| (a) If an employee asserts that he or she does not
currently live in the network's service area, the employee may request
a review by contacting the insurance carrier and providing evidence
to support the employee's assertion.
(b) An insurance carrier must review the employee's
request for review, including any evidence provided by the injured
employee and any evidence collected by the insurance carrier, and
make a determination regarding whether the employee lives within the
network's service area or lives within the service area of any other
workers' compensation network contracted with or established by the
insurance carrier (alternate network). If an insurance carrier makes
a determination that the employee lives within the service area of
an alternate network, the insurance carrier must provide the employee
with the notice of network requirements as described under §10.60
of this title (relating to Notice of Network Requirements; Employee
Information) for the alternate network. Upon receipt of the notice
of network requirements, the employee must select a treating doctor
from the list of the alternate network's treating doctors in the network's
service area.
(c) Not later than seven calendar days after the date
the insurance carrier receives notice of the injured employee's request
for review, the insurance carrier must notify the employee, in writing,
of the carrier's determination. This notice must include a brief description
of the evidence the carrier considered when making the determination,
a copy of the carrier's determination, and a description of how an
employee may file a complaint regarding this issue with the department.
The insurance carrier must also send a copy of the carrier's determination
to the employee's employer.
(d) If an employee disagrees with the insurance carrier's
determination, the employee may file a complaint with the department
in accordance with §10.122 of this title (relating to Submitting
Complaints to the Department). To be considered complete, the employee's
complaint must include:
(1) the employee's contact information, including the
employee's name, current physical address, and telephone number;
(2) a copy of the insurance carrier's determination;
and
(3) any evidence the employee provided to the insurance
carrier for consideration.
(e) An injured employee who disputes whether he or
she lives within a network's service area may seek all medical care
from the network during the pendency of the insurance carrier's review
and the department's investigation of a complaint.
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