Texas Department Of Insurance Division of Workers’ Compensation DWC Claim# Carrier Claim# 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 EXPLANATION OF BENEFITS (DWC Form-062) Distribution of this form will be in accordance with Rule §133.240 DO NOT SEND THIS FORM TO DWC UNLESS DWC SPECIFICALLY REQUESTS IT. An insurance carrier may substitute its own EOB form, but it MUST contain all fields required by DWC. 2. Injured employee’s Social Security no. (last 4 digits) 1. Injured employee's name (Last, First, M.I.) 3. Date of injury 4. Injured employee's mailing address (Street or P.O. Box) 5. Employer's name and address 6. Health care provider's name and address 7. Insurance carrier's name and address 8. Health care provider’s federal tax I.D. number Insurance carrier payment to the health care provider shall be according to Division medical policies and fee guidelines in effect on the date(s) of service(s). 9. Name and address of the company performing the audit Date of the audit 10. Name and telephone number of the person who can be contacted about the bill reduction Date of Service (DOS) CPT / Rev Code Type of Service ICD-9 Code Units Health care providers shall not bill any unpaid amounts to the injured employee or the employer, or make any attempt to collect the unpaid amount from the injured employee or the employer unless the injury is finally adjudicated not to be compensable, or the insurance carrier is relieved of liability under 408.024 of the Texas Workers' Compensation Act. Charges Amount Paid ANSI Reason Code Text to explain Reason for Reduction / Denial The complete ANSI Claim Adjustment Reason Code set is available on the Washington Publishing Company website at www.wpc-edi.com. TDI direction on the use of ANSI Claim Adjustment Reason Codes and jurisdiction reason codes is available at http://www.tdi.state.tx.us/wc/carrier/documents/ansicodedir.xls. NOTE: With few exceptions, you are entitled on request to be informed about the information that TDI-DWC collects about you. Under §552.021 and 552.023 of the Government Code, you are entitled to receive and review the information. Under §559.004 of the Government Code you are entitled to have TDI-DWC correct information about you that is incorrect. For more information, call the TDI-DWC Open Records section at (512) 804-4437. DWC062 Rev. 07/07 Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com