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