All Things Texas Workers' Compensation

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Texas Insurance Code

Title 8. Health Insurance and Other Health Coverages

Subtitle D. Provider Plans

Chapter 1305. Workers' Compensation Health Care Networks

Subchapter A. General Provisions

§ 1305.001. Short Title
§ 1305.002. Purpose
§ 1305.003. Limitations on Applicability
§ 1305.004. Definitions
§ 1305.005. Participation in Network;  Notice of Network Requirements
§ 1305.006. Insurance Carrier Liability for Out–of–Network Health Care
§ 1305.007. Rules
§ 1305.008. Administrator Certificate of Authority Required

Subchapter B. Certification

§ 1305.051. Certification Required
§ 1305.052. Certificate Application
§ 1305.053. Contents of Application
§ 1305.054. Action on Application;  Renewal of Certification
§ 1305.055. Use of Certain Insurance Terms by Network Prohibited
§ 1305.056. Restraint of Trade;  Application of Certain Laws

Subchapter C. General Powers and Duties of Workers' Compensation Health Care Networks

§ 1305.101. Providing or Arranging for Health Care
§ 1305.102. Management Contracts
§ 1305.103. Treating Doctor; Referrals
§ 1305.104. Selection of Treating Doctor
§ 1305.105. Treatment by a Primary Care Physician or Provider Under Chapter 843;  Recommendations Regarding Use of Preferred Provider Plan
§ 1305.106. Payment of Health Care Provider
§ 1305.107. Telephone Access

Subchapter D. Contracting Provisions

§ 1305.151. Transfer of Risk
§ 1305.152. Network Contracts with Providers
§ 1305.153. Provider Reimbursement
§ 1305.154. Network–Carrier Contracts
§ 1305.1545. Restrictions on Payment and Reimbursement
§ 1305.155. Compliance Requirements

Subchapter E. Financial Requirements

§ 1305.201. Network Financial Requirements

Subchapter F. Examinations

§ 1305.251. Examination of Network
§ 1305.252. Examination of Provider or Third Party

Subchapter G. Provision of Services by Network;  Quality Improvement Program

§ 1305.301. Network Organization; Service Areas
§ 1305.302. Accessibility and Availability Requirements
§ 1305.303. Quality of Care Requirements
§ 1305.304. Guidelines and Protocols

Subchapter H. Utilization Review

§ 1305.351. Utilization Review in Network
§ 1305.352. General Standards for Retrospective Review
Repealed
§ 1305.353. Notice of Certain Utilization Review Determinations;  Preauthorization Requirements
§ 1305.354. Reconsideration of Adverse Determination
§ 1305.355. Independent Review of Adverse Determination
§ 1305.356. Contested Case Hearing on and Judicial Review of Independent Review

Subchapter I. Complaint Resolution

§ 1305.401. Complaint System Required
§ 1305.402. Complaint Initiation and Initial Response; Deadlines for Response and Resolution
§ 1305.403. Record of Complaints
§ 1305.404. Retaliatory Action Prohibited
§ 1305.405. Posting of Information on Complaint Process Required

Subchapter J. Employee Information and Responsibilities

§ 1305.451. Employee Information;  Responsibilities of Employee

Subchapter K. Evaluation of Networks;  Consumer Report Card

§ 1305.501. Evaluation of Networks
Repealed
§ 1305.502. Consumer Report Cards
§ 1305.503. Confidentiality Requirements

Subchapter L. Disciplinary Actions

§ 1305.551. Determination of Violation; Notice
§ 1305.552. Disciplinary Actions