| (a) A network is not required to accept an application
for participation in the network from a health care provider that
otherwise meets the requirements specified in this chapter if the
network determines that the network has contracted with a sufficient
number of qualified health care providers, including health care providers
of the same license type or specialty.
(b) Provider contracts and subcontracts must include,
at a minimum, the following provisions:
(1) except as provided in Insurance Code §1305.451(b)(6),
concerning Employee Information; Responsibilities of Employee, a hold-harmless
clause stating that the provider and the provider network will not
bill or attempt to collect any amounts of payment from an employee
for health care services for compensable injuries under any circumstances,
including the insolvency of the insurance carrier or the network;
(2) a statement that the provider agrees to follow
treatment guidelines, return-to-work guidelines, and individual treatment
protocols adopted by the network pursuant to §10.83 of this title
(relating to Guidelines and Protocols) and the pharmacy closed formulary
adopted by the Division of Workers' Compensation under §134.540
of this title (relating to Requirements for Use of the Closed Formulary
for Claims Subject to Certified Networks), as applicable to an employee's
injury;
(3) a statement that the insurance carrier or network
may not deny treatment solely on the basis that a treatment for a
compensable injury in question is not specifically addressed by the
treatment guidelines used by the insurance carrier or network;
(4) a provision that the network will not engage in
retaliatory action, including termination of or refusal to renew a
contract, against a provider because the provider has, on behalf of
an employee, reasonably filed a complaint against, or appealed a decision
of, the network, or requested reconsideration or independent review
of an adverse determination;
(5) a continuity of treatment clause that states that:
(A) if a provider leaves the network, upon the provider's
request, the insurance carrier or network is obligated to continue
to reimburse the provider for a period not to exceed 90 days at the
contracted rate for care of an employee with a life-threatening condition
or an acute condition for which disruption of care would harm the
employee; and
(B) a dispute concerning continuity of care must be
resolved through the complaint resolution process under Insurance
Code Chapter 1305, Subchapter I, concerning Complaint Resolution,
and Subchapter G of this title (relating to Complaints);
(6) a clause regarding appeal by the provider of termination
of network provider status, except for termination due to contract
expiration, and applicable written notification to employees receiving
care regarding such a termination, including requirements that:
(A) the network must provide notice to the provider
at least 90 days before the effective date of a termination;
(B) the network must provide an advisory review panel
that consists of at least three providers of the same licensure and
the same or similar specialty as the provider;
(C) upon receipt of the written notification of termination,
a provider may request a review by the network's advisory review panel
not later than 30 days after receipt of the notification;
(D) the network must complete the advisory panel review
before the effective date of the termination;
(E) a network may not notify patients of the termination
until the earlier of the effective date of the termination or the
date the advisory review panel makes a formal recommendation;
(F) in the case of imminent harm to patient health,
suspension or loss of license to practice, or fraud, the network may
terminate the provider immediately and must notify employees immediately
of the termination; and
(G) if the provider terminates the contract, the network
must provide notification of the termination to employees receiving
care from the terminating provider. The network must give such notice
immediately upon receipt of the provider's termination request or
as soon as reasonably possible before the effective date of termination;
(7) a provision that requires the provider to post,
in the office of the provider, a notice to employees on the process
for resolving workers' compensation health care network complaints
in accordance with Insurance Code §1305.405, concerning Posting
of Information on Complaint Process Required. The notice must include
the department's toll-free telephone number for filing a complaint
and must list all workers' compensation health care networks with
which the provider contracts;
(8) a statement that the network agrees to furnish
to the provider, and the provider agrees to abide by, the list of
any treatments and services that require the network's preauthorization
and any procedures to obtain preauthorization;
(9) a statement that the contract and any subcontract
within the provider network must not be interpreted to involve a transfer
of risk as defined under Insurance Code §1305.004(a)(26), concerning
Definitions;
(10) a statement that the provider and any subcontracting
provider within the provider network must comply with all applicable
statutory and regulatory requirements under federal and state law;
(11) the schedule of fees that will be paid to the
contracting provider;
(12) a statement specifying whether the provider whose
specialty has been designated by the network as a treating doctor
agrees to be a network treating doctor and, if so, any additional
provisions applicable to the provider;
(13) a statement that billing by and payment to the
provider will be made in accordance with Labor Code §408.027,
concerning Payment of Health Care Provider, and other applicable statutes
and rules, including rules governing the billing and payment for certifications
of maximum medical improvement and impairment rating examinations;
(14) a statement that the provider specifically agrees
to provide treatment for injured employees who obtain workers' compensation
health care services through the network that is specifically identified
in the contract as a contracting party; and
(15) a statement that the provider will receive written
notice from the carrier if the carrier contests compensability of
an injury the provider is treating as required under Insurance Code §1305.153(e),
concerning Provider Reimbursement, including that the carrier may
not deny payment for services provided prior to the issuance of the
notice on the grounds that the injury was not compensable.
(c) An insurance carrier and a network may not use
any financial incentive or make a payment to a health care provider
that acts directly or indirectly as an inducement to limit medically
necessary services. The adoption of treatment guidelines, return-to-work
guidelines, and individual treatment protocols by a network under
Insurance Code §1305.304, concerning Guidelines and Protocols,
and §10.83(a) of this title (relating to Guidelines and Protocols)
is not a violation of this section.
(d) An insurance carrier or a network must provide
written notice to a network provider or group of network providers
before the carrier or network conducts economic profiling, including
utilization management studies comparing the provider to other providers,
or other profiling of the provider or group of providers.
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