Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter D - NETWORK REQUIREMENTS › Section 10.61 - Employees Who Live Within the Network Service Area, Employee Access, and Insurance Carrier Liability for Health Care

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  The employees of an employer who elects to contract with an insurance carrier
				  for network health care services, and who live within the network's service
				  area, must obtain medical treatment for a compensable injury from in-network
				  providers, except as provided in Insurance Code §
										1305.006(1)
				  and (3), concerning Insurance Carrier
				  Liability for Out-of-Network Health Care; subsection (e)(1), (3), and (4) of
				  this section; and the rules of the Division of Workers' Compensation.
(b) An employee is presumed to live at the
				  physical address he or she has represented to the employer as his or her
				  address or, if the employee no longer works for the employer, the physical
				  address of record on file with the insurance carrier.
(c) At any time after the receipt of the
				  notice of network requirements, an employee who no longer lives at the physical
				  address described in subsection (b) of this section, or who otherwise asserts
				  that he or she does not live in the network's service area, may notify the
				  insurance carrier and request a review under §
										10.62
				  of this title (relating to Dispute Resolution for Employee Requirements Related
				  to In-Network Care).
(d) An
				  employee who does not live within a network's service area may choose to
				  participate in a network established by the insurance carrier or with which the
				  insurance carrier has a contract upon mutual agreement between the employee and
				  insurance carrier.
(e) An employee
				  who is found to have fraudulently claimed to live outside the network's service
				  area or made an intentional misrepresentation regarding where he or she lives
				  and receives health care outside the network's service area may be liable for
				  payment for that health care.
(f)
				  An insurance carrier that establishes or contracts with a network is liable for
				  in-network health care for a compensable injury that is provided to an injured
				  employee in accordance with Insurance Code Chapter 1305, concerning Workers'
				  Compensation Health Care Networks, and out-of-network care as follows:
(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;
(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 as follows:
(A) if an injured employee's treating doctor
				  requests a referral to an out-of-network provider for medically necessary
				  health care services that are not available from network providers, the network
				  must approve or deny a referral to an out-of-network provider within the time
				  appropriate under the circumstances, but, under any circumstance, not later
				  than seven days after the date the referral is requested;
(B) if the network denies the referral
				  request under subsection (a) of this section because the requested service is
				  available from network providers, the employee may file a complaint in
				  accordance with the network's complaint process under Insurance Code §
												1305.402,
				  concerning Complaint Initiation and Initial Response; Deadlines for Response
				  and Resolution, and §
												10.121
				  of this title (relating to Complaints; Deadlines for Response and
				  Resolution);
(C) if the network
				  denies the referral request under subparagraph (A) of this paragraph because
				  the specialist referral is not medically necessary, the employee may file a
				  request for independent review as described in §
												10.104
				  of this title (relating to Independent Review of Adverse Determination);
				  and
(4) health care
				  services provided to an injured employee before the employee received the
				  notice of network requirements and the employee information for the appropriate
				  network and service area under Insurance Code §
											1305.005,
				  concerning Participation in Network; Notice of Network Requirements, and §
											10.60
				  of this title (relating to Notice of Network Requirements; Employee
				  Information).