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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. 1305.104. SELECTION OF TREATING DOCTOR
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(a) An injured employee is entitled to the employee's initial choice of a treating doctor from the list provided by the network of all treating doctors under contract with the network who provide services within the service area in which the injured employee lives. The following does not constitute an initial choice of treating doctor:
(1) a doctor salaried by the employer;
(2) a doctor providing emergency care; or
(3) any doctor who provides care before the employee is enrolled in the network, except for a doctor selected under Section 1305.105.
(b) An employee who is dissatisfied with the initial choice of a treating doctor is entitled to select an alternate treating doctor from the network's list of treating doctors who provide services within the service area in which the injured employee lives by notifying the network in the manner prescribed by the network. The network may not deny a selection of an alternate treating doctor.
(c) An employee who is dissatisfied with an alternate treating doctor must obtain authorization from the network to select any subsequent treating doctor. The network shall establish procedures and criteria to be used in authorizing an employee to select subsequent treating doctors. The criteria must include, at a minimum, whether:
(1) treatment by the current treating doctor is medically inappropriate;
(2) the employee is receiving appropriate medical care to reach maximum medical improvement or medical care in compliance with the network's treatment guidelines; and
(3) a conflict exists between the employee and the current treating doctor to the extent that the doctor-patient relationship is jeopardized or impaired.
(d) Denial of a request for any subsequent treating doctor is subject to the appeal process for a complaint filed under Subchapter I.
(e) For purposes of this section, the following do not constitute the selection of an alternate or any subsequent treating doctor:
(1) a referral made by the treating doctor, including a referral for a second or subsequent opinion;
(2) the selection of a treating doctor because the original treating doctor:
(A) dies;
(B) retires; or
(C) leaves the network; or
(3) a change of treating doctor required because of a change of address by the employee to a location outside the service area distance requirements, as described by Section 1305.302(g).
(f) A network shall provide that an injured employee with a chronic, life-threatening injury or chronic pain related to a compensable injury may apply to the network's medical director to use a nonprimary care physician specialist that is in the network as the injured employee's treating doctor.
(g) An application under Subsection (f) must:
(1) include information specified by the network, including certification of the medical need provided by the nonprimary care physician specialist; and
(2) be signed by the injured employee and the nonprimary care physician specialist interested in serving as the injured employee's treating doctor.
(h) To be eligible to serve as the injured employee's treating doctor, a physician specialist must agree to accept the responsibility to coordinate all of the injured employee's health care needs.
(i) If a network denies a request under Subsection (f), the injured employee may appeal the decision through the network's established complaint resolution process under Subchapter I.