Health Care Insurance Carrier Reimbursement (DWC26 – 409.0091)

Health insurance carriers seeking reimbursement for claims related to an existing workers’ compensation claim (sub-claims) must complete and submit form DWC 26 (Rev. 01/15).

Submission of illegible, incomplete, or non-conforming requests may significantly delay consideration or result in a denial of reimbursement. To expedite consideration of a reimbursement request, please ensure the following:

  • Include ALL information required by the form, leaving NO blanks;
  • For field 2, check box C if unsure which Texas Labor Code Section(s) apply to your request;
  • For fields 3 and 4, contact the Texas Department of Insurance at (800) 252-7031 for the required information;
  • Provide individual dates of service on the second page of the form. Additional sheets may be used. A separate list may be attached if all categories and information are  included on the form;
  • Provide ALL medical records related to date(s) of service.

Submissions that do not include all required information may be returned to the requestor.\

The first page of the DWC026 form
Effective February 1, 2020, the SORM Workers’ Compensation Network is changing. For additional information visit ourHealth Care Network Transition Page