reglab/housing_qa huggingface dataset:
TX Ins Code § 1305.002 (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 A. General Provisions|Section 1305.002. Purpose

Sec. 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; and(2)  provide standards for the certification, administration, evaluation, and enforcement of the delivery of health care services to injured employees by networks contracting with or established by:(A)  workers' compensation insurance carriers;(B)  employers certified to self-insure under Chapter 407, Labor Code;(C)  groups of employers certified to self-insure under Chapter 407A, Labor Code; and(D)  governmental entities that self-insure, either individually or collectively.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.|
TX Ins Code § 1305.003 (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 A. General Provisions|Section 1305.003. Limitations on Applicability

Sec. 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 under Title 5, Labor Code, that do not conflict with this chapter.(b)  In the event of a conflict between Title 5, Labor Code, and this chapter as to the provision of medical benefits for injured employees, the establishment and regulation of fees for medical treatments and services, the time frames for payment of medical bills, the operation and regulation of workers' compensation health care networks, the regulation of health care providers who contract with those networks, or the resolution of disputes regarding medical benefits provided through those networks, this chapter prevails.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.|
TX Ins Code § 1305.006 (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 A. General Provisions|Section 1305.006. Insurance Carrier Liability for Out-of-Network Health Care

Sec. 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:(1)  emergency care;(2)  health care provided to an injured employee who does not live within the service area of any network established by the insurance carrier or with which the insurance carrier has a contract; and(3)  health care provided by an out-of-network provider pursuant to a referral from the injured employee's treating doctor that has been approved by the network pursuant to Section 1305.103.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.|
TX Ins Code § 1305.007 (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 A. General Provisions|Section 1305.007. Rules

Sec. 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 1, 2005.|
TX Ins Code § 1305.008 (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 A. General Provisions|Section 1305.008. Administrator Certificate of Authority Required

Sec. 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 functions under this chapter for an insurance carrier.|Added by Acts 2007, 80th Leg., R.S., Ch. 1176 (H.B. 472), Sec. 2.02, eff. September 1, 2007.|
TX Ins Code § 1305.051 (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 B. Certification|Section 1305.051. Certification Required

Sec. 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 and rules adopted by the commissioner.(b)  A person may not perform any act of a workers' compensation health care network except in accordance with the specific authorization of this chapter or rules adopted by the commissioner.(c)  A health maintenance organization regulated under Chapter 843 or an organization of physicians and providers that operates as a preferred provider benefit plan, as defined by Chapter 1301, may obtain a certification as a workers' compensation health care network in the same manner as any other person if that entity meets the requirements of this chapter and rules adopted by the commissioner under this chapter.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.|
TX Ins Code § 1305.052 (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 B. Certification|Section 1305.052. Certificate Application

Sec. 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 operate as a network.(b)  A certificate application must be:(1)  filed with the department in the form prescribed by the commissioner;(2)  verified by the applicant or an officer or other authorized representative of the applicant; and(3)  accompanied by a nonrefundable fee set by commissioner rule.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.|
TX Ins Code § 1305.053 (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 B. Certification|Section 1305.053. Contents of Application

Sec. 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 or lists that show:(A)  the relationships and contracts between the applicant and any affiliates of the applicant; and(B)  the internal organizational structure of the applicant's management and administrative staff;(2)  biographical information regarding each person who governs or manages the affairs of the applicant, accompanied by information sufficient to allow the commissioner to determine the competence, fitness, and reputation of each officer or director of the applicant or other person having control of the applicant;(3)  a copy of the form of any contract between the applicant and any provider or group of providers, and with any third party performing services on behalf of the applicant under Subchapter D;(4)  a copy of the form of each contract with an insurance carrier, as described by Section 1305.154;(5)  a financial statement, current as of the date of the application, that is prepared using generally accepted accounting practices and includes:(A)  a balance sheet that reflects a solvent financial position;(B)  an income statement;(C)  a cash flow statement; and(D)  the sources and uses of all funds;(6)  a statement acknowledging that lawful process in a legal action or proceeding against the network on a cause of action arising in this state is valid if served in the manner provided by Chapter 804 for a domestic company;(7)  a description and a map of the applicant's service area or areas, with key and scale, that identifies each county or part of a county to be served;(8)  a description of programs and procedures to be utilized, including:(A)  a complaint system, as required under Subchapter I;(B)  a quality improvement program, as required under Subchapter G; and(C)  the utilization review program described in Subchapter H;(9)  a list of all contracted network providers that demonstrates the adequacy of the network to provide comprehensive health care services sufficient to serve the population of injured employees within the service area and maps that demonstrate that the access and availability standards under Subchapter G are met; and(10)  any other information that the commissioner requires by rule to implement this chapter.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.Amended by: Acts 2009, 81st Leg., R.S., Ch. 1330 (H.B. 4290), Sec. 2, eff. September 1, 2009.|
TX Ins Code § 1305.054 (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 B. Certification|Section 1305.054. Action on Application; Renewal of Certification

Sec. 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 application is received by the department.  An application is considered complete on receipt of all information required by this chapter and any commissioner rules, including receipt of any additional information requested by the commissioner as needed to make the determination.(b)  Additional information requested by the commissioner under Subsection (a) may include information derived from an on-site quality-of-care examination.(c)  The department shall notify the applicant of any deficiencies in the application and may allow the applicant to request additional time to revise the application, in which case the 60-day period for approval or disapproval is tolled.  The commissioner may grant or deny requests for additional time at the commissioner's discretion.(d)  An order issued by the commissioner disapproving an application must specify in what respects the application does not comply with applicable statutes and rules.  An applicant whose application is disapproved may request a hearing not later than the 30th day after the date of the commissioner's disapproval order.  The hearing is a contested case hearing under Chapter 2001, Government Code.(e)  A certificate issued under this subchapter is valid until revoked or suspended.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.|
TX Ins Code § 1305.055 (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 B. Certification|Section 1305.055. Use of Certain Insurance Terms by Network Prohibited

Sec. 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 any other word that is:(1)  descriptive of the insurance, casualty, or surety business; or(2)  deceptively similar to the name or description of an insurer or surety corporation engaging in the business of insurance in this state.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.|
TX Ins Code § 1305.056 (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 B. Certification|Section 1305.056. Restraint of Trade; Application of Certain Laws

Sec. 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 to have entered into a conspiracy in restraint of trade in violation of Chapter 15, Business & Commerce Code.(b)  Notwithstanding any other law, a person who contracts under this chapter with one or more providers in the process of conducting activities that are permitted by law but that do not require a certificate of authority or other authorization under this code is not, because of the contract, considered to have entered into a conspiracy in restraint of trade in violation of Chapter 15, Business & Commerce Code.(c)  A network is subject to Chapters 441 and 443 and is considered an insurer or insurance company, as applicable, for purposes of those laws.|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. 730 (H.B. 2636), Sec. 2G.008, eff. April 1, 2009.|
TX Ins Code § 1305.101 (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 C. General Powers and Duties of Workers' Compensation Health Care Networks|Section 1305.101. Providing or Arranging for Health Care

Sec. 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 under contract with or are employed by the network.(b)  A network doctor may not serve as a designated doctor or perform a required medical examination, as those terms are used under the Texas Workers' Compensation Act, for an employee receiving medical care through a network with which the doctor contracts or is employed.(c)  Notwithstanding any other provision of this chapter, prescription medication or services, as defined by Section 401.011(19)(E), Labor Code, may not, directly or through a contract, be delivered through a workers' compensation health care network.  Prescription medication and services shall be reimbursed as provided by Section 408.0281, Labor Code, other provisions of the Texas Workers' Compensation Act, and applicable rules of the commissioner of workers' compensation.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.Amended by: Acts 2011, 82nd Leg., R.S., Ch. 705 (H.B. 528), Sec. 4, eff. June 17, 2011.|
TX Ins Code § 1305.103 (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 C. General Powers and Duties of Workers' Compensation Health Care Networks|Section 1305.103. Treating Doctor; Referrals

Sec. 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 select a treating doctor from the list of all treating doctors under contract with the network in that service area.(c)  An employee who lives within the service area of a network and who is being treated by a non-network provider for an injury that occurred before the employer's insurance carrier established or contracted with the network, shall select a network treating doctor on notification by the carrier that health care services are being provided through the network.  The carrier shall provide to the employee all information required by Section 1305.451.  If the employee fails to select a treating doctor on or before the 14th day after the date of receipt of the information required by Section 1305.451, the network may assign the employee a network treating doctor.  An issue regarding whether a carrier properly provided an employee the information required by this subsection may be resolved using the process for adjudication of disputes under Chapter 410, Labor Code, as used by the department's division of workers' compensation.(d)  Each network shall, by contract, require treating doctors to provide, at a minimum, the functions and services for injured employees described by this section.(e)  A treating doctor shall provide health care to the employee for the employee's compensable injury and shall make referrals to other network providers, or request referrals to out-of-network providers if medically necessary services are not available within the network.  Referrals to out-of-network providers must be approved by the network.  The network shall approve a referral to an out-of-network provider not later than the seventh day after the date on which the referral is requested, or sooner if circumstances and the condition of the employee require expedited approval.  If the network denies the referral request, the employee may appeal the decision through the network's complaint process under Subchapter I.(f)  The treating doctor shall participate in the medical case management process as required by the network, including participation in return-to-work planning.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.Amended by: Acts 2011, 82nd Leg., R.S., Ch. 1066 (S.B. 809), Sec. 4, eff. September 1, 2011.|
TX Ins Code § 1305.105 (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 C. General Powers and Duties of Workers' Compensation Health Care Networks|Section 1305.105. Treatment by a Primary Care Physician or Provider Under Chapter 843; Recommendations Regarding Use of Preferred Provider Plan

Sec. 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 treating doctor a doctor who the employee selected, prior to injury, as the employee's primary care physician or provider under Chapter 843, as the terms "physician" and "provider" are defined in that chapter.(b)  A doctor serving as an employee's treating doctor under Subsection (a) must agree to abide by the terms of the network's contract and comply with the provisions of this subchapter and Subchapters D and G.  Services provided by such a doctor are considered to be network services and are subject to Subchapters H and I.(c)  Any change of doctor requested by an employee being treated by a doctor under Subsection (a) must be to a network doctor and is subject to the requirements of this chapter.(d)  In studying the adequacy of networks under this chapter, the department shall offer recommendations to the 80th Legislature regarding whether to make statutory changes to allow treatment by non-network providers through a preferred provider benefit plan, as defined by Chapter 1301.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.|
TX Ins Code § 1305.106 (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 C. General Powers and Duties of Workers' Compensation Health Care Networks|Section 1305.106. Payment of Health Care Provider

Sec. 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 workers' compensation health care network only in accordance with Section 408.027, Labor Code.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.|
TX Ins Code § 1305.107 (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 C. General Powers and Duties of Workers' Compensation Health Care Networks|Section 1305.107. Telephone Access

Sec. 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 both time zones in this state if applicable, to discuss an employee's care and to allow response to requests for information, including information regarding adverse determinations.(b)  A network must have a telephone system capable of accepting or recording or providing instructions to incoming calls during other than normal business hours.  The network shall respond to those calls not later than two business days after the date:(1)  the call was received by the network; or(2)  the details necessary to respond were received by the network from the caller.|Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.|
TX Ins Code § 1305.151 (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 1305.151. Transfer of Risk

Sec. 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. September 1, 2005.|