Below are workers’ compensation billing requirements for the State of Texas.

Billing Form Requirements

This table below lists the required forms for compliant workers’ comp billing in Texas.

State-Mandated Physician Reporting Requirements

Texas requires physicians to submit the reports below to document an injured worker’s status.

Electronic Billing Mandate

The Texas Department of Insurance (TDI) requires providers to bill electronically, with some exceptions. Health care providers in the state should e-bill unless they meet the exception criteria below.

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.

Exemptions to Mandatory e-Billing

e-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.

Additional Bill Requirements

Per Texas DWC Rule §133.210, medical documentation includes “all medical reports 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.

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