reglab/statecodes huggingface dataset:
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter D. Relations Between Insureds and Preferred Providers › Section 1301.162. Identification Card

Sec. 1301.162.  IDENTIFICATION CARD.  An identification card or other similar document issued by an insurer regulated by this code and subject to this chapter to an individual insured must display:
(1)  the first date on which the individual became insured under the plan; or
(2)  a toll-free number a physician or health care provider may use to obtain that date.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(e), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter D. Relations Between Insureds and Preferred Providers › Section 1301.163. Applicability of Subchapter to Entities Contracting With Insurer

Sec. 1301.163.  APPLICABILITY OF SUBCHAPTER TO ENTITIES CONTRACTING WITH INSURER.  This subchapter applies to a person to whom an insurer contracts to:
(1)  process or pay claims;
(2)  obtain the services of physicians or other providers to provide health care services to enrollees; or
(3)  issue verifications or preauthorizations.
Added by Acts 2007, 80th Leg., R.S., Ch. 997 (S.B. 1731), Sec. 15, eff. September 1, 2007.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter D. Relations Between Insureds and Preferred Providers › Section 1301.164. Out-of-Network Facility-Based Providers

Sec. 1301.164.  OUT-OF-NETWORK FACILITY-BASED PROVIDERS.  (a)  In this section, "facility-based provider" means a physician or health care provider who provides medical care or health care services to patients of a health care facility.
(b)  Except as provided by Subsection (d), an insurer shall pay for a covered medical care or health care service performed for or a covered supply related to that service provided to an insured by an out-of-network provider who is a facility-based provider at the usual and customary rate or at an agreed rate if the provider performed the service at a health care facility that is a preferred provider.  The insurer shall make a payment required by this subsection directly to the provider not later than, as applicable:
(1)  the 30th day after the date the insurer receives an electronic clean claim as defined by Section 1301.101 for those services that includes all information necessary for the insurer to pay the claim; or
(2)  the 45th day after the date the insurer receives a nonelectronic clean claim as defined by Section 1301.101 for those services that includes all information necessary for the insurer to pay the claim.
(c)  Except as provided by Subsection (d), an out-of-network provider who is a facility-based provider or a person asserting a claim as an agent or assignee of the provider may not bill an insured receiving a medical care or health care service or supply described by Subsection (b) in, and the insured does not have financial responsibility for, an amount greater than an applicable copayment, coinsurance, and deductible under the insured's preferred provider benefit plan that:
(1)  is based on:
(A)  the amount initially determined payable by the insurer; or
(B)  if applicable, a modified amount as determined under the insurer's internal appeal process; and
(2)  is not based on any additional amount determined to be owed to the provider under Chapter 1467.
(d)  This section does not apply to a nonemergency health care or medical service:
(1)  that an insured elects to receive in writing in advance of the service with respect to each out-of-network provider providing the service; and
(2)  for which an out-of-network provider, before providing the service, provides a complete written disclosure to the insured that:
(A)  explains that the provider does not have a contract with the insured's preferred provider benefit plan;
(B)  discloses projected amounts for which the insured may be responsible; and
(C)  discloses the circumstances under which the insured would be responsible for those amounts.
(e)  This section may not be construed to require the imposition of a penalty under Section 1301.137.
Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 1.09, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter D. Relations Between Insureds and Preferred Providers › Section 1301.166. Out-of-Network Emergency Medical Services Provider

Sec. 1301.166.  OUT-OF-NETWORK EMERGENCY MEDICAL SERVICES PROVIDER.  (a)  In this section, "emergency medical services provider" has the meaning assigned by Section 773.003, Health and Safety Code, except that the term does not include an air ambulance.
(b)  Except as provided by Subsection (c), an insurer shall pay for a covered medical care or health care service performed for, or a covered supply or covered transport related to that service provided to, an insured by an out-of-network provider who is an emergency medical services provider at:
(1)  if the political subdivision has submitted the rate to the department under Section 38.006, the rate set, controlled, or regulated by the political subdivision in which:
(A)  the service originated; or
(B)  the transport originated if transport is provided; or
(2)  if the political subdivision has not submitted the rate to the department, the lesser of:
(A)  the provider's billed charge; or
(B)  325 percent of the current Medicare rate, including any applicable extenders and modifiers.
(c)  An insurer shall adjust a payment required by Subsection (b)(1) each plan year by increasing the payment by the lesser of the Medicare Inflation Index or 10 percent of the provider's previous calendar year rates.
(d)  The insurer shall make a payment required by this section directly to the provider not later than, as applicable:
(1)  the 30th day after the date the insurer receives an electronic clean claim as defined by Section 1301.101 for those services that includes all information necessary for the insurer to pay the claim; or
(2)  the 45th day after the date the insurer receives a nonelectronic clean claim as defined by Section 1301.101 for those services that includes all information necessary for the insurer to pay the claim.
(e)  An out-of-network provider who is an emergency medical services provider or a person asserting a claim as an agent or assignee of the provider may not bill an insured receiving a medical care or health care service or supply or transport described by Subsection (b) in, and the insured does not have financial responsibility for, an amount greater than an applicable copayment, coinsurance, and deductible under the insured's preferred provider benefit plan that is based on:
(1)  the amount initially determined payable by the insurer; or
(2)  if applicable, the modified amount as determined under the insurer's internal appeal process.
(f)  This section may not be construed to require the imposition of a penalty under Section 1301.137.
(g)  This section expires September 1, 2025.
Added by Acts 2023, 88th Leg., R.S., Ch. 981 (S.B. 2476), Sec. 8, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter E. Certain Health Care Providers › Section 1301.201. Contracts With and Reimbursement for Nurse First Assistants

Sec. 1301.201.  CONTRACTS WITH AND REIMBURSEMENT FOR NURSE FIRST ASSISTANTS.  A preferred provider may not refuse to:
(1)  contract with a nurse first assistant, as defined by Section 301.1525, Occupations Code, to be included in the provider's network;  or
(2)  reimburse the nurse first assistant for a covered service that a physician has requested the nurse first assistant to perform.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter E. Certain Health Care Providers › Section 1301.202. Contracts With Hospitals

Sec. 1301.202.  CONTRACTS WITH HOSPITALS.  (a)  An insurer that contracts with hospitals to provide services to insureds under a preferred provider benefit plan may not deny a hospital the opportunity to participate in providing health care services as a preferred provider solely because the hospital is not accredited by the Joint Commission on Accreditation of Healthcare Organizations or another specified national accrediting body. If a hospital is certified by the Medicare program, Title XVIII of the Social Security Act (42 U.S.C. Section 1395 et seq.), or accredited by the Joint Commission on Accreditation of Healthcare Organizations or another national accrediting body, an insurer shall accept that certification or accreditation.
(b)  This section does not limit an insurer's authority to establish other reasonable terms under which a hospital may provide health care services to individuals covered by a preferred provider benefit plan.
(c)  On the request of a hospital, the commissioner shall conduct an investigation, review, hearing, or other proceeding to determine whether an insurer is complying with this section.
(d)  The commissioner shall take reasonable action to ensure compliance with this section, including issuing orders and imposing sanctions.
Added by Acts 2005, 79th Leg., Ch. 1305 (H.B. 2999), Sec. 1, eff. June 18, 2005.
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 A. General Provisions › Section 1305.001. Short Title

Sec. 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, eff. September 1, 2005.
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 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.
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 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.
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 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.
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 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.
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 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.
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 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.
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 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.
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 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.
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 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.
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 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.
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 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.
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 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.
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 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.
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 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.
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 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.
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 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.
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 1305.151. 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.
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 1305.152. 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.
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 1305.1545. 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.
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 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.
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 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.
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 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.
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 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.
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 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.
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 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.
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 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.