Workers’ compensation pays for medical care and some lost wages for employees who have work-related injuries or illnesses. Workers’ compensation health care networks are one way that employers can provide workers’ compensation coverage for their employees.
The Texas Department of Insurance (TDI) certifies workers’ compensation networks. A list of certified networks is on our website.
TDI publishes a workers’ compensation network report card each year. The report card compares networks on employees’ satisfaction with care, health outcomes, and health care costs. You can read the report card on the Division of Workers' Compensation web page.
How workers’ compensation networks work
Workers' compensation networks are a type of managed care plan. Employers who choose to use a workers’ compensation network buy coverage from an insurance company that either contracts directly with doctors and hospitals, or contracts with a certified network, for a panel of doctors and hospitals to treat employees with work-related injuries and illnesses. Self-insured employers and political subdivisions can also set up networks or contract with existing networks.
The insurance company pays for all medically necessary care for a work injury or illness. It also pays any income and disability benefits due the employee. The insurance company may review treatments to decide whether they’re medically necessary. If it decides that a treatment isn’t medically necessary, the injured employee or the doctor can ask the company to reconsider.
Networks operate in geographic service areas, usually by county. Employees who live in the service area 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. Injured employees who don’t live in the service area aren’t required to use network providers. The insurance company must still pay for their care, however.
What injured employees in a network need to know
If you're injured on the job, you must:
- report your injury to your employer; and
- file a claim with our Division of Workers' Compensation (DWC). Call DWC at 800-252-7031 if you have questions about filing your claim.
You’ll choose a treating doctor from the network's provider list. Your treating doctor will oversee the care for your work injury. If your regular health plan is with 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 contract terms, and the network must approve the doctor in advance.
If you were injured before your employer started to use a workers’ compensation network, you must choose a treating doctor from the network’s provider list. You have 14 days from the date you got notice that you’re in a network to choose a treating doctor. If you don’t choose a treating doctor in that time, the network will assign one to you.
You must get a referral from your treating doctor before going to a specialist.
Network providers may not bill you for medically necessary care for a work injury. But if you go to a doctor or hospital outside your network without approval, the network may deny payment and you might have to pay the bill yourself. There are exceptions for emergencies and other situations.
What networks must do
Networks must meet state standards. They must have enough doctors and hospitals to:
- treat employees 24 hours a day, seven days a week.
- provide hospital, psychiatric, physical therapy, and chiropractic services.
- provide services in urban areas within 30 miles from any point in the service area.
- provide services in rural areas within 60 miles from any point in the service area.
- have specialists within 75 miles from any point in the service area.
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.
Your employer must tell you you’re in a network
Your employer must give you a written notice that you’re in a workers’ compensation network when:
- the employer joins a network.
- you’re first hired.
- you report a work-related injury.
The notice will tell you the network's service area and the rules and procedures you must follow.
Your employer will ask you to sign a form saying you got the notice. You must follow the network's rules even if you don’t sign the form.
If you don't live in the network's service area, tell your employer. There might be different rules you have to follow.
Your rights in a network
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 to ask for an external review.
You also have these rights:
- You may change treating doctors once without network 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.
- A network must arrange for medical services, including referrals to specialists, within 21 days after you ask.
- You may complain if you think your network did something wrong. First, complain to the network. The network has seven days to tell you it got your complaint. It then has 30 days to resolve it.
- A network may not retaliate against you if you appeal or complain about a network decision. A network also may not retaliate against your doctor or employer.
What employers need to know
Consider where your employees live before joining a workers’ compensation network. If you have employees in other parts of the state or in neighboring counties, they might not be in the network's service area. Employees who don't live in the service area aren’t required to use network providers.
Ask the network if you’re not sure whether an employee must use network providers.
You must tell your employees that they’re in a network
You must tell your employees in writing. The notice must include:
- a list of the health care services that require prior approval or a review to decide whether they’re medically necessary.
- descriptions of network rules and procedures, including how employees can appeal network decisions and file complaints.
- the network's service area.
- a list of network providers.
The notice must be in English, Spanish, and any language spoken by 10 percent or more of your employees. You must give the notice to employees when network coverage takes effect. You must give it to new employees by their third day on the job. You must give employees the notice again when they report a work injury or illness.
If you don't give the notice to an employee, the employee isn't required to follow the network's rules. You must ask employees to sign a form saying they got the notice. An employee must follow the network’s rules even if he or she doesn’t sign the form.
You must keep a copy of all acknowledgment forms and a record of how you delivered the notice. This can help if an employee says you didn’t give the notice.
You must keep a current list of network providers and give it to employees who ask for it. The network will update the list quarterly. You must also post notices in the workplace telling your employees that they’re covered by a network.
What doctors and hospitals need to know
Any licensed health care provider may apply to become a network provider. Each network has its own standards for accepting providers. A network can deny your application if it already has enough providers in its network.
Your requirements and rights as a network provider
You must follow the network's procedures, treatment guidelines, and return-to-work guidelines.
You may not bill an injured worker for any costs to treat a work injury or illness. This includes copays or amounts above your contract rate with the network.
Networks may not offer you financial incentives to limit medically necessary services.
You must post a notice in your office that tells employees how to file complaints about the network. The notice must include TDI’s phone number. It must also list all workers' compensation networks that you contract with. The network can give you a copy of the notice.
You also have these rights:
- You may appeal network coverage decisions. A network can’t cancel or not renew your contract or retaliate against you for appealing.
- The network must tell you in writing if it plans to compare your costs and history of care with that of any other provider.
- You may review the information the network used to decide on your application, correct any errors, and learn the status of a pending application.
Leaving the network
Except in cases of fraud, suspension of a medical license, or possible harm to a patient, the network must tell you 90 days before it ends your contract. You have 30 days to appeal.
If you want to leave a network, you must tell the network in writing 90 days in advance. The network must keep paying for care you’re giving patients with acute or life-threatening conditions for up to 90 days. You must show that stopping care might harm the patient.
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 Division of Workers' Compensation field office at 800-252-7031.