured employee's information, individuals often make errors in the employee’s name or date of injury. Even small mistakes can create significant issues. Double-check that all names are spelled correctly and that dates are accurate.
Additionally, it’s not uncommon for people to skip providing the insurance carrier’s name or the employer's business name. These details are vital for identifying the parties involved in the case. Without them, the form may be deemed incomplete.
Another frequent error involves the requester’s information. Some forget to indicate whether they are the injured employee, a healthcare provider, or another representative. This detail helps TDI-DWC understand who is making the request and how to communicate effectively.
Many individuals also overlook the section asking if the injured employee is a first responder. This information is important for determining if the case qualifies for expedited processing. Marking this box incorrectly can lead to delays.
Providing an incomplete mailing address is another common mistake. Ensure that the address is complete, including the street or P.O. Box, city, state, and zip code. An incomplete address may result in miscommunication or delays in receiving important documents.
People often forget to sign and date the form. A signature is a necessary component of the submission. Without it, the form cannot be processed, and the request will be delayed.
Lastly, some individuals do not keep a copy of the submitted form for their records. This can be problematic if there are any questions or issues later on. Always retain a copy of any documents you submit for your own reference.
Avoiding these common mistakes can streamline the process of scheduling a medical contested case hearing in Texas. Paying attention to detail can make a significant difference in the outcome of your request.
Here are some common misconceptions about the Texas DWC049 form:
Understanding the Purpose: The Texas DWC049 form is essential for requesting a Medical Contested Case Hearing (MCCH). It is used to appeal decisions regarding medical necessity or medical fee disputes.
Completing the Form: Fill out the form clearly and accurately. Use black ink and print each item. Incomplete forms may delay the resolution of your dispute.
Timely Submission: Submit the completed form within 20 days after the Benefit Review Conference ends or after receiving the Independent Review Organization's decision, depending on the type of dispute.
Requester Identification: Clearly indicate who is requesting the hearing. Options include the injured employee, healthcare provider, or attorney. This helps the Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC) process the request correctly.
Expedited Requests: If the injured employee is a first responder, the request for an expedited MCCH may be granted. Ensure you specify the reason for the expedited request in the form.
Attendance Requirements: It is crucial for the injured employee to attend the MCCH. Failing to show up could lead to penalties unless there is a valid reason for the absence.
Filling out the Texas DWC049 form is an essential step in the process of requesting a Medical Contested Case Hearing. The following steps will guide you through the process to ensure that all necessary information is accurately provided. Please follow each step carefully to avoid any delays in your request.
Once the form is completed, it must be submitted to the Texas Department of Insurance, Division of Workers’ Compensation. Ensure that all required information is included to avoid delays. If you have any questions during the process, do not hesitate to reach out for assistance.