This Billing Guide outlines the workers’ compensation billing requirements for Texas.

Billing Form Requirements

This table is a guide to daisyBill's resources on the required forms for compliant paper and electronic workers’ comp billing in Texas.

State-Mandated Physician Reporting Requirements

Texas requires the physician to submit the following reports to document injured worker status.

Electronic Billing Mandate

The Texas Department of Insurance requires e-billing with some exceptions. Healthcare providers in the state should file their bills electronically unless they meet the exception criteria. For more information see Texas Administrative Code Rule §133.500 on Electronic Formats for Electronic Medical Bill Processing and Rule §133.501 on Electronic Medical Bill Processing.

Additional Bill Requirements

Per the DWC Rule §133.210, medical documentation includes “all medical and records, such as evaluation reports, narrative reports, assessment reports, progress report / notes, clinical notes, hospital records and diagnostic test results.” All such documentation must be provided to the insurance agent when submitting a medical bill for reimbursement, unless previously submitted.

Rule §133.210 also requires that any request by an insurance carrier for additional documentation must:

1. be in writing;
2. be specific to the bill or the bill's related episode of care;
3. describe with specificity the clinical and other information to be included in the response;
4. be relevant and necessary for the resolution of the bill;
5. be for information that is contained in or in the process of being incorporated into the injured employee's medical or billing record maintained by the health care provider;
6. indicate the specific reason for which the insurance carrier is requesting the information; and
7. include a copy of the medical bill for which the insurance carrier is requesting the additional documentation.

Exemptions to e-Billing

Electronic billing is required for all providers by the Texas Administrative Code, except in the following cases outlined in Rule § 133.501:

1. the health care provider employs fewer than 10 full time employees;
2. the health care provider provided services to 32 or fewer injured employees during the preceding calendar year;
3. the health care provider can sufficiently demonstrate electronic medical bill implementation will create an unreasonable financial hardship and can provide supporting documentation such as financial statements and other documentation which reflect the cost of implementation.

Providers under such exemptions must provide the Division of Workers’ Compensation with all supporting documentation within 15 days of a request.

daisyBill Solution

Stay up-to-date on the latest developments in Workers’ Compensation medical billing by subscribing to daisyBill’s email list.

SIGN UP FOR EMAILS