| (a) The employees of an employer who elects to contract
with an insurance carrier for network health care services, and who
live within the network's service area, must obtain medical treatment
for a compensable injury from in-network providers, except as provided
in Insurance Code §1305.006(1) and (3), concerning Insurance
Carrier Liability for Out-of-Network Health Care; subsection (e)(1),
(3), and (4) of this section; and the rules of the Division of Workers'
Compensation.
(b) An employee is presumed to live at the physical
address he or she has represented to the employer as his or her address
or, if the employee no longer works for the employer, the physical
address of record on file with the insurance carrier.
(c) At any time after the receipt of the notice of
network requirements, an employee who no longer lives at the physical
address described in subsection (b) of this section, or who otherwise
asserts that he or she does not live in the network's service area,
may notify the insurance carrier and request a review under §10.62
of this title (relating to Dispute Resolution for Employee Requirements
Related to In-Network Care).
(d) An employee who does not live within a network's
service area may choose to participate in a network established by
the insurance carrier or with which the insurance carrier has a contract
upon mutual agreement between the employee and insurance carrier.
(e) An employee who is found to have fraudulently claimed
to live outside the network's service area or made an intentional
misrepresentation regarding where he or she lives and receives health
care outside the network's service area may be liable for payment
for that health care.
(f) An insurance carrier that establishes or contracts
with a network is liable for in-network health care for a compensable
injury that is provided to an injured employee in accordance with
Insurance Code Chapter 1305, concerning Workers' Compensation Health
Care Networks, and out-of-network care as follows:
(1) emergency care;
(2) health care provided to an injured employee who
does not live within the service area of any network established by
the insurance carrier or with which the insurance carrier has a contract;
(3) health care provided by an out-of-network provider
pursuant to a referral from the injured employee's treating doctor
that has been approved by the network as follows:
(A) if an injured employee's treating doctor requests
a referral to an out-of-network provider for medically necessary health
care services that are not available from network providers, the network
must approve or deny a referral to an out-of-network provider within
the time appropriate under the circumstances, but, under any circumstance,
not later than seven days after the date the referral is requested;
(B) if the network denies the referral request under
subsection (a) of this section because the requested service is available
from network providers, the employee may file a complaint in accordance
with the network's complaint process under Insurance Code §1305.402,
concerning Complaint Initiation and Initial Response; Deadlines for
Response and Resolution, and §10.121 of this title (relating
to Complaints; Deadlines for Response and Resolution);
(C) if the network denies the referral request under
subparagraph (A) of this paragraph because the specialist referral
is not medically necessary, the employee may file a request for independent
review as described in §10.104 of this title (relating to Independent
Review of Adverse Determination); and
(4) health care services provided to an injured employee
before the employee received the notice of network requirements and
the employee information for the appropriate network and service area
under Insurance Code §1305.005, concerning Participation in Network;
Notice of Network Requirements, and §10.60 of this title (relating
to Notice of Network Requirements; Employee Information).
|
