SUBCHAPTER A GENERAL PROVISIONS
- Texas Section 1305.001 - Short Title
This chapter may be cited as the Workers' Compensation Health Care Network Act. Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02,...
- Texas Section 1305.002 - Purpose
The purpose of this chapter is to: (1) authorize the establishment of workers' compensation health care networks for the provision of workers' compensation medical benefits;...
- Texas Section 1305.003 - Limitations On Applicability
(a) This chapter does not affect the authority of the division of workers' compensation of the department to exercise the powers granted to the division...
- Texas Section 1305.004 - Definitions
(a) In this chapter, unless the context clearly indicates otherwise: (2) "Affiliate" means a person that directly, or indirectly through one or more intermediaries, controls...
- Texas Section 1305.005 - Participation In Network; Notice Of Network Requirements
(a) An employer that elects to provide workers' compensation insurance coverage under the Texas Workers' Compensation Act may receive workers' compensation health care services for...
- Texas Section 1305.006 - Insurance Carrier Liability For Out-of-network Health Care
An insurance carrier that establishes or contracts with a network is liable for the following out-of-network health care that is provided to an injured employee:...
- Texas Section 1305.007 - Rules
The commissioner may adopt rules as necessary to implement this chapter. Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September...
SUBCHAPTER B CERTIFICATION
- Texas Section 1305.008 - Administrator Certificate Of Authority Required
A person that performs the functions of an administrator under Chapter 4151 must hold a certificate of authority issued under that chapter to provide those...
- Texas Section 1305.051 - Certification Required
(a) A person may not operate a workers' compensation health care network in this state unless the person holds a certificate issued under this chapter...
- Texas Section 1305.052 - Certificate Application
(a) A person who seeks to operate as a workers' compensation health care network shall apply to the department for a certificate to organize and...
- Texas Section 1305.053 - Contents Of Application
Each certificate application must include: (1) a description or a copy of the applicant's basic organizational structure documents and other related documents, including organizational charts...
- Texas Section 1305.054 - Action On Application; Renewal Of Certification
(a) The commissioner shall approve or disapprove an application for certification as a network not later than the 60th day after the date the completed...
- Texas Section 1305.055 - Use Of Certain Insurance Terms By Network Prohibited
A network is not an insurer and may not use in the network's name or informational literature the word "insurance," "casualty," "surety," or "mutual" or...
SUBCHAPTER C GENERAL POWERS AND DUTIES OF WORKERS' COMPENSATION HEALTH CARE NETWORKS
- Texas Section 1305.056 - Restraint Of Trade; Application Of Certain Laws
(a) A network that contracts with a provider or providers practicing individually or as a group is not, because of the contract or arrangement, considered...
- Texas Section 1305.101 - Providing Or Arranging For Health Care
(a) Except for emergencies and out-of-network referrals, a network shall provide or arrange for health care services only through providers or provider groups that are...
- Texas Section 1305.102 - Management Contracts
(a) A network may not enter into a contract with another entity for management services unless the proposed contract is first filed with the department...
- Texas Section 1305.103 - Treating Doctor; Referrals
(a) A network shall determine the specialty or specialties of doctors who may serve as treating doctors. (b) For each injury, an injured employee shall...
- Texas Section 1305.104 - Selection Of Treating Doctor
(a) An injured employee is entitled to the employee's initial choice of a treating doctor from the list provided by the network of all treating...
- Texas Section 1305.105 - Treatment By A Primary Care Physician Or Provider Under Chapter 843; Recommendations Regarding Use Of Preferred Provider Plan
(a) Notwithstanding any other provision of this chapter, an injured employee required to receive health care services within a network may select as the employee's...
- Texas Section 1305.106 - Payment Of Health Care Provider
Notwithstanding any other provision of this chapter, an insurance carrier shall pay, reduce, deny, or determine to audit, a claim for services provided through a...
SUBCHAPTER D CONTRACTING PROVISIONS
- Texas Section 1305.107 - Telephone Access
(a) Each network shall have appropriate personnel reasonably available through a toll-free telephone service at least 40 hours per week during normal business hours, in...
- Texas Section 1305.151 - Transfer Of Risk
A contract under this subchapter may not involve a transfer of risk. Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff....
- Texas Section 1305.152 - Network Contracts With Providers
(a) A network shall enter into a written contract with each provider or group of providers that participates in the network. A provider contract under...
- Texas Section 1305.153 - Provider Reimbursement
(a) The amount of reimbursement for services provided by a network provider is determined by the contract between the network and the provider or group...
- Texas Section 1305.154 - Network-carrier Contracts
(a) Except for emergencies and out-of-network referrals, a network may provide health care services to employees only through a written contract with an insurance carrier....
- Texas Section 1305.1545 - Restrictions On Payment And Reimbursement
(a) An insurance carrier or administrator may not reimburse a doctor or other health care provider, an institutional provider, or an organization of doctors and...
SUBCHAPTER E FINANCIAL REQUIREMENTS
- Texas Section 1305.155 - Compliance Requirements
(a) An insurance carrier that becomes aware of any information that indicates that the network, any management contractor, or any third party to which the...
SUBCHAPTER F EXAMINATIONS
- Texas Section 1305.201 - Network Financial Requirements
(a) Each network shall prepare financial statements in accordance with generally accepted accounting standards, which must include adequate provisions for liabilities, including incurred but not...
- Texas Section 1305.251 - Examination Of Network
(a) As often as the commissioner considers necessary, the commissioner or the commissioner's designated representative may review the operations of a network to determine compliance...
SUBCHAPTER G PROVISION OF SERVICES BY NETWORK; QUALITY IMPROVEMENT PROGRAM
- Texas Section 1305.252 - Examination Of Provider Or Third Party
If requested by the commissioner or the commissioner's representative, each provider, provider group, or third party with which the network has contracted to provide health...
- Texas Section 1305.301 - Network Organization; Service Areas
(a) The chief executive officer, operations officer, or governing body of a network is responsible for: (1) the development, approval, implementation, and enforcement of: (A)...
- Texas Section 1305.302 - Accessibility And Availability Requirements
(a) All services specified by this section must be provided by a provider who holds an appropriate license, unless the provider is exempt from license...
- Texas Section 1305.303 - Quality Of Care Requirements
(a) A network shall develop and maintain an ongoing quality improvement program designed to objectively and systematically monitor and evaluate the quality and appropriateness of...
SUBCHAPTER H UTILIZATION REVIEW
- Texas Section 1305.304 - Guidelines And Protocols
Each network shall adopt treatment guidelines, return-to-work guidelines, and individual treatment protocols. The treatment guidelines and individual treatment protocols must be evidence-based, scientifically valid, and...
- Texas Section 1305.351 - Utilization Review In Network
(a) The requirements of Chapter 4201 apply to utilization review conducted in relation to claims in a workers' compensation health care network. In the event...
- Texas Section 1305.353 - Notice Of Certain Utilization Review Determinations; Preauthorization Requirements
(a) The entity performing utilization review shall notify the employee or the employee's representative, if any, and the requesting provider of a determination made in...
- Texas Section 1305.354 - Reconsideration Of Adverse Determination
(a) A utilization review agent shall maintain and make available a written description of the reconsideration procedures involving an adverse determination. The reconsideration procedures must...
- Texas Section 1305.355 - Independent Review Of Adverse Determination
(a) The utilization review agent shall: (1) permit the employee or person acting on behalf of the employee and the employee's requesting provider whose reconsideration...
SUBCHAPTER I COMPLAINT RESOLUTION
- Texas Section 1305.356 - Contested Case Hearing On And Judicial Review Of Independent Review
(a) A party to a medical dispute that remains unresolved after a review under Section 1305.355 is entitled to a contested case hearing. A hearing...
- Texas Section 1305.401 - Complaint System Required
(a) Each network shall implement and maintain a complaint system that provides reasonable procedures to resolve an oral or written complaint. (b) The network may...
- Texas Section 1305.402 - Complaint Initiation And Initial Response; Deadlines For Response And Resolution
(a) If a complainant notifies a network of a complaint, the network, not later than the seventh calendar day after the date the network receives...
- Texas Section 1305.403 - Record Of Complaints
(a) Each network shall maintain a complaint and appeal log regarding each complaint. The commissioner shall adopt rules designating the classification of network complaints under...
- Texas Section 1305.404 - Retaliatory Action Prohibited
A network may not engage in any retaliatory action against an employer or employee because the employer or employee or a person acting on behalf...
SUBCHAPTER J EMPLOYEE INFORMATION AND RESPONSIBILITIES
- Texas Section 1305.405 - Posting Of Information On Complaint Process Required
(a) A contract between a network and a provider must require the provider to post, in the provider's office, a notice to injured employees on...
SUBCHAPTER K EVALUATION OF NETWORKS; CONSUMER REPORT CARD
- Texas Section 1305.451 - Employee Information; Responsibilities Of Employee
(a) An insurance carrier that establishes or contracts with a network shall provide to employers, and the employer shall provide to its employees, an accurate...
- Texas Section 1305.501 - Evaluation Of Networks
In accordance with the research duties assigned to the group under Chapter 405, Labor Code, the group shall, in accordance with the requirements adopted under...
- Texas Section 1305.502 - Consumer Report Cards
(a) The group shall develop and issue an annual informational report card that identifies and compares, on an objective basis, the quality, costs, health care...
SUBCHAPTER L DISCIPLINARY ACTIONS
- Texas Section 1305.503 - Confidentiality Requirements
(a) As necessary to implement this subchapter, the department may access information from an executive agency that is otherwise confidential under any law of this...
- Texas Section 1305.551 - Determination Of Violation; Notice
(a) If the commissioner determines that a network, insurance carrier, or any other person or third party operating under this chapter, including a third party...
- Texas Section 1305.552 - Disciplinary Actions
If under Section 1305.551 the commissioner determines that a network, insurance carrier, or other person or third party described under Section 1305.551 has violated or...