28 Tex. Admin. Code § 10.61 - Employees Who Live Within the Network Service Area, Employee Access, and Insurance Carrier Liability for Health Care
(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).
Notes
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