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You are here: Home . bulletins . 2011 . cc5

COMMISSIONER'S BULLETIN # B-0006-11

January 13, 2011


To: Workers' Compensation System Participants


Re: Informal and Voluntary Networks and Health Care Reimbursement after January 1, 2011

The Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC) reminds all system participants of the following:

  • As required by Labor Code §413.0115(b), each informal network or voluntary network must have been certified as a workers' compensation health care network under Chapter 1305, Insurance Code, no later than January 1, 2011.
  • Labor Code §413.011 Subsections (d-1) through (d-3), which authorized insurance carriers to contract with health care providers for fees that are different than TDI-DWC's fee guidelines, expired on December 31, 2010.
  • Reimbursement for health care services (including inpatient hospital, outpatient hospital, dental, ambulatory surgical center, as well as professional services such as durable medical equipment) rendered on or after January 1, 2011 shall be in accordance with TDI-DWC's fee guidelines (see 28 TAC Chapter 134 for copies of all fee guideline rules).
  • For network and non-network claims, pharmacy services shall be reimbursed in accordance with newly adopted 28 TAC §134.503.
  • In accordance with Labor Code §413.011 Subsection (d-4), insurance carriers may continue to contract with health care providers for fees above TDI-DWC's fee guidelines as needed to ensure adequate access to care for injured employees.
  • In accordance with Labor Code §413.011(d-6), the provisions of 28 TAC §133.4, regarding Written Notification to Health Care Providers of Contractual Agreements for Informal and Voluntary Networks, and 28 TAC §133.5, regarding Informal Network and Voluntary Network Reporting Requirements to the Division, expired on January 1, 2011. However, these rules continue to apply to health care services that were rendered between August 1, 2008, and December 31, 2010, pursuant to an insurance carrier or informal network or voluntary network fee agreement with a health care provider.

Failure to comply with the statutes and TDI-DWC rules may result in ordered restitution and enforcement action, including, but not limited to, administrative penalties of up to $25,000 per day per occurrence.

If there are any questions regarding the information in this bulletin, please call Comp Connection toll-free at 1-800-372-7713.

_____________________________
Rod Bordelon
Commissioner of Workers' Compensation

Texas Department of Insurance



Last updated: 09/07/2014

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