FOLIO

DWC Adopts New PLN-15 Form; Updates Other Forms

Jul 22, 2021 | by FOL

The Division of Workers’ Compensation has formally adopted a new plain language notice (PLN-15, Notice of Request to Reprocess a SARS-CoV-2 or COVID-19 Claim Subject to Government Code Section 607.0545), which insurance carriers must use when reprocessing COVID-19 claims. The Agency has also updated the font type and instructions on the PLN-14 to show that the notice applies to claims subject to SB 22. The changes were made to assist in implementing SB 22, the COVID-19 presumption bill. DWC has also adopted a new document, Sample Request to Reprocess a SARS-CoV-2 or COVID-19 Claim for injured employees or beneficiaries to use. DWC recommends that claimants use the new request to reprocess document, but they are not required to do so.

The new forms are available for use immediately and can be found at this link. With respect to the PLN-15, the Division advises carriers that they must:

• • • File a copy of this notice with DWC and the appropriate electronic data interchange (EDI) transaction as the basis of a dispute.
    • Send a copy of this notice to all beneficiaries if the claim involves a fatality.
    • Provide a full and complete statement of the facts surrounding the claim that justify and serve as the grounds for the denial of compensability or liability for the claim. A generic statement such as “liability in question,” “compensability in dispute,” “under investigation,” or similar phrases with no further description of the factual basis for the action taken does not satisfy the requirements of 28 Texas Administrative Code Section 124.2. Explain the reasons for disputing the issues in plain language without overusing technical terms, acronyms, or abbreviations.

Examples of acceptable plain language:

“We found out that you were injured by falling off the bleachers at your son’s little league game. There is a video of the accident.”

“Your employer doesn’t have workers’ compensation insurance coverage with our insurance company. We are not responsible for paying workers’ compensation benefits on this claim.”

• • • Explain whether the insurance carrier applied the statutory presumption under Texas Government Code Section 607.0545 to the claim and describe the evidence the insurance carrier used in making the determination.

DWC has also adopted revisions to the PLN 01*, as well as the BRC request forms, DWC-045, Request to Schedule, Reschedule, or Cancel a Benefit Review Conference, or to Proceed Directly to Contested Case Hearing and DWC-045M, Request to Schedule, Reschedule, or Cancel a Benefit Review Conference to Appeal a Medical Fee Dispute Decision, effective July 19, 2021. These changes were made to assist in implementing HB 1752, the virtual BRC bill.

These changes have been made in response to recent legislation passed during the 87^th regular legislative session. In addition to the changes required by that legislation, the Division is in the process of “modernizing” many of its forms and notices. Those planned changes are designed to incorporate use of a new letterhead and an updated mailing address. The agency also plans to make changes involving form content, font size, and plain language. The project is planned for completion in the summer of 2022.

* Note, DWC’s memo on these changes also references a PLN-13. There is no PLN-13. This reference appears to have been made in error.