Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter C - CONTRACTING › Section 10.42 - Network Contracts with Providers

Current through Reg. 49, No. 28; July 12, 2024
(a) A network
				  is not required to accept an application for participation in the network from
				  a health care provider that otherwise meets the requirements specified in this
				  chapter if the network determines that the network has contracted with a
				  sufficient number of qualified health care providers, including health care
				  providers of the same license type or specialty.
(b) Provider contracts and subcontracts must
				  include, at a minimum, the following provisions:
(1) except as provided in Insurance Code
				  §
											1305.451(b)(6),
				  concerning Employee Information; Responsibilities of Employee, a hold-harmless
				  clause stating that the provider and the provider network will not bill or
				  attempt to collect any amounts of payment from an employee for health care
				  services for compensable injuries under any circumstances, including the
				  insolvency of the insurance carrier or the network;
(2) a statement that the provider agrees to
				  follow treatment guidelines, return-to-work guidelines, and individual
				  treatment protocols adopted by the network pursuant to §
											10.83 of
				  this title (relating to Guidelines and Protocols) and the pharmacy closed
				  formulary adopted by the Division of Workers' Compensation under §
											134.540
				  of this title (relating to Requirements for Use of the Closed Formulary for
				  Claims Subject to Certified Networks), as applicable to an employee's
				  injury;
(3) a statement that the
				  insurance carrier or network may not deny treatment solely on the basis that a
				  treatment for a compensable injury in question is not specifically addressed by
				  the treatment guidelines used by the insurance carrier or network;
(4) a provision that the network will not
				  engage in retaliatory action, including termination of or refusal to renew a
				  contract, against a provider because the provider has, on behalf of an
				  employee, reasonably filed a complaint against, or appealed a decision of, the
				  network, or requested reconsideration or independent review of an adverse
				  determination;
(5) a continuity of
				  treatment clause that states that:
(A) if a
				  provider leaves the network, upon the provider's request, 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; and
(B) a
				  dispute concerning continuity of care must be resolved through the complaint
				  resolution process under Insurance Code Chapter 1305, Subchapter I, concerning
				  Complaint Resolution, and Subchapter G of this title (relating to
				  Complaints);
(6) a clause
				  regarding appeal by the provider of termination of network provider status,
				  except for termination due to contract expiration, and applicable written
				  notification to employees receiving care regarding such a termination,
				  including requirements that:
(A) the network
				  must provide notice to the provider at least 90 days before the effective date
				  of a termination; [ ]
(B) the
				  network must provide an advisory review panel that consists of at least three
				  providers of the same licensure and the same or similar specialty as the
				  provider;
(C) upon receipt of the
				  written notification of termination, a provider may request a review by the
				  network's advisory review panel not later than 30 days after receipt of the
				  notification;
(D) the network must
				  complete the advisory panel review before the effective date of the
				  termination;
(E) a network may not
				  notify patients of the termination until the earlier of the effective date of
				  the termination or the date the advisory review panel makes a formal
				  recommendation;
(F) in the case of
				  imminent harm to patient health, suspension or loss of license to practice, or
				  fraud, the network may terminate the provider immediately and must notify
				  employees immediately of the termination; and
(G) if the provider terminates the contract,
				  the network must provide notification of the termination to employees receiving
				  care from the terminating provider. The network must give such notice
				  immediately upon receipt of the provider's termination request or as soon as
				  reasonably possible before the effective date of termination;
(7) a provision that requires the
				  provider to post, in the office of the provider, a notice to employees on the
				  process for resolving workers' compensation health care network complaints in
				  accordance with Insurance Code §
											1305.405,
				  concerning Posting of Information on Complaint Process Required. The notice
				  must include the department's toll-free telephone number for filing a complaint
				  and must list all workers' compensation health care networks with which the
				  provider contracts;
(8) a statement
				  that the network agrees to furnish to the provider, and the provider agrees to
				  abide by, the list of any treatments and services that require the network's
				  preauthorization and any procedures to obtain preauthorization;
(9) a statement that the contract and any
				  subcontract within the provider network must not be interpreted to involve a
				  transfer of risk as defined under Insurance Code §
											1305.004(a)(26),
				  concerning Definitions;
(10) a
				  statement that the provider and any subcontracting provider within the provider
				  network must comply with all applicable statutory and regulatory requirements
				  under federal and state law;
(11)
				  the schedule of fees that will be paid to the contracting provider;
(12) a statement specifying whether the
				  provider whose specialty has been designated by the network as a treating
				  doctor agrees to be a network treating doctor and, if so, any additional
				  provisions applicable to the provider;
(13) a statement that billing by and payment
				  to the provider will be made in accordance with Labor Code §
											408.027,
				  concerning Payment of Health Care Provider, and other applicable statutes and
				  rules, including rules governing the billing and payment for certifications of
				  maximum medical improvement and impairment rating examinations;
(14) a statement that the provider
				  specifically agrees to provide treatment for injured employees who obtain
				  workers' compensation health care services through the network that is
				  specifically identified in the contract as a contracting party; and
(15) a statement that the provider will
				  receive written notice from the carrier if the carrier contests compensability
				  of an injury the provider is treating as required under Insurance Code §
											1305.153(e),
				  concerning Provider Reimbursement, including that the carrier may not deny
				  payment for services provided prior to the issuance of the notice on the
				  grounds that the injury was not compensable.