28 Tex. Admin. Code § 180.1 - Definitions
The following words and terms, when used in this chapter, will have the following meanings:
(1)
Act--The Texas Workers' Compensation Act, Labor Code, Title 5, Subtitle
A.
(2) Administrative violation--A
violation, failure to comply with, or refusal to comply with the Act, or a
rule, order, or decision of the commissioner. This term is synonymous with the
terms "violation" or "violate."
(3)
Agent--A person who a system participant uses or contracts with for the purpose
of providing claims service or fulfilling duties under the Labor Code Title 5
and rules. The system participant who uses or contracts with the agent may also
be responsible for the administrative violations of that agent.
(4) Appropriate credentials--The
certifications, education, training, and experience to provide the health care
that an injured employee is receiving or is requesting to receive. Under Texas
Labor Code §
408.0043, a physician who
performs a peer review, utilization review, or independent review of health
care services requested, ordered, provided, or to be provided by a physician
must be of the same or similar specialty as the physician who requested,
ordered, provided, or will provide the health care service. A dentist must meet
the requirements of Texas Labor Code §
408.0044. A chiropractor
must meet the requirements of Texas Labor Code §
408.0045.
(5) Commissioner--The commissioner of
workers' compensation.
(6)
Complaint--A written submission to the division alleging a violation of the Act
or rules by a system participant.
(7) Compliance Audit (also Performance
Review)--An official examination of compliance with one or more duties under
the Act and rules. A compliance audit does not include monitoring or review
activities involving the Medical Advisor or the Medical Quality Review
Panel.
(8) Conviction or
convicted--
(A) A system participant is
considered to have been convicted when:
(i) a
judgment of conviction has been entered against the system participant in a
federal, state, or local court;
(ii) the system participant has been found
guilty in a federal, state, or local court;
(iii) the system participant has entered a
plea of guilty or nolo contendere (no contest) that has been accepted by a
federal, state, or local court;
(iv) the system participant has entered a
first offender or other program and judgment of conviction has been withheld;
or
(v) the system participant has
received probation or community supervision, including deferred
adjudication.
(B) A
conviction is still a conviction until and unless overturned on appeal even if:
(i) it is stayed, deferred, or
probated;
(ii) an appeal is
pending; or
(iii) the system
participant has been discharged from probation or community supervision,
including deferred adjudication.
(9) Department--Texas Department of
Insurance.
(10) Division--Texas
Department of Insurance, Division of Workers' Compensation.
(11) Emergency--As defined in §
133.2 of this title (relating to
Definitions). This definition does not apply to "emergency" as used in the term
"ex parte emergency cease and desist orders."
(12) Frivolous--That which does not have a
basis in fact or is not warranted by existing law or a good faith argument for
the extension, modification, or reversal of existing law.
(13) Frivolous complaint--A complaint that
does not have a basis in fact or is not warranted by existing law or a good
faith argument for the extension, modification, or reversal of existing
law.
(14) Immediate post-injury
medical care--That health care provided on the date that the injured employee
first seeks medical attention for the workers' compensation injury.
(15) Notice of Violation (NOV)--A notice
issued to a system participant by the division when the division has found that
the system participant has committed an administrative violation and the
division seeks to impose a sanction in accordance with Labor Code, Title 5 or
division rules.
(16) Peer
Review--An administrative review by a health care provider performed at the
insurance carrier's request without a physical examination of the injured
employee.
(17) Remuneration--Any
payment or other benefit made directly or indirectly, overtly or covertly, in
cash or in kind, including, but not limited to, forgiveness of debt.
(18) Rules--The division's rules adopted
under Labor Code, Title 5.
(19)
Sanction--A penalty or other punitive action or remedy imposed by the
commissioner on an insurance carrier, representative, injured employee,
employer, or health care provider, or any other person regulated by the
division under the Act, for an administrative violation.
(20) SOAH--The State Office of Administrative
Hearings.
(21) System
Participant--A person or their agent subject to the Act or a rule, order, or
decision of the commissioner.
Notes
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