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Workers' Compensation Health Care Networks: Information for Injured Employees

(July 2017)

(En Español) (PDF version)

Some employers provide workers' compensation coverage for their employees through workers' compensation health care networks. These networks contract with doctors, hospitals, and other health care providers that work together to treat employees injured at work.

The Texas Department of Insurance certifies and regulates the networks. Texas employers aren't required to provide workers' compensation or to participate in a network.

If your employer provides workers’ compensation coverage:

  • Read your network notice and rules carefully. Your employer must give you the notice and rules when it joins a network. This notice tells you about your rights and responsibilities. Employers must also give the network notice and rules to new employees within three days of their hire date and to any employee who reports a work-related injury. You must follow the network’s rules.
  • Understand the network's rules. If you don't understand something, ask your employer or insurance company to explain. After you get the network rules, you will be asked to sign a form stating that you got the notice. You must still follow the network's rules even if you don't sign the form.
  • Tell your employer and the insurance company if you don't think you live in the network service area. The network service area may include some or all Texas counties. If you don’t think you live in any of the network’s approved counties, notify your company immediately. The company will then evaluate if you actually live in or out of the network service area within seven days of receiving notice. If you have a work-related claim while awaiting response from your company, you may use the network's treating doctors. If you get treatment from out-of-network doctors and the company later decides that you live in the service area, you may have to pay the out-of-network medical bills yourself. You can file a complaint with TDI if you disagree with the company’s decision.
  • Report your injury. You must report your work-related injury to your employer within 30 days of the injury. You must also file a workers' compensation claim with TDI's Division of Workers' Compensation within one year. To learn how to file a claim, call the Division of Workers’ Compensation at 1-800-252-7031
  • After reporting the claim, choose an in-network treating doctor. If you live in the network's service area, you must choose a network doctor. You will have 14 days to choose an in-network doctor after you file your claim. If you don't choose a doctor, the network will choose one for you. You will get a copy of the network doctor list when your employer joins a network and again if you become injured. Your employer can provide this list to you any time if you ask. You may change doctors, but you may change only once without approval. If you have existing coverage with a health maintenance organization (HMO) and have an existing primary care physician (PCP), you may ask the network to let you use your existing HMO PCP. The HMO PCP must agree to the network's terms, and the workers’ compensation network must approve the doctor in advance.
    Note: If you're injured and your employer or insurance company changes networks, you might have to change your treating doctor. Your insurance company or employer will tell you what to do.
  • Use only doctors and hospitals in the network. You must use doctors and hospitals in the workers’ compensation network, except in emergencies and when the network approves out-of-network services. You must go to the treating doctor approved by the network for all the routine health care related to your work injury. If you go outside the network for care, you might have to pay the medical bills yourself.
  • Get a referral from the treating doctor before going to a specialist.  The network must approve or deny all workers’ compensation-related health care and provide referrals to specialists within 21 days of the date you ask for a referral.

Appealing Denials

If the network or insurance company denies a treatment you think you need, you can appeal the denial. The network will tell you how to appeal a denial. If the company denies your appeal based on medical necessity, you have the right to a review by an independent review organization. 

Get Help from TDI

For insurance questions or for help with an insurance-related complaint, call the Consumer Help Line at 1-800-252-3439 or visit our website.

For more information about workers’ compensation, call DWC at 1-800-252-7031.

The information in this publication is only a summary of network requirements and is current only as of the revision date. Changes in laws and agency administrative rules made after the revision date may affect the accuracy of the content. View complete requirements and current information on TDI’s website. TDI distributes this publication for educational purposes only. This publication is not an endorsement by TDI of any service, product, or company.



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Last updated: 08/09/2017

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