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.\