The Texas Department of Insurance regulates Texas Workers' Compensation Health Care Networks. These networks provide health care services to injured employees through certified health care networks. The MCQA office is responsible for the certification and regulation of the health care networks. In Texas, an employer may elect to use, but is not required to use, a certified workers' compensation network.
Information for Injured Employees
- How do I find a certified WCNet?
- How do I request a review by an IRO?
- Return to work program
- Notify TDI of any communication you receive from a network about complaint contact changes
- More information for injured employees
Information for Carriers/Networks
- Do I need to become a certified WCNet?
- How do I become a certified WCNet?
- What are my responsibilities as a certified WCNet?
- Contract Requirements
- How do I file a network configuration or modification?
- Subsequent Filings
- Delegation Information
- What happens if a complaint is filed against me?
- Annual Quality Improvement (QI) Reports
- Helpful tools for reviewing your network prior to examination
- Return to work program
Rules and Regulations
Below you will find links to county maps and a current list of the certified WCNets in Texas as well as other useful information. Whether you know what WCNet you are looking for or just doing some research, the links provided below will help you find what you need.
- List of certified Workers' Compensation Networks
- Certified WCNet County Search
- All Network Coverage Map
If you are an organization formed as a health care provider network to provide health care services to injured employees, you must be certified by the Texas Department of Insurance to operate as a certified WCNet. A WCNet must be certified in accordance with Chapter 1305, Texas Insurance Code.
In this section you will find links to the Workers' Compensation Health Care Network application, associated checklists, and other useful information.
Original application - Complete all sections and fields in the Workers' Compensation Health Care Network Application (LHL705); submit all exhibits listed in the section titled "required exhibits for an original application"; and submit $5,000 filing fee, payable to the Texas Department of Insurance, with the application.
- Applicant Fingerprint Instructions - all applicants for licensure must comply with fingerprint requirements.
- What is an access plan
- WCNet access plan checklist
Material modifications to network configuration - material changes to physician and provider network require the department's approval prior to implementing the modification. Complete all fields in Sections 1, 2, and 3 of the Workers' Compensation Health Care Network Application (LHL705). If applicable, complete any field in the application form that is no longer current as stated in the original or the last application that the network submitted. Submit all exhibits listed in the section titled “required exhibits for material modifications to network configuration.”
Modifications (reductions or expansions) - modifications to the service area require the department's approval prior to implementing the modification. Complete all fields in Sections 1, 2, and 3 of the Workers' Compensation Health Care Network Application (LHL705). If applicable, complete any field in the application form that is no longer current as stated in the original or the last application that the network submitted. Submit all exhibits listed in the section titled “required exhibits for modifications to service area.”
Changes to application exhibits (subsequent filings)
After certification, a network is required to file any information that amends, supplements, or replaces the items previously filed with the department. This must be done no later than 30 days prior to implementation. Several exhibits must be filed for approval before implementation and others are filed for information. Complete all fields in Sections 1, 2, and 3 of the Workers' Compensation Health Care Network Application (LHL705). If applicable, complete any field in the application form that is no longer current as stated in the original or the last application that the network submitted. If the network submits a subsequent filing, the network must fill out the exhibits list titled "changes to application exhibits (subsequent filings)" to identify the exhibits the network is submitting for this purpose.
What are my responsibilities as a certified WCNet?
A certified WCNet is responsible for arranging health care services for injured employees 24 hours a day, seven days a week. A certified WCNet must arrange these services within a certain mileage radii and within no later than 21 days. For additional information and listing of a certified WCNet's responsibilities please see Chapter 10 of the Texas Administrative Code and Chapter 1305 of Texas Insurance Code. This information has been provided as a courtesy and is not inclusive of all and/or other responsibilities a certified WCNet may be required to perform. This does not exempt a certified WCNet/entity from complying with all requirements in the Texas Insurance Code, Texas Administrative Code, and all applicable rules and regulations.
WCNet Delegation Information
A carrier may contract to delegate a certified WCNet, management contractor, or third party administrator (TPA) to perform functions related to the operation of a quality improvement program as defined by 28 TAC §10.81 and credentialing. Texas Insurance Code §1305.154 and 28 TAC §§10.41- 10.42 lists required contract provisions. While a carrier may delegate functions, it is ultimately responsible for ensuring that all delegated functions are performed in accordance with applicable statutes and rules.
A carrier may delegate "medical case management". As of January 1, 2007, case managers are required to be certified by an accrediting organization such as the National Commission for Certifying Agencies (NCCA), the American Board of Nursing Specialties, or another national accrediting agency with similar standards. Case managers must be certified in at least one of the following: case management; case management administration; rehabilitation case management; continuity of care; disability management; or occupational health. For additional information see 28 TAC §10.81. In compliance with Labor Code §413.021(a), a claims adjuster may not serve as a case manager.
Return to Work Program
A return to work program provides a mechanism to encourage employers and employees to return to work as soon as possible and medically appropriate after injury or illness. Statistics indicate that a return to work program is a valuable tool to help control workers' compensation costs. Return to work is a responsibility shared by employers, employees, health care providers, insurance carriers, and Workers' Compensation Networks. The return to work guidelines can be found at 28 TAC Section 137.10.
What happens if a complaint is filed against a WC Network?
If a complaint is filed against a Workers' Compensation (WC) carrier, carrier representative (carrier), or Workers' Compensation Network (WCNet), the department will send an opening letter along with a copy of the complaint to the carrier or WCNet. The carrier or WCNet must provide a written response no later than the date provided in TDI's request.
Once the department receives the response from the carrier or WCNet, the department will review the response to see if the response has complied with the department's rules and regulations. Based on the department's review of the carrier's or WCNet's response, additional documentation may be requested.
Annual Quality Improvement Reports
Each certified WCNet is required to submit annual quality improvement (QI) reports to the department by March 1. The QI work plan should be the foundation for the QI annual report. The network's annual QI report should include:
- Completed activities;
- Trending of clinical and service goals;
- Analysis of program performance;
- Conclusions regarding the effectiveness of the program;
- Employee satisfaction;
- Provider satisfaction;
- Complaint and appeals for the past year;
- Contract monitoring and oversight, as applicable;
- Provider billing and payment processes, as applicable;
- Utilization review and retrospective review processes, as applicable;
- Credentialing issues;
- Employee services such as after hours telephone access;
- Return to work processes and outcomes;
- Medical case management outcomes; and
- Any significant miscellaneous issues.
When the annual QI report is received by the department, it is compared to any previously submitted QI reports; previously submitted QI work plans; and complaints received by the department regarding WCNet issues. The reports become a baseline for the certified networks for future monitoring purposes. The annual QI reports are utilized to determine where additional education or regulation by the department is needed, as well as to assess the priority of WC Network Quality Assurance examinations.
A sample of the narrative and reporting requirements for the annual QI report is available on the TDI website at www.tdi.texas.gov/forms/finmcqa/sn008-0617.pdf.
Reviewing Your Network Prior to an Examination
The department may examine a certified Workers' Compensation Health Care Network to determine its compliance with TIC, Chapter 1305 and 28 TAC, Chapter 10. This examination may include on site reviews. A WCNet may be examined as often as the commissioner deems necessary.
A WCNet is notified of the department's decision to open an exam in writing prior to the scheduled exam date. This notification will include a list of documents necessary to conduct an examination. The exam is conducted by the department's Quality of Care Examination Section.
More WCNet Information
- Workers' Compensation News
- Information for Employers
- Information for Providers
- Information for Injured Employees
- Datacalls and Registrations
- WCNet Forms
- Data on Current Providers in the Texas Workers' Compensation System (Word)
- WCNet for Injured Employees
- TDI News
- Division of Workers' Compensation (DWC) Homepage
- Disability Management