(a) A network's contract with a carrier must include
the following:
(1) a description of the functions to be performed
by the network or its delegated entity, consistent with the requirements
of Insurance Code §1305.154(b), concerning Network-Carrier Contracts,
and the reporting requirements for each function;
(2) a statement that the network will perform all delegated
functions in full compliance with all requirements of the Workers'
Compensation Health Care Network Act, Insurance Code Chapter 1305,
concerning Workers' Compensation Health Care Networks; the Texas Workers'
Compensation Act, Labor Code Title 5, Subtitle A, concerning Workers'
Compensation; and the rules of the department and the Division of
Workers' Compensation;
(3) a provision that the contract:
(A) may not be terminated without cause by either party
without 90 days' prior written notice; and
(B) must be terminated immediately if cause exists;
(4) a hold-harmless provision stating that the network,
a management contractor, a third party to which the network delegates
a function, and the network's contracted providers are prohibited
from billing or attempting to collect any amounts from an employee
for health care services for compensable injuries under any circumstances,
including the insolvency of the carrier or the network;
(5) a statement that the carrier and the network retain
ultimate responsibility for ensuring that all delegated functions
and all management contractor functions are performed in accordance
with applicable statutes and rules, and that the contract may not
be construed to limit in any way the carrier's or network's responsibility,
including financial responsibility, to comply with all statutory and
regulatory requirements;
(6) a statement that the network's role is to provide
the services listed in Insurance Code §1305.154(b) as well as
any other services or functions the carrier delegates, including functions
delegated to a management contractor, subject to the carrier's oversight
and monitoring of the network's performance;
(7) a requirement that the network provide the carrier,
on at least a monthly basis and in a form that is usable for audit
purposes, the data necessary for the carrier to comply with reporting
requirements of the department and the Division of Workers' Compensation
of the department with respect to any services provided pursuant to
the carrier-network contract, including the following data:
(A) last name, first name, date of injury, date of
birth, sex, address, telephone number, claim number, and social security
number of each injured employee who is being served by the network,
and name and license number of the injured employee's treating doctor;
(B) initial date of health care services delivered
by the network for each employee; and
(C) any other data, as determined by the contract,
necessary to assure proper monitoring of functions delegated to the
network by the carrier;
(8) a requirement that the carrier, the network, any
management contractor, and any third party to which the network delegates
a function comply with a provision that requires the network to provide
to the insurance carrier and department the license number of a management
contractor or any delegated third party performing any function that
requires a license under the Insurance Code or another insurance law
of this state, including a license as a utilization review agent under
Insurance Code Chapter 4201, concerning Utilization Review Agents;
(9) a contingency plan under which the carrier would,
in the event of termination of the contract or a failure to perform,
reassume one or more functions of the network under the contract,
including functions related to:
(A) payment to providers and notification to employees,
as applicable;
(B) quality of care;
(C) utilization review;
(D) continuity of care, including a plan for identifying
and transitioning employees to new providers; and
(E) collecting and reporting of data necessary to comply
with the reporting requirements described in paragraph (7) of this
subsection;
(10) a provision that requires that any agreement by
which the network delegates any function to a third party be in writing,
and that such agreement require the delegated third party to be subject
to all the requirements under Insurance Code Chapter 1305 and this
chapter;
(11) a provision that requires the network to provide
to the department the license number of a management contractor or
any delegated third party performing any function that requires a
license under the Insurance Code or another insurance law of this
state, including a license as a utilization review agent under Insurance
Code Chapter 4201;
(12) an acknowledgment that:
(A) any management contractor or third party to whom
the network delegates a function must comply with this chapter and
other applicable statutes and rules, and that the management contractor
or third party is subject to the carrier's and the network's oversight
and monitoring of its performance; and
(B) if the management contractor or third party fails
to meet monitoring standards established to ensure that functions
delegated or assigned to the management contractor or third party
under the delegation contract are in full compliance with all statutory
and regulatory requirements, the carrier or network may cancel delegation
of any or all delegated functions;
(13) a requirement that the network and any management
contractor or third party to which the network delegates a function
provide all necessary information to allow the carrier to provide
the information required by §10.60 of this title (relating to
Notice of Network Requirements; Employee Information) to employers
or employees;
(14) a provision that requires the network to require
any third party with which it contracts, whether directly or through
another third party, to permit the Commissioner to examine at any
time any information the Commissioner believes is relevant to the
third party's financial condition or the ability of the network to
meet the network's responsibilities in connection with any function
the third party performs or that has been delegated to the third party.
(15) a requirement that if the network delegates the
complaint function, the delegate must:
(A) implement and maintain a complaint system in accordance
with requirements under Insurance Code §1305.401, concerning
Complaint System Required, and §10.120 of this title (relating
to Complaint System Required); and
(B) make the complaint log and complaint files available
to the carrier and the network upon request to the extent permitted
by law;
(16) a statement that the contract and any network
contract with a provider, management contractor, or other third party
must not be interpreted to involve a transfer of risk as defined under
Insurance Code §1305.004(a)(26), concerning Definitions;
(17) a statement that any network contract with a provider
or third party must allow the carrier to effect a contingency plan
in the event that the carrier is required to reassume functions from
the network as contemplated under Insurance Code §1305.155, concerning
Compliance Requirements;
(18) a statement that any network contract with a provider
or third party must comply with all applicable statutory and regulatory
requirements under federal and state law, including Insurance Code §1305.152,
concerning Network Contracts with Providers, and §10.42 of this
title (relating to Network Contracts with Providers); and
(19) a statement that if a network's delegate subdelegates
a network function, the delegate must first obtain the network's consent
to the subdelegation and have a delegation agreement that complies
with this section.
(b) Except for the functions described under Insurance
Code §1305.154(b) and §10.121 of this title (relating to
Complaints; Deadlines for Responses and Resolution), a network's authority
to perform a function under a network-carrier contract is conditioned
upon whether:
(1) the carrier has delegated the function to the network
by contract; and
(2) the network is appropriately licensed to perform
the function.
(c) A network must not act as a network for any entity
regarding an insurance plan being operated in violation of Insurance
Code §101.102, concerning Unauthorized Insurance Prohibited.
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