Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter C - CONTRACTING › Section 10.41 - Network-Carrier Contracts

Current through Reg. 49, No. 28; July 12, 2024
(a) A network's
				  contract with a carrier must include the following:
(1) a description of the functions to be
				  performed by the network or its delegated entity, consistent with the
				  requirements of Insurance Code §
											1305.154(b),
				  concerning Network-Carrier Contracts, and the reporting requirements for each
				  function;
(2) a statement that the
				  network will perform all delegated functions in full compliance with all
				  requirements of the Workers' Compensation Health Care Network Act, Insurance
				  Code Chapter 1305, concerning Workers' Compensation Health Care Networks; the
				  Texas Workers' Compensation Act, Labor Code Title 5, Subtitle A, concerning
				  Workers' Compensation; and the rules of the department and the Division of
				  Workers' Compensation;
(3) a
				  provision that the contract:
(A) may not be
				  terminated without cause by either party without 90 days' prior written notice;
				  and
(B) must be terminated
				  immediately if cause exists;
(4) a hold-harmless provision stating that
				  the network, a management contractor, a third party to which the network
				  delegates a function, and the network's contracted providers are prohibited
				  from billing or attempting to collect any amounts from an employee for health
				  care services for compensable injuries under any circumstances, including the
				  insolvency of the carrier or the network;
(5) a statement that the carrier and the
				  network retain ultimate responsibility for ensuring that all delegated
				  functions and all management contractor functions are performed in accordance
				  with applicable statutes and rules, and that the contract may not be construed
				  to limit in any way the carrier's or network's responsibility, including
				  financial responsibility, to comply with all statutory and regulatory
				  requirements;
(6) a statement that
				  the network's role is to provide the services listed in Insurance Code §
											1305.154(b)
				  as well as any other services or functions the carrier delegates, including
				  functions delegated to a management contractor, subject to the carrier's
				  oversight and monitoring of the network's performance;
(7) a requirement that the network provide
				  the carrier, on at least a monthly basis and in a form that is usable for audit
				  purposes, the data necessary for the carrier to comply with reporting
				  requirements of the department and the Division of Workers' Compensation of the
				  department with respect to any services provided pursuant to the
				  carrier-network contract, including the following data:
(A) last name, first name, date of injury,
				  date of birth, sex, address, telephone number, claim number, and social
				  security number of each injured employee who is being served by the network,
				  and name and license number of the injured employee's treating
				  doctor;
(B) initial date of health
				  care services delivered by the network for each employee; and
(C) any other data, as determined by the
				  contract, necessary to assure proper monitoring of functions delegated to the
				  network by the carrier;
(8) a requirement that the carrier, the
				  network, any management contractor, and any third party to which the network
				  delegates a function comply with a provision that requires the network to
				  provide to the insurance carrier and department the license number of a
				  management contractor or any delegated third party performing any function that
				  requires a license under the Insurance Code or another insurance law of this
				  state, including a license as a utilization review agent under Insurance Code
				  Chapter 4201, concerning Utilization Review Agents;
(9) a contingency plan under which the
				  carrier would, in the event of termination of the contract or a failure to
				  perform, reassume one or more functions of the network under the contract,
				  including functions related to:
(A) payment to
				  providers and notification to employees, as applicable;
(B) quality of care;
(C) utilization review;
(D) continuity of care, including a plan for
				  identifying and transitioning employees to new providers; and
(E) collecting and reporting of data
				  necessary to comply with the reporting requirements described in paragraph (7)
				  of this subsection;
(10)
				  a provision that requires that any agreement by which the network delegates any
				  function to a third party be in writing, and that such agreement require the
				  delegated third party to be subject to all the requirements under Insurance
				  Code Chapter 1305 and this chapter;
(11) a provision that requires the network to
				  provide to the department the license number of a management contractor or any
				  delegated third party performing any function that requires a license under the
				  Insurance Code or another insurance law of this state, including a license as a
				  utilization review agent under Insurance Code Chapter 4201;
(12) an acknowledgment that:
(A) any management contractor or third party
				  to whom the network delegates a function must comply with this chapter and
				  other applicable statutes and rules, and that the management contractor or
				  third party is subject to the carrier's and the network's oversight and
				  monitoring of its performance; and
(B) if the management contractor or third
				  party fails to meet monitoring standards established to ensure that functions
				  delegated or assigned to the management contractor or third party under the
				  delegation contract are in full compliance with all statutory and regulatory
				  requirements, the carrier or network may cancel delegation of any or all
				  delegated functions;
(13)
				  a requirement that the network and any management contractor or third party to
				  which the network delegates a function provide all necessary information to
				  allow the carrier to provide the information required by §
											10.60
				  of this title (relating to Notice of Network Requirements; Employee
				  Information) to employers or employees;
(14) a provision that requires the network to
				  require any third party with which it contracts, whether directly or through
				  another third party, to permit the Commissioner to examine at any time any
				  information the Commissioner believes is relevant to the third party's
				  financial condition or the ability of the network to meet the network's
				  responsibilities in connection with any function the third party performs or
				  that has been delegated to the third party.
(15) a requirement that if the network
				  delegates the complaint function, the delegate must:
(A) implement and maintain a complaint system
				  in accordance with requirements under Insurance Code §
												1305.401,
				  concerning Complaint System Required, and §
												10.120
				  of this title (relating to Complaint System Required); and
(B) make the complaint log and complaint
				  files available to the carrier and the network upon request to the extent
				  permitted by law;
(16) a
				  statement that the contract and any network contract with a provider,
				  management contractor, or other third party must not be interpreted to involve
				  a transfer of risk as defined under Insurance Code §
											1305.004(a)(26),
				  concerning Definitions;
(17) a
				  statement that any network contract with a provider or third party must allow
				  the carrier to effect a contingency plan in the event that the carrier is
				  required to reassume functions from the network as contemplated under Insurance
				  Code §
											1305.155,
				  concerning Compliance Requirements;
(18) a statement that any network contract
				  with a provider or third party must comply with all applicable statutory and
				  regulatory requirements under federal and state law, including Insurance Code
				  §
											1305.152,
				  concerning Network Contracts with Providers, and §
											10.42
				  of this title (relating to Network Contracts with Providers); and
(19) a statement that if a network's delegate
				  subdelegates a network function, the delegate must first obtain the network's
				  consent to the subdelegation and have a delegation agreement that complies with
				  this section.