Texas Regulations 10.62
From Wcc
§ 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 shall 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 shall provide the employee with the notice of network requirements as described under § 10.60 of this subchapter (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 shall notify the employee, in writing, of the carrier�s determination. This notice shall 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 shall 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 chapter (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. |
