Texas Form Dwc049 – Fill Out and Use This PDF

DWC049

Complete if known:

DWC Claim #

Carrier Claim #

Request to Schedule a Medical Contested Case Hearing (MCCH)

Type (or print in black ink) each item on this form

I. REQUEST SPECIFICATIONS

1. Check the appropriate box to indicate the type of medical contested case hearing you are requesting:

Appeal of an Independent Review Organization (IRO) Medical Necessity Decision to the TDI-DWC. Attach a copy of the IRO decision.

Appeal of Medical Fee Dispute Decision to State Office of Administrative Hearings (SOAH). Enter the date the Benefit Review Conference ended (mm/dd/yyyy)

IMPORTANT NOTE: In an appeal to SOAH, the non-prevailing (losing) party is required to reimburse the TDI-DWC for the costs of the services provided at SOAH. In the event of a dismissal, the party who requested the SOAH hearing is required to reimburse the TDI-DWC. These requirements do not apply to the injured employee.

2.Check the appropriate box(es) for services you are requesting, if any:

Expedited MCCH (specify reason*)

Special Accommodations (specify)

*Does not include claim involving a first responder. See Section III, Box 10 regarding expedited first responder claims.

II. INJURED EMPLOYEE CLAIM INFORMATION

5.Employee’s Physical Address (Street, City, State, Zip Code)

6.Insurance Carrier’s Name

7.Employer’s Business Name (at the time of the injury)

8.Employer’s Business Address (Street or PO Box, City, State, Zip Code)

For TDI-DWC Use Only

DWC049

III. REQUESTER INFORMATION

9. Check the appropriate box:

10. Provide the following information:

Is the injured employee a first responder, as defined in Texas Labor Code §504.055, who sustained a serious bodily

If yes, TDI-DWC will expedite an MCCH as follows:

• Medical Fee Dispute: MCCH will be expedited only if the requester is the injured employee.

• Medical Necessity Dispute: MCCH will be expedited regardless of requester type.

*bodily injury that creates a substantial risk of death or that causes death, serious permanent disfigurement, or protracted loss or impairment of the function of any bodily member or organ

11. If injured employee is checked in Box 9, is the employee assisted by the Office of Injured Employee

NOTE: With few exceptions, upon your request, you are entitled to be informed about the information TDI-DWC collects about you; get and review the information (Government Code, §§552.021 and 552.023); and have TDI-DWC correct information that is incorrect (Government Code, §559.004). For more information, contact agencycounsel@tdi.texas.gov or you may refer to the Corrections Procedure section at www.tdi.texas.gov.

DWC049

Frequently Asked Questions

Request to Schedule Medical Contested Case Hearing (MCCH)

Where will the MCCH be held?

•Medical Fee Dispute: The State Office of Administrative Hearings (SOAH) will schedule the hearing at the SOAH offices in Travis County.

•Medical Necessity Dispute: The Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) will schedule the MCCH at a location not more than 75 miles from the injured employee’s residence at the time of the injury or the address on this form, unless good cause exists for the selection of a different location. You may request another location, but must provide an acceptable reason to relocate the proceeding. The TDI-DWC will determine whether a change in location is appropriate. In addition, injured employees may request the MCCH be held through a telephone conference.

What type of special accommodations will be provided?

The TDI-DWC or SOAH will provide accommodations to parties who qualify under the Americans with Disabilities Act (ADA), and other reasonable accommodations at the discretion of the Administrative Law Judge.

Who determines whether an MCCH is expedited?

If an expedited MCCH is requested in Section I, Box 2, the TDI-DWC will determine whether scheduling the MCCH more quickly is appropriate.

If Yes is checked in Section III, Box 10 to indicate that the injured employee is a first responder, the TDI-DWC will expedite an MCCH as follows:

•Medical Fee Dispute: MCCH will be expedited only if the requester is the injured employee.

•Medical Necessity Dispute: MCCH will be expedited regardless of requester type.

What is the deadline for filing the DWC Form-049?

•Medical Fee Dispute: You must submit the form to the TDI-DWC no later than the 20th day after the conclusion of the Benefit Review Conference.

•Medical Necessity Dispute: You must submit the form to the TDI-DWC no later than the 20th day after the date the Independent Review Organization (IRO) decision is sent to the appealing party.

Where do I send the DWC Form-049?

The completed form, including a copy of the IRO decision (if applicable), must be faxed to (512) 804-4011 or mailed to the address shown below.

Texas Department of Insurance Division of Workers’ Compensation

7551 Metro Center Drive, Suite 100 • MS-35 Austin, TX 78744-1645

Is any of the requested information optional?

No, provide all requested information. An MCCH will only be scheduled if the form is complete. An incomplete form may delay resolution of your dispute.

Am I required to attend the MCCH?

If you do not attend, the MCCH may be held without you. Failure to attend an MCCH could result in a recommendation of a penalty or fine unless you can show good cause for your absence. An injured employee should attend any proceeding related to a dispute about his or her claim, even if the injured employee did not request the proceeding.

Who do I contact if I have questions about requesting an MCCH?

Contact the TDI-DWC by calling (512) 804-4010 or 1-800-252-7031. An injured employee who is not represented by an attorney may also receive assistance by calling the Office of Injured Employee Counsel (OIEC) at 1-866-393-6432.