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What are my responsibilities as a WCNet provider?

The purpose of this webpage is to provide information about the statutory responsibilities of a WCNet-contracted health care provider.

Treating Doctors and Specialists

An employee who suffers a compensable injury will receive health care from either their treating doctor or a specialist.

A treating doctor provides health care to an employee for the employee's compensable injury. The treating doctor is responsible for making referrals to other network providers, and requesting referrals to out-of-network providers if medically necessary services are not available within the network. This includes referrals to specialists. Treating doctors also participate in the medical case management process as required by the network, including participation in return-to-work planning.

A specialist would provide health care to an injured employee who has suffered a compensable injury that would require a specific type of health care. The specialist is also required to coordinate the injured employee's health care with their treating doctor.

An injured employee with a chronic, life-threatening injury or chronic pain related to a compensable injury may apply to the network's medical director to use a non- primary care physician specialist that is in the network as the injured employee's treating doctor. This request must include information specified by the network, including, certification of the medical need provided by the specialist and it must be signed by the injured employee and the specialist interested in serving as the injured employee's treating doctor. To be eligible to serve as the injured employee's treating doctor, a specialist must agree to accept the responsibility to coordinate all of the injured employee's health care needs.

Posting of Complaint Notice

Physicians and providers who participate in a certified workers' compensation health care network have contractually agreed to post, in their office, a notice to employees on the process for resolving workers' compensation health care network complaints. The complaint notice must include the toll-free telephone number of the Texas Department of Insurance for filing a complaint and must list all workers' compensation health care networks with which the provider contracts.

Balance Billing

Physicians and providers who participate in a certified workers' compensation health care network have contractually agreed not to balance bill the injured employee for services related to the injury.

When a certified workers' compensation health care network authorizes a referral to an out-of-network provider because necessary care is not available within the network, the out-of-network provider has agreed to accept the workers' compensation health care network's fee schedule or will be bound by the Division of Workers' Compensation's fee schedule.

Except for emergency care, an injured employee who is required to use network physicians and providers but seeks care outside of the network without network authorization may be responsible for payment for the care received.

A physician or provider who is participating in a certified workers' compensation health care network and believes that claims are not being paid appropriately can file a complaint with the network using the network's complaint and appeal procedures or file a complaint with the Texas Department of Insurance.

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Last updated: 03/16/2015

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