| (a) An insurance carrier that establishes or contracts
with a network must deliver to the employer, and the employer or carrier,
as applicable under subsection (g) of this section, must deliver to
the employer's employees in the manner and at the times prescribed
by Insurance Code §1305.005, concerning Participation in Network;
Notice of Network Requirements:
(1) the notice of network requirements and employee
information required by Insurance Code §1305.005 and §1305.451,
concerning Employee Information; Responsibilities of Employee, and
this section; and
(2) the employee acknowledgment form described by Insurance
Code §1305.005 and this section.
(b) An employee who lives within the service area of
a network and who is being treated by a non-network provider for an
injury that occurred before the employer's insurance carrier established
or contracted with the network may:
(1) select a network treating doctor from the list
of contracted doctors who contracted with the workers' compensation
network; or
(2) request a doctor who the employee selected, prior
to the injury, as the employee's HMO primary care physician or provider
under Insurance Code Chapter 843, concerning Health Maintenance Organizations.
(c) The carrier must provide to the employee all information
required by Insurance Code §1305.451. The notice must include
an employee acknowledgment form and comply with all requirements under
subsections (d) - (i) of this section, as applicable.
(d) The notice of network requirements and employee
acknowledgment form:
(1) must be in English, Spanish, and any other language
common to 10 percent or more of the employer's employees;
(2) must be in a readable and understandable format
that meets the plain language requirements under §10.63 of this
title (relating to Plain Language Requirements); and
(3) may be in an electronic format as long as a paper
version is available upon request.
(e) The insurance carrier and employer may use an employee
acknowledgment form that complies with this section or a sample acknowledgment
form that may be obtained from the department's website.
(f) The employee acknowledgment form must include:
(1) a statement that the employee has received information
that describes what the employee must do to receive health care under
workers' compensation insurance;
(2) a statement that if the employee is injured on
the job and lives in the service area described in the information,
the employee understands that:
(A) the employee:
(i) must select a treating doctor from the list of
doctors who contracted with the workers' compensation network; or
(ii) ask the employee's HMO primary care physician
to agree to serve as the employee's treating doctor; and
(iii) must obtain all health care and specialist referrals
for a compensable injury through the treating doctor except for emergency
services;
(B) the network provider will be paid by the insurance
carrier and will not bill the employee for a compensable injury; and
(C) if the employee seeks health care, other than emergency
care, from someone other than a network provider without network approval,
the insurance carrier may not be liable, and the employee may be liable,
for payment for that health care;
(3) separate lines for the employee to fill in the
date and employee's signature, printed name, and where the employee
lives;
(4) a separate line that indicates the name of the
employer; and
(5) a separate line that indicates the name of the
network.
(g) The employer must obtain a signed employee acknowledgment
form from each employee, and a carrier required to provide employee
information to an employee under Insurance Code §1305.103(c),
concerning Treating Doctor; Referrals, and subsection (b) of this
section must obtain a signed employee acknowledgment form from that
employee. For purposes of this subsection, an employer or carrier,
as applicable, may obtain an acknowledgment of the notice required
under this section through electronic means from an employee who makes
an electronic signature in accordance with applicable law.
(h) The notice of network requirements must comply
with Insurance Code §1305.005 and §1305.451 and include:
(1) a statement that the entity providing health care
to employees is a certified workers' compensation health care network;
(2) the network's toll-free number and address for
obtaining additional information about the network, including information
about network providers;
(3) a description and map of the network's service
area, with key and scale, that clearly identifies each county or ZIP
code area or any parts of a county or ZIP code area that are included
in the service area;
(4) a statement that an employee who does not live
within the network's service area may notify the carrier as described
under §10.62 of this title (relating to Dispute Resolution for
Employee Requirements Related to In-Network Care);
(5) a statement that an employee who asserts that he
or she does not currently live in the network's service area may choose
to receive all health care services from the network during the pendency
of the insurance carrier's review under §10.62 of this title
and the pendency of the department's review of a complaint; and the
employee may be liable, and the carrier may not be liable, for payment
for health care services received out of network if it is ultimately
determined that the employee lives in the network's service area;
(6) a statement that, except for emergency services,
the employee must obtain all health care and specialist referrals
through the employee's treating doctor;
(7) an explanation that network providers have agreed
to look only to the network or insurance carrier and not to employees
for payment of providing health care for a compensable injury, except
as provided by paragraph (8) of this subsection;
(8) a statement that if the employee obtains health
care from non-network providers without network approval, except for
emergency care, the insurance carrier may not be liable, and the employee
may be liable, for payment for that health care;
(9) information about how to obtain emergency care
services, including emergency care outside the service area, and after-hours
care;
(10) a list of the health care services for which the
insurance carrier or network requires preauthorization or concurrent
review;
(11) an explanation regarding continuity of treatment
in the event of the termination from the network of a treating doctor;
(12) a description of the network's complaint system,
including:
(A) a statement that an employee must file complaints
with the network regarding dissatisfaction with any aspect of the
network's operations or with network providers;
(B) any deadline for the filing of complaints, provided
that the deadline may not be less than 90 days after the date of the
event or occurrence that is the basis for the complaint;
(C) a single point of contact within the network for
receipt of complaints, including the address and email address of
the contact; and
(D) a statement that the network is prohibited from
retaliating against:
(i) an employee, employer, or person acting on behalf
of the employee or employer if the employee, employer, or person acting
on behalf of the employee or employer files a complaint against the
network or appeals a decision of the network; or
(ii) a provider if the provider, on behalf of an employee,
reasonably files a complaint against the network or appeals a decision
of the network; and
(E) a statement explaining how an employee may file
a complaint with the department as described under §10.122 of
this title (relating to Submitting Complaints to the Department);
(13) a summary of the insurance carrier's or network's
procedures relating to adverse determinations and the availability
of the independent review process;
(14) a list of network providers updated at least quarterly,
including:
(A) the names and addresses of network providers grouped
by specialty. Treating doctors must be identified and listed separately
from specialists. Providers who are authorized to assess maximum medical
improvement and render impairment ratings and providers who provide
a telehealth service, telemedicine medical service, or teledentistry
dental service must be clearly identified;
(B) a statement of limitations of accessibility and
referrals to specialists; and
Cont'd... |
