28 Tex. Admin. Code § 10.62 - Dispute Resolution for Employee Requirements Related to In-Network Care
(a) If an employee asserts that he or she
does not currently live in the network's service area, the employee may request
a review by contacting the insurance carrier and providing evidence to support
the employee's assertion.
(b) An
insurance carrier must review the employee's request for review, including any
evidence provided by the injured employee and any evidence collected by the
insurance carrier, and make a determination regarding whether the employee
lives within the network's service area or lives within the service area of any
other workers' compensation network contracted with or established by the
insurance carrier (alternate network). If an insurance carrier makes a
determination that the employee lives within the service area of an alternate
network, the insurance carrier must provide the employee with the notice of
network requirements as described under §
10.60 of this title (relating to
Notice of Network Requirements; Employee Information) for the alternate
network. Upon receipt of the notice of network requirements, the employee must
select a treating doctor from the list of the alternate network's treating
doctors in the network's service area.
(c) Not later than seven calendar days after
the date the insurance carrier receives notice of the injured employee's
request for review, the insurance carrier must notify the employee, in writing,
of the carrier's determination. This notice must include a brief description of
the evidence the carrier considered when making the determination, a copy of
the carrier's determination, and a description of how an employee may file a
complaint regarding this issue with the department. The insurance carrier must
also send a copy of the carrier's determination to the employee's
employer.
(d) If an employee
disagrees with the insurance carrier's determination, the employee may file a
complaint with the department in accordance with §
10.122 of this title (relating to
Submitting Complaints to the Department). To be considered complete, the
employee's complaint must include:
(1) the
employee's contact information, including the employee's name, current physical
address, and telephone number;
(2)
a copy of the insurance carrier's determination; and
(3) any evidence the employee provided to the
insurance carrier for consideration.
(e) An injured employee who disputes whether
he or she lives within a network's service area may seek all medical care from
the network during the pendency of the insurance carrier's review and the
department's investigation of a complaint.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.