2023 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 1305.155. Compliance Requirements

Sec. 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 network delegates a function is not operating in accordance with the contract or is operating in a condition that renders the continuance of the network's business hazardous to employees shall:
(1)  notify the network in writing of those findings;
(2)  request in writing a written explanation, with documentation supporting the explanation, of:
(A)  the network's apparent noncompliance with the contract; or
(B)  the existence of the condition that apparently renders the continuance of the network's business hazardous to employees; and
(3)  notify the commissioner and provide the department with copies of all notices and requests submitted to the network and the responses and other documentation the carrier generates or receives in response to the notices and requests.
(b)  A network shall respond to a request from a carrier under Subsection (a) in writing not later than the 30th day after the date the request is received.
(c)  The carrier shall cooperate with the network to correct any failure by the network to comply with any regulatory requirement of the department.
(d)  On receipt of a notice under Subsection (a), or if a complaint is filed with the department, on receipt of that complaint, the commissioner or the commissioner's designated representative shall examine the matters contained in the notice or complaint as well as any other matter relating to the financial solvency of the network or the network's ability to meet its responsibilities in connection with any function performed by the network or delegated to the network by the carrier.
(e)  Except as provided by this subsection, on completion of the examination, the department shall report to the network and the carrier the results of the examination and any action the department determines is necessary to ensure that the carrier meets its responsibilities under this chapter, this code, and rules adopted by the commissioner, and that the network can meet the network's responsibilities in connection with any function delegated by the carrier or performed by the network, any management contractor, or any third party to which the network delegates a function.  The department may not report to the carrier any information regarding fee schedules, prices, cost of care, or other information not relevant to the monitoring plan.
(f)  The network and the carrier shall respond to the department's report and submit a corrective plan to the department not later than the 30th day after the date of receipt of the report.
(g)  The commissioner may order a carrier to take any action the commissioner determines is necessary to ensure that the carrier can provide all health care services under the Texas Workers' Compensation Act, including:
(1)  reassuming the functions performed by or delegated to the network, including claims payments for services previously provided to injured employees;
(2)  temporarily or permanently ceasing coverage of employees through the network;
(3)  complying with the contingency plan required by Section 1305.154(c)(9), including permitting an injured employee to select a treating doctor in the manner provided by Section 408.022, Labor Code; or
(4)  terminating the carrier's contract with the network.
(h)  The carrier retains ultimate responsibility for ensuring that all delegated functions and all management contractor functions are performed in accordance with applicable statutes and rules and nothing in this section may be construed to limit in any way the carrier's responsibility, including financial responsibility, to comply with all statutory and regulatory requirements.
Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.