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Workers' Compensation Health Care Networks

(May 2016)

(En Español) (PDF)

OverviewInformation for EmployeesInformation for EmployersInformation for Doctors and HospitalsGet Help from TDI

Workers' compensation health care networks contract with insurance companies and doctors and hospitals to treat injured employees. Except in emergencies and approved out-of-network referrals, employees whose employers are part of a network must use the network’s doctors, hospitals, and other health care providers to get care for a work-related injury.

Overview

The Texas Department of Insurance certifies and regulates networks. TDI sets financial standards and requirements for accessibility and availability of care. TDI also issues an annual report card that compares satisfaction of care, health outcomes, and health care costs. You can look at the report card on the Division of Workers' Compensation web page.

Insurance companies, certified self-insured employers, groups of certified self-insured employers, and political subdivisions can set up their own networks or contract with certified networks.

Insurance companies with networks pay the cost of health care and any income benefits owed to the employee for lost wages or permanent physical impairment.

Visiting a Doctor or Hospital

Networks are similar to managed care plans like health maintenance organizations (HMOs) and preferred provider plans (PPOs). Managed care plans control costs by contracting with networks of doctors and hospitals to provide patient care.

Employees who live in the network's service area must use doctors and hospitals in the network. Insurance companies may deny payment if employees don't use doctors in the service area. There are exceptions for emergencies or for employees who have approval to go to a doctor outside the network.

Injured employees must choose a treating doctor from the network's list. If an injured employee is in an HMO, the employee may use the HMO doctor as the treating doctor. The HMO doctor must agree to the network's terms, however.

The treating doctor provides employees' workers' compensation-related care and makes referrals to specialists. Employees must get a treating doctor's referral and network approval before seeing a specialist. For certain types of care, a network may require the treating doctor to get preauthorization for treatments and referrals so the network can decide if the treatments are medically necessary.

In most cases, an insurance company will only pay for health care that is work-related and medically necessary. Networks must have a process to allow patients and doctors to appeal their decisions.

Information for Employees

If you're injured on the job and your employer is part of a network, you must do the following:

  • Report your injury to your employer.
  • Send a claim to TDI's Division of Workers' Compensation by calling the Injured Worker Hotline.
  • Choose a treating doctor from the network's list.

If you live within a network's service area, you must choose a treating doctor who will oversee your treatment and make referrals to specialists if needed. The network or insurance company will give your employer a list of participating treating doctors every three months.

Your treating doctor must follow the network's rules, treatment guidelines, and return-to-work guidelines. The network may require you to get prior approval for certain treatments or services so it can decide if the care is medically necessary.

The insurance company usually pays the cost to treat your work-related injury and illness. An insurance company, doctor, or hospital may not bill you for any treatment or services that are related to your work-related injury or illness.

Note: Be aware that if you use a doctor or hospital outside the network without approval, the insurance company may deny payment and you might have to pay the bills yourself. There are exceptions for emergencies and other situations.

Network Requirements

Networks operate in service areas, usually by county, and must provide all necessary medical services within the area. Networks must contract with enough doctors and hospitals to:

  • treat employees 24 hours a day, seven days a week;
  • provide all necessary hospital, psychiatric, and physical therapy and chiropractic services;
  • have treating doctors and hospitals in urban areas within 30 miles from any given point (the area is expanded to 75 miles for specialty services); and
  • have treating doctors and hospitals in rural areas within 60 miles from any given point (the area is expanded to 75 miles for specialty services).

If the network can’t meet these standards, the network must have a plan to ensure that injured employees get all medically necessary services that aren’t available in the service area.

Employees who live outside the service area aren’t usually required to follow the network's rules and requirements. If you live in a network's service area, you may also be exempted from some or all the network requirements if:

  • you require emergency care. In an emergency, the network must cover the cost of treatment from any doctor or hospital, regardless of network status. You must change to a network-approved doctor or hospital when your condition stabilizes.
  • there isn't a network doctor that is available to deliver the care you need. The network must approve your use of a non-network doctor if the service is medically necessary.
  • you’re in an HMO. You might be able to choose your HMO primary care doctor as your treating doctor for your work injury. Your HMO doctor must agree to the network's rules, treatment guidelines, and return-to-work guidelines.

Notification Requirements

Employers must give employees the network notice and rules when:

  • they join a network,
  • they hire new workers, and
  • a worker reports a work-related injury.

The notice of rules must include information about the network's service area and network rules, including procedures for complaints and appeals of the network's treatment decisions.

You'll be asked to sign and return a form saying that you received the notice. However, you must still follow the network's rules even if you don’t sign the form.

Employees who live outside the service area may have different requirements than employees who live in the service area. If you don't live in the network's service area, you must tell the insurance company immediately, or the company will assume that you live at the address you gave your employer. Never lie about where you live to avoid a network's rules or to transfer to another network or doctor. If the insurance company learns about the lie, you might have to pay for your treatment yourself.

Your Rights

If your network makes a medical necessity decision you or your doctor disagrees with, you, your representative, or your doctor have 30 days to file an appeal to have the decision considered by a different doctor. The entity that issued the medical necessity denial must complete your review as soon as reasonably possible, but usually not later than 30 days after receiving your appeal.  If the appeal is about poststabilization treatment, a life-threatening condition, or continued hospital stay, then the entity must resolve the appeal sooner. You will get a letter that tells you the decision and the procedures to appeal the decision.

You also have the right to ask for an independent review by an independent review organization. If your condition is life-threatening or relates to a medical interlocutory order, you have the right to request an immediate review by an independent review organization.

If you get medical care through a network, you have the following additional rights:

  • You may choose a different doctor from the network's list of treating doctors if you aren't happy with your first choice of treating doctor. You must tell the network, but the network may not deny your request. If you aren't happy with the second doctor you choose, you must get network approval to change your treating doctor.
  • A network must arrange for medical services, including referrals to specialists, within 21 days after you request the services.
  • A network may not retaliate against you or your employer if you or your employer file an appeal or complaint. A network may not retaliate against your doctor if the doctor sends a complaint or appeal on your behalf.
  • You have the right to send a complaint to the network if you believe the network has acted improperly. The network must acknowledge your complaint within seven days and must resolve your complaint within 30 days.

If you think the network has acted improperly, you may send a complaint to TDI. You may send a complaint to TDI in writing, through our website, or by calling the Consumer Help Line.

Information for Employers

Employers should consider where their employees live when deciding whether to participate in a certified network. Employees living in different areas of the state or in neighboring counties may not be in a network's service area. Employees who don't live in the service area aren't required to use the network.

To operate in Texas, TDI must approve a network as meeting the minimum coverage and service standards required by law. A list of approved certified networks is available on TDI’s website.

Some employees may not be subject to network requirements if the injury is very old or if the employee was injured before you agreed to participate in a network. Ask the insurance company or network if you aren’t sure whether an employee is subject to network requirements.

Required Notice

If you decide to participate in a network, you must give your employees written notice of the network's rules and requirements. Your insurance company will give you the notice. The notice must include:

  • a list of any health care services that require preauthorization or utilization review;
  • descriptions of all network processes, including complaint and appeal procedures;
  • information on the network's service area; and
  • a complete list of network providers

You must provide the notice in English, Spanish, and any language common to 10 percent or more of your employees. You are required to provide this notice to existing employees at the time coverage takes effect and to all new employees no later than the third day after the hire. You must also provide the notice again when an employee reports a work-related injury or illness.

If you don't give the notice to an employee, the employee isn't required to follow the network's rules. Employees must sign a form saying that they received the network rules, but an employee isn’t exempt from the network rules if he or she doesn’t sign it.

You are required to keep a record of all acknowledgment forms and documentation about how you delivered them. This is important because it can help support your case if an employee disputes whether you provided the notice.

Employers are also required to keep a list of the network's doctors and hospitals. You must also give employees a copy if they ask for it. Your insurance company must update the list quarterly. You are also required to post notices about network coverage in the workplace where they can be seen by your employees.

Information for Doctors and Hospitals

Any licensed health care professional may apply to become a participating provider in one or more networks. Each network has its own credentialing process and may set its own minimum standards for participation in its network.

A network may decline your application if it has already contracted with enough doctors and hospitals to meet the needs of injured employees.

Your Requirements and Rights

As a network provider, you must follow the plan's policies, procedures, treatment guidelines, and return-to-work guidelines for all patients. You will also have to sign a contract that includes all of TDI’s requirements.

Network doctors and hospitals may not bill an injured worker for any costs related to treatment of work-related injuries or illnesses, including copays or balance billing amounts for additional payment beyond the network's contract rate. All payment for services must come either from the insurance company or a third party acting on behalf of the insurance company.

If you are accepted as a participating provider, the network may not offer you any financial incentives to limit medically necessary services. You are also required to post the toll-free number prominently in your office for anyone who wants to send a complaint about a network's operations.

You have the following additional rights and protections under state law:

  • You may appeal an adverse determination for pre-authorization, concurrent review, retrospective review, or other network coverage decisions. A network may never terminate or non-renew your contract or otherwise retaliate against you for filing an appeal or a complaint on behalf of the employee.
  • The network must give you written notice before conducting economic profiling or utilization management studies comparing your history of care to that of any other provider.
  • You have the right to review any information used in the network's credentialing process, correct any errors, and learn the status of any pending application.

Leaving the Network

Except in cases of fraud, suspension of a medical license, or possible imminent harm to a patient, the network must provide 90 days’ prior notice of termination of your network contract. You may appeal the termination within 30 days of receiving notice.

You may leave the network for any reason after providing 90 days’ advance written notice. If you ask to leave the network, the network must continue to reimburse you for up to 90 days for care you provide to patients who have acute or life-threatening conditions. You must show that disruption of care could potentially harm the patient.

Get Help from TDI

If you have a dispute involving workers' compensation benefits, call the Injured Employee Hotline at 1-800-252-7031.

You may send a complaint about workers' compensation claims, benefits, and workplace safety by calling any Division of Workers' Compensation field office at 1-800-252-7031.

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

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. It is not an endorsement by TDI of any service, product, or company.



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Last updated: 05/31/2016

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Translation by WorldLingo