DWC026 Texas Department Of Insurance Division of Workers' Compensation 7551 Metro Center Drive, Suite 100 Austin, TX 78744-1645 (800) 252-7031 · www.tdi.texas.gov Submit to: Workers' Compensation Insurance Carrier listed in Section IV of this form REQUEST FOR REIMBURSEMENT OF PAYMENT MADE BY HEALTH CARE INSURER I. DATE AND TYPE OF REQUEST 1. Date of Request 2. Check ONLY one box to indicate the Texas Labor Code Section(s) that apply to this request: a. §409.009 b. §409.0091 c. both §409.009 and §409.0091 1 If b. or c. is checked in Box 2 above, provide the following information: 3. TDI-DWC Data Match Date (mm/dd/yyyy) 4. TDI-DWC Data Match File Name II. HEALTH CARE INSURER INFORMATION 5. Health Care Insurer Name 8. Point of Contact Name 6. Federal Employer ID Number 9. Point of Contact Phone Number 7. Address (Street or PO Box, City State Zip) 10. Point of Contact Fax Number 11. Point of Contact E-mail Address III. HEALTH CARE INSURER ASSIGNEE OR AUTHORIZED REPRESENTATIVE INFORMATION (if applicable) 12. Assignee/Authorized Representative Name 15. Point of Contact Name 13. Federal Employer ID Number 16. Point of Contact Phone Number 14. Address (Street or PO Box, City State Zip) 17. Point of Contact Fax Number 18. Point of Contact E-mail Address IV. WORKERS' COMPENSATION INSURANCE CARRIER INFORMATION 19. Workers Compensation Insurance Carrier Name 21. Point of Contact Name (if known) 22. Point of Contact Phone Number 20. Address (Street or PO Box, City State Zip) 23. Point of Contact Fax Number 24. Point of Contact E-mail Address V. WORKERS' COMPENSATION CLAIM INFORMATION 25. Patient / Injured Employee Name 26. TDI-DWC Claim Number 27. Date of Injury 28. Patient / Injured Employee SSN NOTE: With few exceptions, upon your request, you are entitled to be informed about information TDI-DWC collects about you; receive and review the information (Government Code, §§552.021 and 552.023); and have TDI-DWC correct information that is incorrect (Government Code, §559.004). DWC026 Rev. 01/15 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com DWC026 VI. HEALTH CARE SERVICE INFORMATION Provide the required information in the table below or by attaching documents such as explanations of benefits, medical bills, or other automated reports that contain the required information. Provider Name Provider FEIN Provider 2 NPI Date of 3 Service Diagnosis Code Procedure 4 Code Amount Charged by Provider Amount Paid by Health Care Insurer Place of Service Unit(s) 5 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTALS 1 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Tex. Lab. Code §409.0091(n) and §409.0091(s) require a data match as described by §402.084 (c-3) in order to establish timeliness of a request for reimbursement by the health care insurer. The TDI-DWC Data Match File Name will conform to the naming convention listed for Claim Data Request Files in Addendum B of the Claim Data Request and Response Implementation Guide found at www.tdi.texas.gov/wc/indexwc/html. 2 Optional 3 Provide date of service for each specific service/line item. 4 Procedure codes include: · CPT or HCPCS Code, and Modifier if applicable, for professional services · National Drug Code (NDC) for pharmacy services · Revenue Code, and HCPCPS Code and Modifier if applicable, for hospital services · Dental codes for dental services 5 Provide number of units for each specific service/line item (if applicable). DWC026 Rev. 01/15 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com