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Workers' Compensation Health Care Networks

(July 2017)

(En Español) (PDF)

Information for Employees | Information for Employers | Information for Doctors and Hospitals | Get Help from TDI

Workers' compensation health care networks contract with doctors and hospitals to treat injured employees. If your employer participates in a workers’ compensation network, you must use doctors, hospitals, and other health care providers in the network to get care for a work-related injury. The only exception is for emergencies or if the network approves a referral to an out-of-network provider.

Overview

The Texas Department of Insurance (TDI) certifies and regulates workers’ compensation 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

Workers’ compensation networks are similar to managed care plans like health maintenance organizations (HMOs) and preferred provider plans. 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 in-network doctors in the approved service area. There are exceptions for emergencies or for employees who have prior approval to go to an out-of-network doctor.

Injured Employees must choose a treating doctor from the network's list. If an injured employee has existing coverage with a health maintenance organization (HMO) and has an existing primary care physician (PCP), the employee may ask the network for permission to use the existing HMO PCP. The HMO PCP must agree to the network's terms, and the workers’ compensation network must approve the doctor in advance.

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 workers’ compensation 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 approved medically necessary 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 in the service area (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 in the service area (the area is expanded to 75 miles for specialty services).

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

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 and your employer, or the company will assume that you do. Never lie about where you live to avoid a network's rules or to transfer to another network or doctor. This may result in the insurance company denying your claim.

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 within 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.

If the network denies your appeal. you have the right to ask for a review by an independent review organization. If your condition is life-threatening or relates to a medical interlocutory order, you may 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 change treating doctors. You must choose your new doctor from the network's list of treating doctors. You must tell the network, but the network may not deny the change. If you want to change doctors again, you must get approval from the network.
  • 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 may 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 complain to TDI. You may file a complaint through our website, or call the Consumer Help Line to learn how to file a complaint.

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 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 their first day of employment. 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 must 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 must also 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 may 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 with acute or life-threatening conditions. You must show that disruption of care might 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: 08/09/2017

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