reglab/housing_qa huggingface dataset:
TX Ins Code § 1305.152 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1305 - Workers' Compensation Health Care Networks|Subchapter D. Contracting Provisions|Section 1305.152. Network Contracts With Providers

Sec. 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 this section is confidential and is not subject to disclosure as public information under Chapter 552, Government Code.(b)  A network is not required to accept an application for participation in the network from a health care provider who otherwise meets the requirements specified in this chapter for participation if the network determines that the network has contracted with a sufficient number of qualified health care providers.(c)  Provider contracts and subcontracts must include, at a minimum, the following provisions:(1)  a hold-harmless clause stating that the network and the network's contracted providers are prohibited from billing or attempting to collect any amounts from employees for health care services under any circumstances, including the insolvency of the insurance carrier or the network, except as provided by Section 1305.451(b)(6);(2)  a statement that the provider agrees to follow treatment guidelines adopted by the network under Section 1305.304, as applicable to an employee's injury;(3)  a continuity of treatment clause that states that if a provider leaves the network, 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;(4)  a clause regarding appeal by the provider of termination of provider status and applicable written notification to employees regarding such a termination, including provisions determined by the commissioner; and(5)  any other provisions required by the commissioner by rule.(d)  Continued care as described by Subsection (c)(3) must be requested by a provider.  A dispute involving continuity of care is subject to the dispute resolution process under Subchapter I.(e)  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.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.|
TX Ins Code § 1305.1545 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1305 - Workers' Compensation Health Care Networks|Subchapter D. Contracting Provisions|Section 1305.1545. Restrictions on Payment and Reimbursement

Sec. 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 health care providers on a discounted fee basis for services that are provided to an injured employee unless:(1)  the carrier or administrator has contracted with either:(A)  the doctor or other health care provider, institutional provider, or organization of doctors and health care providers; or(B)  a network that has contracted with the doctor or other health care provider, institutional provider, or organization of doctors and health care providers; and(2)  the doctor or other health care provider, institutional provider, or organization of doctors and health care providers has agreed to the contract and has agreed to provide health care services under the terms of the contract.(b)  A party to a carrier-network contract may not sell, lease, or otherwise transfer information regarding the payment or reimbursement terms of the contract without the express authority of and prior adequate notification to the other contracting parties.  This subsection does not affect the authority of the commissioner under this code to request and obtain information.(c)  An insurance carrier or administrator who violates this section:(1)  commits an unfair claim settlement practice in violation of Subchapter A, Chapter 542, Insurance Code; and(2)  is subject to administrative penalties under Chapters 82 and 84, Insurance Code.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.Amended by: Acts 2007, 80th Leg., R.S., Ch. 1176 (H.B. 472), Sec. 2.03, eff. September 1, 2007.|
TX Ins Code § 1305.201 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1305 - Workers' Compensation Health Care Networks|Subchapter E. Financial Requirements|Section 1305.201. Network Financial Requirements

Sec. 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 reported obligations relating to providing benefits or services.(b)  Each network shall file the financial statement under Subsection (a) with the department in the manner prescribed by commissioner rule.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.|
TX Ins Code § 1305.251 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1305 - Workers' Compensation Health Care Networks|Subchapter F. Examinations|Section 1305.251. Examination of Network

Sec. 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 with this chapter.  The review may include on-site visits to the network's premises.(b)  During on-site visits, the network must make available to the department all records relating to the network's operations.(c)  A network shall pay a fee to the department, in an amount set by the commissioner and in accordance with rules adopted by the commissioner, for the expenses of an examination conducted under this section or Section 1305.252 that:(1)  are incurred by the commissioner or under the commissioner's authority; and(2)  are directly attributable to that examination, including the actual salaries and expenses of the examiners directly attributable to that examination, as determined under rules adopted by the commissioner.(d)  Fees collected under this section shall be deposited to the credit of the Texas Department of Insurance operating account.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.Amended by: Acts 2007, 80th Leg., R.S., Ch. 188 (S.B. 1253), Sec. 2, eff. September 1, 2007.|
TX Ins Code § 1305.252 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1305 - Workers' Compensation Health Care Networks|Subchapter F. Examinations|Section 1305.252. Examination of Provider or Third Party

Sec. 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 care services or any other services delegated to the network by an insurance carrier shall make available for examination by the department that portion of the books and records of the provider, provider group, or third party that is relevant to the relationship with the network of the provider, provider group, or third party.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.|
TX Ins Code § 1305.301 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1305 - Workers' Compensation Health Care Networks|Subchapter G. Provision of Services by Network; Quality Improvement Program|Section 1305.301. Network Organization; Service Areas

Sec. 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)  administrative, operational, personnel, and patient care policies; and(B)  network procedures; and(2)  the development of any documents necessary for the operation of the network.(b)  Each network shall have a chief executive officer or operations officer who:(1)  is accountable for the day-to-day administration of the network; and(2)  shall ensure compliance with all applicable statutes and rules pertaining to the operation of the network.(c)  Each network shall have a medical director, who must be an occupational medicine specialist or employ or contract with an occupational medicine specialist, and who must be licensed to practice medicine in the United States.  The medical director shall:(1)  be available at all times to address complaints, clinical issues, and any quality improvement issues on behalf of the network;(2)  be actively involved in all quality improvement activities; and(3)  comply with the network's credentialing requirements.(d)  The network shall establish one or more service areas within this state.  For each defined service area, the network must:(1)  demonstrate to the satisfaction of the department the ability to provide continuity, accessibility, availability, and quality of services;(2)  specify the counties and zip code areas, or any parts of a county or zip code area, included in the service area; and(3)  provide a complete provider directory to all policyholders who have selected a network in the service area.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.|
TX Ins Code § 1305.303 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1305 - Workers' Compensation Health Care Networks|Subchapter G. Provision of Services by Network; Quality Improvement Program|Section 1305.303. Quality of Care Requirements

Sec. 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 care and services and to pursue opportunities for improvement.  The quality improvement program must include return-to-work and medical case management programs.(b)  The network's governing body is ultimately responsible for the quality improvement program.  The governing body shall:(1)  appoint a quality improvement committee that includes network providers;(2)  approve the quality improvement program;(3)  approve an annual quality improvement plan;(4)  meet at least annually to receive and review reports of the quality improvement committee or group of committees, and take action as appropriate; and(5)  review the annual written report on the quality improvement program.(c)  The quality improvement committee or committees shall evaluate the overall effectiveness of the quality improvement program as determined by commissioner rules.(d)  The quality improvement program must be continuous and comprehensive and must address both the quality of clinical care and the quality of services.  The network shall dedicate adequate resources, including adequate personnel and information systems, to the quality improvement program.(e)  The network shall develop a written description of the quality improvement program that outlines the organizational structure of the program, the functional responsibilities of the program, and the frequency of committee meetings.(f)  The network shall develop an annual quality improvement work plan designed to reflect the type of services and the populations served by the network in terms of age groups, disease or injury categories, and special risk status, such as type of industry.(g)  The network shall prepare an annual written report to the department on the quality improvement program.  The report must include:(1)  completed activities;(2)  the trending of clinical and service goals;(3)  an analysis of program performance; and(4)  conclusions regarding the effectiveness of the program.(h)  Each network shall implement a documented process for the selection and retention of contracted providers, in accordance with rules adopted by the commissioner.(i)  The quality improvement program must provide for a peer review action procedure for providers, as described by Section 151.002, Occupations Code.(j)  The network shall have a medical case management program with certified case managers.  Case managers shall work with treating doctors, referral providers, and employers to facilitate cost-effective care and employee return-to-work.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.|
TX Ins Code § 1305.304 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1305 - Workers' Compensation Health Care Networks|Subchapter G. Provision of Services by Network; Quality Improvement Program|Section 1305.304. Guidelines and Protocols

Sec. 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 outcome-focused and be designed to reduce inappropriate or unnecessary health care while safeguarding necessary care.  Treatment may not be denied solely on the basis that the treatment for the compensable injury in question is not specifically addressed by the treatment guidelines used by the insurance carrier or network.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.|
TX Ins Code § 1305.351 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1305 - Workers' Compensation Health Care Networks|Subchapter H. Utilization Review|Section 1305.351. Utilization Review in Network

Sec. 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 of a conflict between Chapter 4201 and this chapter, this chapter controls.(b)  Any screening criteria used for utilization review related to a workers' compensation health care network must be consistent with the network's treatment guidelines.(c)  The preauthorization requirements of Section 413.014, Labor Code, and commissioner of workers' compensation rules adopted under that section, do not apply to health care provided through a workers' compensation network.  If a network or carrier uses a preauthorization process within a network, the requirements of this subchapter and commissioner rules apply.  A network or an insurance carrier may not require preauthorization of treatments and services for a medical emergency.(d)  A utilization review agent or an insurance carrier that uses doctors to perform reviews of health care services provided under this chapter, including utilization review, or peer reviews under Section 408.0231(g), Labor Code, may only use doctors licensed to practice in this state.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.Amended by: Acts 2007, 80th Leg., R.S., Ch. 134 (H.B. 1006), Sec. 6, eff. September 1, 2007.Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2G.010, eff. April 1, 2009.Acts 2009, 81st Leg., R.S., Ch. 1330 (H.B. 4290), Sec. 5, eff. September 1, 2009.Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 3.11, eff. September 1, 2019.|
TX Ins Code § 1305.356 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1305 - Workers' Compensation Health Care Networks|Subchapter H. Utilization Review|Section 1305.356. Contested Case Hearing on and Judicial Review of Independent Review

Sec. 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 under this subsection shall be conducted by the department's division of workers' compensation in the same manner as a hearing conducted under Section 413.0311, Labor Code.(b)  At a contested case hearing held under Subsection (a), the administrative law judge conducting the hearing shall consider evidence-based treatment guidelines adopted by the network under Section 1305.304.(c)  A party that has exhausted all administrative remedies under Subsection (a) and is aggrieved by a final decision of the department's division of workers' compensation may seek judicial review of the decision.(d)  Judicial review under Subsection (c) shall be conducted in the manner provided for judicial review of a contested case under Subchapter G, Chapter 2001, Government Code, and is governed by the substantial evidence rule.|Added by Acts 2011, 82nd Leg., R.S., Ch. 1162 (H.B. 2605), Sec. 3, eff. September 1, 2011.Amended by: Acts 2017, 85th Leg., R.S., Ch. 839 (H.B. 2111), Sec. 1, eff. September 1, 2017.|
TX Ins Code § 1305.401 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1305 - Workers' Compensation Health Care Networks|Subchapter I. Complaint Resolution|Section 1305.401. Complaint System Required

Sec. 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 require a complainant to file the complaint not later than the 90th day after the date of the event or occurrence that is the basis for the complaint.(c)  The complaint system must include a process for the notice and appeal of a complaint.(d)  The commissioner may adopt rules as necessary to implement this section.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.|
TX Ins Code § 1305.402 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1305 - Workers' Compensation Health Care Networks|Subchapter I. Complaint Resolution|Section 1305.402. Complaint Initiation and Initial Response; Deadlines for Response and Resolution

Sec. 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 the complaint, shall respond to the complainant, acknowledging the date of receipt of the complaint and providing a description of the network's complaint procedures and deadlines.(b)  The network shall investigate and resolve a complaint not later than the 30th calendar day after the date the network receives the complaint.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.|
TX Ins Code § 1305.403 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1305 - Workers' Compensation Health Care Networks|Subchapter I. Complaint Resolution|Section 1305.403. Record of Complaints

Sec. 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 this section.(b)  Each network shall maintain a record of and documentation on each complaint, complaint proceeding, and action taken on the complaint until the third anniversary of the date the complaint was received.(c)  A complainant is entitled to a copy of the network's record regarding the complaint and any proceeding relating to that complaint.(d)  The department, during any investigation or examination of a network, may review documentation maintained under this subchapter, including original documentation, regarding a complaint and action taken on the complaint.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.|
TX Ins Code § 1305.404 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1305 - Workers' Compensation Health Care Networks|Subchapter I. Complaint Resolution|Section 1305.404. Retaliatory Action Prohibited

Sec. 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 of the employer or employee has filed a complaint against the network.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.|
TX Ins Code § 1305.405 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1305 - Workers' Compensation Health Care Networks|Subchapter I. Complaint Resolution|Section 1305.405. Posting of Information on Complaint Process Required

Sec. 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 the process for resolving complaints with the network.(b)  The notice required under Subsection (a) must include the department's toll-free telephone number for filing a complaint.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.|
TX Ins Code § 1305.502 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1305 - Workers' Compensation Health Care Networks|Subchapter K. Evaluation of Networks; Consumer Report Card|Section 1305.502. Consumer Report Cards

Sec. 1305.502.  CONSUMER REPORT CARDS.  (a)  Not later than December 1 of each even-numbered year, the group shall develop and issue an informational report card that identifies and compares, on an objective basis, the quality, costs, health care provider availability, and other analogous factors of workers' compensation health care networks operating under the workers' compensation system of this state with each other and with medical care provided outside of networks.(b)  The group may procure services as necessary to produce the report card.  The report card must include a risk-adjusted evaluation of:(1)  employee access to care;(2)  return-to-work outcomes;(3)  health-related outcomes;(4)  employee satisfaction with care; and(5)  health care costs and utilization of health care.(c)  The report cards may be based on information or data from any person, agency, organization, or governmental entity that the group considers reliable.  The group may not endorse or recommend a specific workers' compensation health care network or plan, or subjectively rate or rank networks or plans, other than through comparison and evaluation of objective criteria.(d)  The commissioner shall ensure that consumer report cards issued by the group under this section are accessible to the public on the department's Internet website and available to any person on request.  The commissioner by rule may set a reasonable fee for obtaining a paper copy of report cards.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.Amended by: Acts 2021, 87th Leg., R.S., Ch. 670 (H.B. 1753), Sec. 1, eff. June 15, 2021.Acts 2021, 87th Leg., R.S., Ch. 856 (S.B. 800), Sec. 21, eff. September 1, 2021.|