Providers' Role in the
Workers' Compensation System
As a provider, you have a responsibility to treat patients and a right to be reimbursed for your services. Texas Mutual Insurance Company is required by law to pay for those services in accordance with the laws and rules in effect on the date of service.
Workers' compensation is different from group health. Following these steps when treating a patient who was injured on the job will help you navigate the workers' compensation system.
Step 1. The patient arrives at your office.
- Treat emergencies immediately.
- Ask questions to determine whether the injury occurred while the patient was at work.
- How did the injury occur?
- Where were you at the time of the injury?
- Ask the patient if his or her employer has workers' compensation coverage. If the patient does not know, use the Texas Department of Insurance (TDI) TXCOMP system to find out if the employer has workers' compensation coverage.
- Remember, just because an injury occurred at work does not mean it is compensable and covered under workers' compensation.
An injury could be noncompensable if it did not occur in the course and scope of employment. For example, if it:
- Was caused by a third party for a personal reason
- Was caused by an act of nature, such as lightning
- Occurred during a non-mandatory, off-duty recreational social or athletic activity
- Occurred during horseplay
Step 2. Determine whether the claim is in-network or out-of-network.
- Texas law allows insurance carriers to offer workers' compensation health care networks to policyholders.
- Ask the patient who their employer is, and then call the employer to find out if the employee is covered by a network.
- You may also visit TDI's TXCOMP system to find out who the employer's carrier is, and then call the carrier to determine the employer's network status.
- If the patient is covered by Texas Mutual Insurance Company, call (888) 532-5246 to determine whether the employer participates
in our Texas Star Network®.
Step 3. Treat the patient.
Step 5. Wait for the carrier to receive and process your bill.
- Carriers have 45 days to review and process your complete bill.
- If you have not heard from us within 30 days after you submit your bill, we encourage you to use our online system or call (888) 532-5246 to verify that we received your bill and it is in line for processing.
- If the bill is incomplete, we will return it to you.
- Texas Mutual reviews bills to ensure that they were submitted timely and accurately, and that treatment and services were necessary and related to the compensable injury.
- After we take final action on your bill, we will generate an explanation of benefits.
Final action may include:
- Send payment that constitutes fair and reasonable reimbursement
- Deny a charge(s) on the bill
- Request reimbursement for overpayment
- If you disagree with our determination, you may submit a request for reconsideration in accordance with DWC Rule 133.250. If you still disagree, you may request dispute resolution in accordance with DWC Rule 133.305.
- If we overpay you, DWC Rule 133.260 requires you to return the excess payment to us.