Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS
Subchapter D - NETWORK REQUIREMENTS
Section 10.61 - Employees Who Live Within the Network Service Area, Employee Access, and Insurance Carrier Liability for Health Care

Universal Citation: 28 TX Admin Code § 10.61

Current through Reg. 50, No. 13; March 28, 2025

(a) The employees of an employer who elects to contract with an insurance carrier for network health care services, and who live within the network's service area, must obtain medical treatment for a compensable injury from in-network providers, except as provided in Insurance Code § 1305.006(1) and (3), concerning Insurance Carrier Liability for Out-of-Network Health Care; subsection (e)(1), (3), and (4) of this section; and the rules of the Division of Workers' Compensation.

(b) An employee is presumed to live at the physical address he or she has represented to the employer as his or her address or, if the employee no longer works for the employer, the physical address of record on file with the insurance carrier.

(c) At any time after the receipt of the notice of network requirements, an employee who no longer lives at the physical address described in subsection (b) of this section, or who otherwise asserts that he or she does not live in the network's service area, may notify the insurance carrier and request a review under § 10.62 of this title (relating to Dispute Resolution for Employee Requirements Related to In-Network Care).

(d) An employee who does not live within a network's service area may choose to participate in a network established by the insurance carrier or with which the insurance carrier has a contract upon mutual agreement between the employee and insurance carrier.

(e) An employee who is found to have fraudulently claimed to live outside the network's service area or made an intentional misrepresentation regarding where he or she lives and receives health care outside the network's service area may be liable for payment for that health care.

(f) An insurance carrier that establishes or contracts with a network is liable for in-network health care for a compensable injury that is provided to an injured employee in accordance with Insurance Code Chapter 1305, concerning Workers' Compensation Health Care Networks, and out-of-network care as follows:

(1) emergency care;

(2) health care provided to an injured employee who does not live within the service area of any network established by the insurance carrier or with which the insurance carrier has a contract;

(3) health care provided by an out-of-network provider pursuant to a referral from the injured employee's treating doctor that has been approved by the network as follows:
(A) if an injured employee's treating doctor requests a referral to an out-of-network provider for medically necessary health care services that are not available from network providers, the network must approve or deny a referral to an out-of-network provider within the time appropriate under the circumstances, but, under any circumstance, not later than seven days after the date the referral is requested;

(B) if the network denies the referral request under subsection (a) of this section because the requested service is available from network providers, the employee may file a complaint in accordance with the network's complaint process under Insurance Code § 1305.402, concerning Complaint Initiation and Initial Response; Deadlines for Response and Resolution, and § 10.121 of this title (relating to Complaints; Deadlines for Response and Resolution);

(C) if the network denies the referral request under subparagraph (A) of this paragraph because the specialist referral is not medically necessary, the employee may file a request for independent review as described in § 10.104 of this title (relating to Independent Review of Adverse Determination); and

(4) health care services provided to an injured employee before the employee received the notice of network requirements and the employee information for the appropriate network and service area under Insurance Code § 1305.005, concerning Participation in Network; Notice of Network Requirements, and § 10.60 of this title (relating to Notice of Network Requirements; Employee Information).

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