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Texas Statutes (Last Updated: January 4, 2014) |
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INSURANCE CODE |
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Title 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES |
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Subtitle D. PROVIDER PLANS |
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Chapter 1305. WORKERS' COMPENSATION HEALTH CARE NETWORKS |
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Subchapter C. GENERAL POWERS AND DUTIES OF WORKERS' COMPENSATION HEALTH CARE NETWORKS |
Sec. 1305.103. TREATING DOCTOR; REFERRALS
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(a) A network shall determine the specialty or specialties of doctors who may serve as treating doctors.
(b) For each injury, an injured employee shall select a treating doctor from the list of all treating doctors under contract with the network in that service area.
(c) An employee who lives within the service area of a network and who is being treated by a non-network provider for an injury that occurred before the employer's insurance carrier established or contracted with the network, shall select a network treating doctor on notification by the carrier that health care services are being provided through the network. The carrier shall provide to the employee all information required by Section 1305.451. If the employee fails to select a treating doctor on or before the 14th day after the date of receipt of the information required by Section 1305.451, the network may assign the employee a network treating doctor. An issue regarding whether a carrier properly provided an employee the information required by this subsection may be resolved using the process for adjudication of disputes under Chapter 410, Labor Code, as used by the department's division of workers' compensation.
(d) Each network shall, by contract, require treating doctors to provide, at a minimum, the functions and services for injured employees described by this section.
(e) A treating doctor shall provide health care to the employee for the employee's compensable injury and shall make referrals to other network providers, or request referrals to out-of-network providers if medically necessary services are not available within the network. Referrals to out-of-network providers must be approved by the network. The network shall approve a referral to an out-of-network provider not later than the seventh day after the date on which the referral is requested, or sooner if circumstances and the condition of the employee require expedited approval. If the network denies the referral request, the employee may appeal the decision through the network's complaint process under Subchapter I.
(f) The treating doctor shall participate in the medical case management process as required by the network, including participation in return-to-work planning.