Contents
Form Example
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
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
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
3. Employee’s Name (Last, First, Middle) |
4. Date of Injury (mm/dd/yyyy) |
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
DWC049 Rev. 11/17 |
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DWC049
III. REQUESTER INFORMATION
9. Check the appropriate box:
Injured Employee |
Health Care Provider |
Subclaimant |
Pharmacy Processing Agent |
Insurance Carrier |
Attorney for__________ |
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|
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
injury*? |
Yes |
No |
If yes,
• 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
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Counsel (OIEC)? |
Yes |
No |
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12. |
Requester's Mailing Address (Street or PO Box, City, State, Zip Code) |
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13. |
Requester’s Printed Name/Title |
14. |
Phone Number |
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15. |
Requester’s Signature |
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16. |
Date of Signature (mm/dd/yyyy) |
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NOTE: With few exceptions, upon your request, you are entitled to be informed about the information
Employee’s Name: DWC Claim Number:
For
DWC049 Rev. 11/17 |
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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
What type of special accommodations will be provided?
The
Who determines whether an MCCH is expedited?
If an expedited MCCH is requested in Section I, Box 2, the
If Yes is checked in Section III, Box 10 to indicate that the injured employee is a first responder, the
•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
•Medical Fee Dispute: You must submit the form to the
•Medical Necessity Dispute: You must submit the form to the
Where do I send the DWC
The completed form, including a copy of the IRO decision (if applicable), must be faxed to (512)
Texas Department of Insurance Division of Workers’ Compensation
7551 Metro Center Drive, Suite 100 •
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
DWC049 Rev. 11/17 |
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Common mistakes
-
Failing to check the appropriate box for the type of medical contested case hearing being requested. This can lead to delays in processing the request.
-
Not providing a copy of the Independent Review Organization (IRO) decision when appealing a medical necessity decision. This documentation is essential for the appeal process.
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Leaving out the date the Benefit Review Conference ended when appealing a medical fee dispute. This information is crucial for determining the filing timeline.
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Neglecting to specify the reason for requesting expedited MCCH services. Without this information, the request may be denied.
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Providing incomplete or incorrect employee information, such as the name, date of injury, or physical address. Accuracy in these details is vital for proper identification of the claim.
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Failing to indicate whether the injured employee is a first responder when applicable. This status can affect the expedited processing of the MCCH.
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Omitting the requester's mailing address or contact information. This can hinder communication regarding the case.
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Not signing and dating the form. A signature is necessary for the request to be considered valid.
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Submitting the form after the deadline. For medical fee disputes, the form must be submitted within 20 days after the Benefit Review Conference.
Key takeaways
Complete the Texas DWC049 form accurately, using black ink or typing. This ensures clarity and legibility.
Indicate the type of hearing you are requesting by checking the appropriate box. This could be an appeal of a medical necessity decision or a medical fee dispute.
Attach any necessary documentation, such as a copy of the IRO decision if you are appealing that decision.
Be aware that if you are appealing a decision to the State Office of Administrative Hearings (SOAH), the losing party may need to reimburse costs incurred by the TDI-DWC.
Fill in all required information about the injured employee, including their name, date of injury, and contact details. Incomplete forms may delay the process.
If applicable, check whether the injured employee is a first responder. This may expedite the hearing process.
Submit the completed form within the specified deadlines: 20 days after the Benefit Review Conference for medical fee disputes or 20 days after the IRO decision for medical necessity disputes.
Send the form via fax or mail to the designated TDI-DWC address. Ensure you keep a copy for your records.
Attend the hearing. If you do not show up, the hearing may proceed without you, potentially leading to penalties.
Steps to Using Texas Dwc049
Completing the Texas DWC049 form is an important step in requesting a Medical Contested Case Hearing (MCCH). This process helps ensure that your concerns are formally addressed. Make sure you have all the necessary information ready before you start filling out the form.
- Begin by writing the DWC Claim Number and Carrier Claim Number at the top of the form.
- In Section I, check the appropriate box to specify the type of medical contested case hearing you are requesting. If appealing an Independent Review Organization (IRO) decision, attach a copy of that decision.
- If applicable, check the boxes for any services you are requesting, such as expedited MCCH or special accommodations, and provide the reason for your request.
- In Section II, fill in the injured employee’s name, date of injury, and physical address, including street, city, state, and zip code.
- Provide the insurance carrier’s name and the employer’s business name at the time of the injury.
- Also, include the employer’s business address, including street or PO Box, city, state, and zip code.
- In Section III, check the appropriate box to indicate your status as the requester (injured employee, healthcare provider, etc.).
- Answer whether the injured employee is a first responder who sustained a serious bodily injury. If yes, follow the instructions provided for expedited MCCH.
- If the injured employee is checked in Box 9, indicate whether they are assisted by the Office of Injured Employee Counsel (OIEC).
- Fill in the requester’s mailing address, printed name or title, and phone number.
- Sign and date the form at the bottom. Make sure the date is in the mm/dd/yyyy format.
Once completed, the form must be submitted to the Texas Department of Insurance, Division of Workers’ Compensation. You can fax it to (512) 804-4011 or mail it to the provided address. Make sure to keep a copy for your records. If you have any questions, you can reach out to the TDI-DWC for assistance.