SECTION 5.6601. Texas Detailed Claim Information Statistical Plan

(a) Applicability.

(1) This section applies to workers' compensation insurance and includes employers' liability insurance. Whenever the term "workers' compensation" is used in this section, the term includes and applies to employers' liability insurance.

(2) This section applies to each insurance company authorized to write workers' compensation insurance in the State of Texas as specified in the Insurance Code §2053.001(2). Each insurance company is required to report to the commissioner, or the commissioner's designated statistical agent, information prescribed by the commissioner under the Insurance Code §2053.151 for each workers' compensation insurance claim.

(b) Purpose. The purpose of this section is to:

(1) prescribe the reporting requirements for the information and data to be submitted to the commissioner, or the commissioner's designated statistical agent, concerning workers' compensation claims pursuant to the Insurance Code §2053.151 to ensure that the data collection methodology will yield data necessary for research and medical cost containment efforts; and

(2) adopt by reference the Texas Detailed Claim Information Statistical Plan, 2010 Edition.

(c) Definitions. The following words and terms when used in this division shall have the following meanings unless the context clearly indicates otherwise:

(1) Centrally-located--Located in a place with ready access to the insurance company's claims files and detailed claims information.

(2) Insurance company, insurance carrier, insurer, and carrier--Has the same meaning as "Insurance company" as defined by the Insurance Code §2053.001(2).

(3) Jurisdiction state--The state responsible for the claim.

(4) Statistical Plan--The Texas Detailed Claim Information Statistical Plan, 2010 Edition adopted by reference pursuant to this section.

(d) Adoption by Reference. The commissioner adopts by reference the Texas Detailed Claim Information Statistical Plan, 2010 Edition. The Statistical Plan includes the rules, requirements, and examples for reporting detailed claim information for claims with a Reported to Insurer Date of September 1, 2010 and later and provides reporting instructions, a data dictionary, and claim selection and sampling methodologies.

(e) Statistical Plan Availability. The Statistical Plan is published by the Texas Department of Insurance and is available from the Data Services Division, Mail Code 105-5D, Texas Department of Insurance, P.O. Box 149104, Austin, Texas 78714-9104 or the department's website at www.tdi.state.tx.us.

(f) Reporting Requirements.

(1) The Statistical Plan specifies the requirements for reporting claims data, including:

(A) criteria for determining which claims to report;

(B) data elements and record layouts for the information that must be reported on each claim;

(C) standards and procedures for categorizing insurance and medical benefits required to be reported on each claim;

(D) information to be used for determining the specific loss valuation levels for each claim, which requires it to be reported; and

(E) instructions regarding how and when to report required data on claims.

(2) Each insurance company is required to comply with the reporting requirements of the Statistical Plan pursuant to the Insurance Code §2053.151. Each insurance company must submit required information and data on each claim to the commissioner, or the commissioner's designated statistical agent, no later than three months after the loss valuation dates specified in the Statistical Plan.

(g) Claims Required to be Reported. A claim's eligibility for reporting is based on an incurred indemnity loss value greater than zero. Even if no income benefit payments have been made, but reserves have been set on the claim in anticipation of payment, the claim is still eligible to be reported. The following claims must be reported:

(1) death claims;

(2) lifetime income benefit claims (i.e., permanent total disability claims);

(3) other open indemnity claims; and

(4) closed claims selected in accordance with the sampling method outlined in the Statistical Plan adopted under this section.

(h) Claims Excluded from Reporting. The following claims are not required to be reported:

(1) claims where the jurisdiction state is not Texas;

(2) claims in which income benefits have not yet accrued or been paid (i.e., medical only claims);

(3) losses paid to another insurance company because of reinsurance assumed by the reporting insurance company; and

(4) claims that involve benefits payable under federal workers' compensation laws.

(i) Designated Carrier Coordinator. Each insurance company must designate one individual as the coordinator for claims reporting within its organization and provide the coordinator's contact information, including the coordinator's name, working title, mailing address, e-mail address, and telephone number, to the commissioner, or the commissioner's designated statistical agent.

(1) The designated carrier coordinator must:

(A) be a centrally-located employee of the insurance company who has responsibility for claims, statistical, or data management;

(B) receive and appropriately disperse data reporting information received from the commissioner, or the commissioner's designated statistical agent; and

(C) serve as central compliance control for data reporting under the Statistical Plan.

(2) An insurance company authorized to write workers' compensation insurance in this state as of the effective date of this section must provide the coordinator's contact information required by this subsection to the commissioner, or the commissioner's designated statistical agent, no later than September 1, 2010. Except as otherwise provided by this subsection, an insurance company that obtains a certificate of authority to write workers' compensation insurance in this state after September 1, 2010, must provide the coordinator's contact information required by this subsection to the commissioner, or the commissioner's designated statistical agent, no later than the 30th day after the insurance company's certificate of authority becomes effective.

(3) An insurance company must report any changes to the designated insurance company coordinator's contact information to the commissioner, or the commissioner's designated statistical agent, not later than 30 days after the effective date of the change.

(j) Effective Date.

(1) This section is effective on September 1, 2010.

(2) Claims with a Reported to Insurer Date of September 1, 2010 and later must be reported in accordance with the Statistical Plan. Claims with a Reported to Insurer Date prior to September 1, 2010 must be reported in accordance with the Texas Detailed Claim Information Statistical Plan effective January 1, 1997 up to and including reports due April 30, 2014.

Source Note: The provisions of this §5.6601 adopted to be effective August 3, 2010, 35 TexReg 6663