Some employers provide workers' compensation coverage for their employees through workers' compensation health care networks. Workers’ compensation networks are a type of managed care plan. The networks contract with groups of doctors and hospitals to treat employees who have work-related injuries and illnesses.
The Texas Department of Insurance (TDI) certifies workers’ compensation networks. Networks must meet state standards, including having enough doctors and hospitals to provide health care services 24 hours a day.
If you’re in a workers’ compensation network:
- Read the notice your employer gives you. Your employer will give you a written notice explaining your rights in the network. The notice will also tell you any rules or procedures you must follow. You’ll get the notice when your employer joins a network, when you’re first hired, and again if you’re injured on the job. You must follow the network’s rules.
- Tell your employer if you don’t live in the network’s service area. Networks operate in geographic service areas, usually by county. If you live in the service area, you must use doctors and hospitals in the network for care related to a work injury or illness. If you don’t live in the service area, you don’t have to use network providers. Always tell the truth about where you live. If you get care from an out-of-network doctor, and the network later learns that you live in its service area, you might have to pay the bill yourself.
- Follow the network’s rules and procedures. Your employer will ask you to sign a form saying you got the notice with the network’s rules. You must follow the network's rules even if you don't sign the form. If you don't understand something in the notice, ask your employer or the network to explain.
- Report your injury. You must report a work-related injury to your employer within 30 days of the injury. You must also file a claim with TDI's Division of Workers' Compensation (DWC) within one year. To learn how to file a claim, call DWC at 800-252-7031.
- If you’re injured at work, choose a treating doctor. If you live in the network's service area, you must choose a treating doctor on the network’s provider list. You’ll get the provider list when your employer joins a network and again if you’re injured on the job. If you don't choose a treating doctor, the network will choose one for you. The treating doctor will oversee the care for your work injury. You may change treating doctors once without approval. You must tell the network, but it can’t deny the change. Your new doctor must be on the network’s provider list. If you want to change doctors again, you must first get approval from the network. If your regular health plan is a health maintenance organization (HMO), you can ask the network to let you use your primary care physician (PCP) as your treating doctor. Your PCP must agree to the network's terms, and the network must approve the doctor in advance.
Note: If your employer changes networks or your doctor leaves the network, you might have to choose a new treating doctor. Your employer will tell you what you need to do. - Use only doctors and hospitals in the network. You must use doctors and hospitals in the network for care related to a work injury or illness. There are exceptions for emergencies and for employees who get prior approval to go to an out-of-network doctor. If you need medically necessary care that’s not available in the network, the network must make sure that you’re able to get it.
- Get a referral from your treating doctor before going to a specialist. The network must approve or deny referrals to specialists within 21 days of the date of the referral.
Appealing treatment denials
If the network denies a treatment, you can ask it to reconsider. You must ask within 30 days of the denial. You, someone acting for you, or your doctor can ask. The network must decide on your appeal as soon as possible, but usually within 30 days. If the appeal is about a life-threatening condition, a continued hospital stay, or poststabilization care, the network must decide sooner.
If the network denies the treatment again, you can ask for a review by an independent review organization. The network will tell you how.
Getting help
If you have a dispute about workers' compensation benefits, call the Injured Employee Hotline at 800-252-7031.
If you have a complaint about workers' compensation claims, benefits, or workplace safety, call any DWC field office at 800-252-7031.
If you have questions or a complaint about other types of insurance, call our Help Line at 800-252-3439 or visit our website.