Texas Department Of Insurance Submit this form to the Workers’ Compensation Insurance Carrier listed in Section III of this form. Division of Workers’ Compensation Records Processing 7551 Metro Center Dr. Ste.100 • MS-94 Austin, TX 78744-1609 (800) 252-7031 (512) 804-4378 fax www.tdi.state.tx.us REIMBURSEMENT REQUEST FOR PAYMENT MADE BY HEALTH CARE INSURER (DWC Form-026) Section I Health Care Insurer Information Health Care Insurer Name Federal Employer Identification Number Address (Street, City, State, Zip Code) Point of Contact Name Point of Contact Phone Number Point of Contact Fax Number Section II Point of Contact E-mail Address Health Care Insurer Assignee or Authorized Representative Information Assignee or Authorized Representative Name Federal Employer Identification Number Address (Street, City, State, Zip Code) Point of Contact Name Point of Contact Phone Number Point of Contact Fax Number Point of Contact E-mail Address Section III Workers’ Compensation Insurance Carrier Information Workers Compensation Insurer Name Point of Contact Name (if known) Address (Street, City, State, Zip Code) Point of Contact Phone Number Point of Contact Fax Number Point of Contact E-mail Address Section IV Workers’ Compensation Claim Information Patient or Injured Employee Name Division Claim Number Patient or Injured Employee SSN: (last four digits only) xxx-xx- Date of Injury Section V Health Care Service Information – Use additional sheets as required, or provide required data below by attaching automated reports Amount Paid Units Amount Provider Date of ICD-9 by Health (if Procedure* Charged Provider Name FEIN Service Place of Service Code Care Insurer applicable) Total Dollar Amount * CPT or HCPCS, and modifiers if applicable; NDC, Revenue Code, or Dental Code DWC026 Rev. 09/07 Page 1 American LegalNet, Inc. www.FormsWorkflow.com Instructions for Completing the Reimbursement Request Made by a Health Care Insurer Form (DWC Form-026) This form shall be submitted to the Workers’ Compensation Insurance Carrier. Do not submit the form to the Texas Department of Insurance, Division of Workers’ Compensation (TDI/DWC). Section I Health Care Insurer Information Provide the Health Care Insurer name (HCI), Federal Employer Identification Number (FEIN), address and point of contact name information. Section II Health Care Insurer Assignee or Authorized Representative Information Complete Section II if an entity other than the HCI submits the reimbursement request form. For example, the HCI has assigned reimbursement rights to another entity or the form is submitted by an authorized representative. Provide the Health Care Insurer Assignee or Authorized Representative name, FEIN, address and point of contact name information. Section III Workers’ Compensation Insurance Carrier Information Provide the name and address of the Workers’ Compensation Insurance Carrier to which the reimbursement request is being submitted. Provide Workers’ Compensation Insurance Carrier point of contact information, if known. Section IV Workers’ Compensation Claim Information Provide the name of the patient/injured employee, the patient’s/injured employee’s Social Security Number, the TDI/DWC-assigned claim number, and the date of injury. Section V Health Care Service Information Provide information related to the health care services for the patient/injured employee listed in Section IV and paid for by the HCI. Additional sheets or automated reports may be attached as necessary. Provide the full name, credentials, and FEIN of the health care provider, and billing information for the health care services including: • • • • • • • • Date(s) of Service(s) for each specific service/line item Place of Service (POS) ICD-9 Diagnosis Code(s) Procedure Code, including: o CPT or HCPCS Code, and Modifier if applicable, for professional services. o National Drug Code (NDC) for pharmacy services. o Revenue Code, and HCPCPS Code and Modifier if applicable, for hospital services. o Dental codes for dental services. Number of units for each specific service/line item (if applicable). Amount charged by the health care provider to the HCI. Amount paid to the health care provider by the HCI. Total amount charged and paid. NOTE: With few exceptions, you are entitled, on request, to be informed about the information that the Division collects or maintains about you and your workers’ compensation claim. Under §552.021 and 552.023 of the Texas Government Code, you are entitled to receive and review the information. Under §559.004 of the Texas Government Code you are entitled to have the Division correct information the Division creates about you or your workers’ compensation claim that is incorrect. For more information, call the local Division Field Office at 1-800-252-7031. DWC026 Rev. 09/07 Instructions American LegalNet, Inc. www.FormsWorkflow.com