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RULE §10.62Dispute Resolution for Employee Requirements Related to In-Network Care

(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.

Source Note: The provisions of this §10.62 adopted to be effective December 5, 2005, 30 TexReg 8099; amended to be effective August 2, 2022, 47 TexReg 4534

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