28 Tex. Admin. Code § 137.5 - Case Manager Certification
(a) This section
applies to all case management services as defined by Labor Code §
401.011 (5-a) that are
provided under Labor Code Title 5 to injured employees by an insurance carrier
on or after September 1, 2011.
(b)
This section does not apply to case management services:
(1) subject to Insurance Code Chapter
1305;
(2) subject to Labor Code §
504.053(b)(2);
or
(3) of a health care provider
subject to §
134.204 of this title (relating to
Medical Fee Guideline for Workers' Compensation Specific Services).
(c) Case managers who are
certified must be certified by an established accredited organization including
the National Commission for Certifying Agencies, the American Board of Nursing
Specialties, or other national accrediting agencies with similar standards for
case management certification. Case managers must be certified in one or more
of the following areas:
(1) case
management;
(2) case management
administration;
(3) continuity of
care;
(4) disability
management;
(5) occupational
health; or
(6) rehabilitation case
management.
(d) When
conducting evaluations to determine if case management services are required,
insurance carriers shall utilize case managers who are certified in accordance
with subsection (c) of this section.
(e) When providing case management services
other than those specified in subsection (d) of this section, an insurance
carrier shall utilize case managers who are:
(1) appropriately certified in accordance
with subsection (c) of this section; or
(2) skilled, non-certified case managers as
specified in subsection (f) of this section.
(f) Skilled, non-certified case managers are
eligible to provide services other than those identified in subsection (d) of
this section if:
(1) they meet all of the
requirements of subsection (c) to sit for a case management certification
examination, with the exception of work experience; and
(2) they are working under the direct
supervision of an identified case manager that is certified in accordance with
subsection (c) of this section in order to meet the experience requirements to
sit for a case management certification examination.
(g) Individuals may only be employed or
contracted as skilled, non-certified case managers as specified in subsection
(f) of this section for an aggregate total of 24 months, beginning with the
first month in which the individual first performs case management related
services that occurs after the effective date outlined in subsection (a) of
this section. After accrual of the 24 months, these individuals shall not
conduct case management services until a certification is obtained in
accordance with subsection (c) of this section.
(h) Insurance carriers shall be responsible
for verifying and documenting in writing compliance with the requirements of
subsections (d), (e) and (f) of this section. Insurance carriers shall provide
this verification and documentation information to the division upon
request.
(i) Claims adjusters shall
not be used as case managers. This does not prohibit claims adjusters from
performing claims services that are within the scope of licensure in accordance
with the Insurance Code Chapter 4101.
(j) Reimbursement policies and maximum
allowable reimbursement rates set forth in the adopted fee guidelines under §
134.204 of this title between the
treating doctor and other health care providers does not apply to the
reimbursement of case managers employed or contracted by insurance carriers
under this section.
(k) If the
requirements of this section are not met, the insurance carrier may be held
liable for administrative violations in accordance with Labor Code provisions
and division rules.
Notes
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