Form DWC049 "Request to Schedule a Medical Contested Case Hearing (Mcch)" - Texas

What Is Form DWC049?

This is a legal form that was released by the Texas Department of Insurance - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2017;
  • The latest edition provided by the Texas Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DWC049 by clicking the link below or browse more documents and templates provided by the Texas Department of Insurance.

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Download Form DWC049 "Request to Schedule a Medical Contested Case Hearing (Mcch)" - Texas

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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
3. Employee’s Name
4. Date of Injury
(Last, First, Middle)
(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 TDI-DWC Use Only
DWC049 Rev. 11/17
Page 1 of 3
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
3. Employee’s Name
4. Date of Injury
(Last, First, Middle)
(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 TDI-DWC Use Only
DWC049 Rev. 11/17
Page 1 of 3
DWC049
III. REQUESTER INFORMATION
9. Check the appropriate box:
Injured Employee
Health Care Provider
Subclaimant
Pharmacy Processing Agent
Insurance Carrier
Attorney for__________
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, 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
Counsel (OIEC)?
Yes
No
12. Requester's Mailing Address
(Street or PO Box, City, State, Zip Code)
13. Requester’s Printed Name/Title
14. Phone Number
15. Requester’s Signature
16. Date of Signature
(mm/dd/yyyy)
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.
For TDI-DWC Use Only
Employee’s Name:
DWC Claim Number:
DWC049 Rev. 11/17
Page 2 of 3
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?
th
Medical Fee Dispute: You must submit the form to the TDI-DWC no later than the 20
day after the
conclusion of the Benefit Review Conference.
th
Medical Necessity Dispute: You must submit the form to the TDI-DWC no later than the 20
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.
DWC049 Rev. 11/17
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