Reporting A Claim
Definitions and Links
ABOUT UT SYSTEM WCI
The WCI staff of CCMSI administers all aspects of the Systemwide program, which provides income and medical benefits to employees who have sustained job-related injuries or occupational injuries. Administering the program includes receiving, investigating, and making liability determinations on WCI claims; determining the reasonableness and necessity of medical treatment and services; generating income benefit payments to injured employees and medical payments to health care providers; representing The University of Texas System (the UT System) in administrative hearings before the Texas Department of Insurance, Division of Workers' Compensation (TDI/DWC); and ensuring that claims are adjusted in accordance with Texas law.
UT System oversees CCMSI's administration of the WCI program. The Associate Director of Workers' Compensation coordinates the program throughout the UT System, establishes uniform Systemwide procedures and records, and acts as the liaison with other State of Texas agencies, including DWC. The claims supervisor oversees the day-to-day claims operation at each claims office. Claims offices located in Austin, Dallas and Houston receive and process all workers' compensation claims.
Each UT System Institution provides direct employee contact on workers' compensation matters, including return-to-work initiatives through designated WCI Institution Representatives.
For further information regarding The University of Texas System Workers' Compensation Insurance Program, visit The Board of Regents' Rules and Regulations.
What is Workers' Compensation Insurance?
Workers' Compensation Insurance is a type of insurance specifically designed to provide medical benefits and, in some cases, financial payments to employees on the payroll of The University of Texas System who suffer injuries or occupational disease in the course and scope of employment.
In instances of injury arising out of or in the course of employment, the employee is entitled to all medical aid, hospital services and medication reasonably required at the time of injury and anytime thereafter to cure and relieve the effects naturally resulting from the injury. If the employee is in a network service area, treatment must be from a network provider.
In some instances, financial benefits will be available to offset a temporary loss of wage earning capacity and/or to compensate for permanent impairment due to the injury. Workers' Compensation Insurance is not health insurance, nor does it provide compensation for damage to or loss of personal property.
For more information, refer to Injured Employee Resources from the Texas Department of Insurance, Division of Workers' Compensation (TDI/DWC).
To report injuries at The University of Texas System Institutions, contact the your Institution's respective WCI Representative.
IMO MED-SELECT HEALTHCARE NETWORK
The 79th legislature passed HB 7 that enacted Texas Insurance Code Chapter 1305. Chapter 1305 authorized the establishment of workers' compensation health care networks for the provision of workers' compensation medical benefits.
The UT System has contracted with IMO Med-Select Health Care Network to assist employees with obtaining appropriate medical treatment for work-related injuries. A listing of additional IMO Med-Select HCN resources can be found at the bottom of this page.
WHAT EMPLOYEES NEED TO KNOW
The UT System has contracted with the IMO Med-Select HealthCare Network to provide UT System employees who live in network service areas the opportunity for improved quality of care and help in returning to work as soon as medically appropriate.
The network service areas currently cover ninety-four percent of all UT System employees. The IMO Med-Select network only provides treatment for workers' compensation injuries. It is not a substitute for traditional group health care coverage.
Not all counties of the State are covered by the health care network (HCN). If an employee lives in a county not covered by the HCN, that employee is not subject to the requirements of the network.
The link to the Provider Search and Network Service Areas to the right will assist employees in determining if their county falls within the network.
If an employee experiences a workplace injury after the network has been implemented, they will receive another copy of the network notification packet and will be asked to sign an acknowledgement form. In addition, a copy of the packet is available anytime and will be posted with other notifications at the place of employment.
What is the process of choosing a doctor?
If you require medical treatment for a work-related injury, you should immediately choose a treating doctor from the network provider list to coordinate your care. Tell your treating doctor that any bills for your work-related injury should be sent directly to CCMSI. Bills for services unrelated to a reported on-the-job injury should be sent to your regular health insurer or should be paid by you.
What is the process of changing the primary physician?
If it becomes necessary to change treating doctors for treatment of a work-related injury, you must contact the network at 888-466-6381 to notify them of your alternate selection. Any additional change will require a request and permission from the network.
What is the process of purchasing prescription medication?
When purchasing prescription drugs for treatment of the work-related injury, the employee will use the RxBridge RX First Fill Form or prescription card. Most pharmacies will submit bills to RxBridge upon verification of coverage. Only prescriptions related to your compensable injury will be covered.
What payments are expected of employees?
Unless the injured employee has received medical treatment from an unauthorized physician, the employee will not be billed directly for health care intended to treat a work-related injury. If the employee receives a bill from a health care provider, the employee must send the invoice to WCI immediately. All medical related expenses are subject to fee guidelines established by TDI/DWC.
Except in an emergency, if you receive medical care for a work-related injury which is not by or at the direction of your treating doctor, you may become responsible for payment of any charges associated with that care.
IMO Med-Select HealthCare Network Resources
IMO Med-Select HCN Information
Notice of Network Requirements
Questions about the network:
Complaints about the network:
IMO Net Complaint Dept.
FOR MEDICAL PROVIDERS:
ELECTRONIC BILLING (eBilling)
Workers' compensation system health care providers and insurance carriers are required to be able to exchange medical billing and reimbursement data electronically in accordance with 28 Texas Administrative Code (TAC) 133.500.
The primary benefit of eBilling is that the insurance carriers will provide an electronic acknowledgement to health care providers that the bill was received. The eBill process is expected to reduce payment processing time as well as reduce billing and coding errors.
The University of Texas System (UT System), through Injury Management Organization, Inc. (IMO) has selected Work Comp EDI as its clearinghouse for the electronic receipt of medical bills from medical providers treating UT System employees with work-related injuries or illnesses.
UT System encourages all providers to become a trading partner with Work Comp EDI.
For more information regarding Work Comp EDI; Workers' Compensation Clearinghouse:
Call toll-free: 800.297.6909
Register on-line: Work Comp EDI
Or contact Injury Management Organization, Inc.
Call toll-free: 877.742.4477
If the treating doctor has questions about the types of services that must be pre-authorized or about how to complete required reports and invoices, he or she may contact IMO at the numbers listed below.
Benefit payments for the injured employee are generally expressed in terms of "weeks of compensation." One week's benefit is equal to seventy percent (70%) of the employee's average weekly wage.
An income benefit for an employee who is employed on less than a full work day basis may not exceed sixty percent (60%) of the employee's average weekly wage. The average weekly wage is calculated from the Employer's Wage Statement using a formula defined in the law. The weekly benefit is subject to a statutory minimum and maximum payment.
No compensation accrues during the first seven days of absence from work due to the injury. During this waiting period, the employee must utilize accrued sick leave, vacation leave or be placed on leave without pay status. If the disability continues for two weeks, the waiting period then becomes payable provided the employee was not in a paid leave status for that time.
If absence beyond seven days, the employee may continue to receive full wages under accrued sick or vacation leave or receive weekly compensation benefits. If temporary income benefits are paid, the employee must be placed on leave without pay until the employee returns to work.
It is the employee's responsibility to inform his or her department of this choice and the department must keep CCMSI advised of current leave status. The employee may also be responsible for maintaining his or her other insurance coverage while on leave without pay.
If the injury or occupational illness results in the death of the employee, current statute provides for a lump sum funeral expense benefit not to exceed $2,500 for compensable injuries occurring prior to 9/1/1999. Funeral expenses for compensable injuries occurring after 9/1/1999 will be reimbursed. In addition, the surviving spouse is eligible for a weekly benefit payable until the spouse's death or re-marriage. For more information, see Death and Burial Benefits from the Texas Department Of Insurance, Division of Workers’ Compensation (TDI/DWC).
REPORTING A CLAIM
Report to a Supervisor
There's an injury; what do I do? How do I file a workers' compensation claim?
If an employee sustains injuries or an occupational disease as a direct result of employment, the employee must inform their supervisor immediately.
Failure to report the injury within 30 days of the occurrence of the injury (or the manifestation of the occupational disease) may result in the denial of a claim. If you are injured while performing work on behalf of your employer or if you acquire an occupational disease as a direct result of your employment, you should immediately inform your supervisor of the injury or disease. In reporting your injury, or occupational disease, you must provide your supervisor with the following information:
- Your name, current address and current telephone number.
- The date, time and place the injury occurred.
- A description of the circumstances and the nature of the injury.
- The names of any witnesses.
- The name of the doctor who has treated, or will treat you for the injury, if any.
The supervisor will work with the WCI Representatives to ensure that a First Report of Injury form is completed and filed with CCMSI. You will be contacted by the CCMSI adjuster handling your claim.
If an employee has lost time from work due to a work-related injury, a Employee's Claim for Compensation for a Work-Related Injury or Occupational Disease from The Department of Insurance, Division of Workers' Compensation (TDI/DWC) must be completed immediately and mailed directly to TDI/DWC.
The employer shall report to the carrier each death, each occupational disease, and each injury that results in the injured employee missing more than one day from work. A claim determination will be made by the carrier following a thorough investigation.
An injury is not covered if it:
- occurred while the employee was intoxicated;
- was caused by the employee's willful intention and attempt to injure himself or another person;
- was caused by the employee's horseplay;
- arose out of an act of a third person intended to injure the employee because of personal reasons;
- arose out of voluntary participation in an off-duty recreational, social, or athletic activity not constituting part of the employee's work-related duties; or
- arose out of an act of God unless the employment exposes the employee to a greater risk than ordinarily applies to the general public.
Filing a False Claim
Filing a workers' compensation claim for an injury that did not occur while performing work on behalf of your employer is an administrative violation punishable by a penalty up to $5,000.
Your Claim is Reported to a Carrier
Who will be handling my Workers' Compensation Insurance claim?
Your claim file will be managed by a workers' compensation claims adjuster at CCMSI. Upon notice of your injury, the adjuster will conduct a thorough investigation which will include obtaining a statement from the injured employee, supervisor, and any witnesses.
How can I obtain more information about Workers' Compensation Insurance?
For more information, refer to The University of Texas System Workers' Compensation Insurance Office website or The Texas Department of Insurance, Division of Worker's Compensation (TDI/DWC) website.
Employee/Employer Responsibilities to the UT System WCI Office, WCI Representative and TDI/DWC include:
- Gathering all pertinent information regarding the job-related injury to be reported to The University of Texas System WCI Representative (WCI Representative).This will include witness statements if circumstances warrant.
- The WCI Representative at each employing institution is responsible for ensuring that all documentation is submitted to The University of Texas System Workers' Compensation Insurance Office and to The Texas Department of Insurance, Division of Workers' Compensation (TDI/DWC) in a timely manner. Failure to do so will result in administrative violations which constitute fines of $500 or more.
*The University of Texas System Administration employees
If you miss time from work:
- Your supervisor or your WCI Representative should receive written note from your treating doctor indicating you are unable to work. You must continue communicating with your employer throughout any period of disability unless you are physically unable to do so.
- You are expected to return to work as soon as you are physically able. If you are released to return to work by your doctor with restrictions, please work with your employer and your WCI Representative to comply with these restrictions.
- Your employer may have other specific rules for you to follow while missing time from work. Please communicate with your supervisor to make sure you are complying with any other policies.
If you choose to miss work on your own without your treating doctor's order, your lost time, for purposes of calculating income benefits will be disputed.
An employee is injured. What do I do?
If the injury or occupational disease causes the employee to have limited ability to perform their regular job duties, temporary job modifications may be required. Please refer to your respective Institution's Return-to-Work Policy.
EMPLOYER’S SUPPLEMENTAL REPORT OF INJURY OR OCCUPATIONAL INJURY FORM (DWC-6)
What is the Employer's Supplemental Report of Injury or Occupational Injury (DWC-6 Form) designed to accomplish?
The Employer's Supplemental Report of Injury form (DWC-6) is required by The Texas Department of Insurance, Division of Workers' Compensation (TDI/DWC) to account for any period of time lost from work for which the injured worker might be entitled to compensation benefits. The DWC-6 form also serves as written notice to The University of Texas System Workers' Compensation Insurance office program via CCMSI of an employee's lost time, return-to-work after a period of disability and change in employment status.
When does the Employer's Supplemental Report (DWC-6 Form) need to be completed and filed?
For all injuries that require the filing of an Employer's First Report of Injury or Illness (DWC-1 Form), the employing department must also file an Employer's Supplemental Report (DWC-6 Form) with The University of Texas System Workers' Compensation Insurance program via CCMSI and the injured employee after each occurrence of any of the following events:
REQUEST PAID LEAVE
What is the Request for Paid Leave Form (Form-23) designed to accomplish?
An injured employee who sustains disability as a result of an injury has the option to use sick leave and/or other leave to remain on the payroll in lieu of temporary income benefits (TIBs). This form records the employee’s election. The Request for Paid Leave Form should be completed as soon as the injured employee begins to lose time from work.
- The injured employee returns to work after having lost time from work within three days.
- The injured employee, after returning to work, experiences an additional day or days of disability as a result of the injury within three days.
- The injured employee has a change in earnings as a result of the work-related injury within 10 days.
- The injured employee resigns or terminates employment within 10 days.
- The injured employee has subsequent lost time from work due to the injury within 10 days.
What are the employee's options?
The employee may:
- Use all sick leave to remain on the payroll
- Use all or a portion of other available leave once all sick leave is exhausted
- Use no leave and go off the payroll immediately. TIBs will begin after 7 days off work due to the injury.
- No leave is available to use. Employee is placed off the payroll immediately.
If the employee elects to save accrued leave, or if the employee has no accrued leave to utilize, the employee will be placed on leave without pay and workers' compensation benefits will begin following the seven day waiting period (provided the inability to work is medically substantiated). The employee should understand that being on leave without pay for any reason means one is not eligible for the state's contribution towards insurance premiums (unless the employee continues to participate by paying the required premiums or is granted Family Medical Leave). The employee's credit toward Teacher Retirement System of Texas and longevity may also be affected depending upon how long the disability lasts and whether or not the employee returns to work. Questions regarding continuation of insurance coverage should be directed to the institutional Benefits Office.
EMPLOYER’S WAGE STATEMENT FORM (DWC-3)
What is the Employer's Wage Statement Form (DWC-3) designed to accomplish?
The Texas Workers' Compensation Act provides for payment of weekly income benefits in certain instances. The rate of compensation to which an employee is entitled is based upon his or her average weekly wage as defined in the law. The information in the Employer's Wage Statement Form is necessary to properly calculate the employee's average weekly wage.
When does the DWC-3 form need to completed and filed?
Please see form: DWC-3 Form
May an injured employee who is receiving workers' compensation benefits intermittently use sick and/or vacation leave in order to retain entitlement to the State contribution toward insurance premiums?
Is an employee entitled to mileage reimbursement when he or she must travel to receive medical care?
An employee will be entitled to reimbursement for travel if it becomes reasonably necessary to travel more than 20 miles (one way) in order to obtain appropriate and necessary medical care.
Can an employee who is receiving workers' compensation benefits also be eligible for Long Term Disability, Unemployment Compensation, and/or Social Security Disability benefits?
Yes. Receipt of workers' compensation income benefits does not automatically make a person ineligible for the benefits listed above. However, the amount of benefits due under other programs may be affected by receipt of workers' compensation income benefits. The institutional Benefits Office should be contacted for specific information regarding eligibility for Long Term Disability
Are workers' compensation benefits taxable?
Workers' compensation benefits are currently not subject to federal income taxation. If an employee has specific questions about this matter, we recommend the employee contact the Internal Revenue Service or to his or her legal advisor.
When do benefits begin?
Medical benefits for compensable injuries are payable from the date of injury. An injured employee is specifically entitled to reasonable and necessary health care that:
- cures or relieves the effects naturally resulting from the compensable injury and is provided by a network provider from employees within the service area with dates of injury on or after 4/1/13;
- promotes recovery; and
- enhances the ability of the employee to return to or retain employment
Temporary income benefits accrue from the eighth day of disability and are paid weekly unless an injured employee elects to use leave to remain on the employer’s payroll. An employee's inability to work because of a compensable injury should be documented by his or her treating physician.
Failure to comply with the following requirements without good cause is a Class D administrative violation. Penalties will be imposed by The Texas Department of Insurance, Division of Workers' Compensation and employers may be assessed an administrative penalty not to exceed $500 per record.
Administrative Violation - a violation of the Texas Workers' Compensation Act or a rule adopted under the Act that is subject to penalties and sanctions as provided in the Act. Fines range from $500-$25, 000 per violation.
Benefit - includes medical, income, death or burial benefits an employee or beneficiary receives based on a compensable injury.
Compensable Injury - an injury that arises out of and in the course and scope of employment for which compensation is payable under The Texas Workers' Compensation Act.
Course and Scope of Employment - an activity of any kind or character that has to do with and originates in the work, business, trade or profession of the employer and that is performed by an employee while engaged in or about the furtherance of the affairs or business of the employer.
Disability - the inability to obtain and retain employment as a result of a compensable injury.
Exhaustion of Leave- For the purposes of entitlement to income benefits, sick leave shall be considered exhausted when remaining sick leave hours are insufficient to cover a full work shift. Sick leave can be used in conjunction with other paid leave to cover a full work shift if other paid leave is elected by the employee. Other paid leave shall be considered exhausted when remaining leave hours are insufficient to cover a full work shift.
Health Care - Includes all reasonable and necessary medical aid, medical examinations, medical treatments, medical diagnoses, medical evaluations and medical services. This excludes vocational rehabilitation.
Injury - damage or harm to the physical structure of the body and those diseases or infections naturally resulting from the damage or harm. Also includes occupational diseases.
Occupational Disease - a disease arising out of an in the course of employment that causes damage or harm to the physical structure of the body. The term includes other diseases or infection that naturally result from the work-related disease. Occupational disease excludes any ordinary disease of life to which the general public is exposed outside of employment, unless that disease is an incident to a compensable injury. Excludes repetitive trauma injuries.
Repetitive Trauma Injury - damage or harm to the physical structure of the body occurring as the result of repetitious physically traumatic activities over time in the course and scope of employment.
Wages - includes every form of remuneration payable for a given period to an employee for personal services. This includes the market value of board, lodging, laundry, fuel and any other advantage estimated in money which the employee receives from the employer as part of the employee's remuneration.
Texas Department of Insurance, Division of Workers' Compensation
Texas Department of Insurance, Injured Employee Resources
Office of Injured Employee Counsel