1. What is a Workers' Compensation Healthcare Network?
2. Why is Network vs. Non-Network Important?
3. Texas CorCare® Network Call Center
4. Employer Network Implementation
5. Network Requirements

1. What is a Workers' Compensation Healthcare Network?

Workers' compensation networks are groups of doctors, hospitals, and other health care providers that work together to treat injured workers. These networks are certified by the Texas Department of Insurance (TDI). CorCare® is CorVel Corporation's Certified Healthcare Network, number 6016. The Texas law has many requirements on what networks must do in addition to providing care to injured workers.

2. Why is Network vs. Non-Network Important?

While many of the rules are the same for network and non-network claimants there are some differences. These include preauthorization, changes in treating doctor, provision of medical care, claims processing, disputes and other issues.

How to Tell if an Employee is in the Network

1. The employer has contracted with a carrier who has contracted with CorVel Corporation to provide network services.

2. The employee lives in the service area or if the employee lives outside of the network service area the carrier has given approval for the employee to treat in the network.

3. Ultimately the carrier decides who does and who does not live in a network service area.

Definition of Lives--Where an employee lives includes:

(A) the employee's principal residence for legal purposes, including the physical address which the employee represented to the employer as the employee's address;

(B) a temporary residence necessitated by employment; or

(C) a temporary residence taken by the employee primarily for the purpose of receiving necessary assistance with routine daily activities because of a compensable injury. [28 TAC §10.2 (14)]

Provision of Medical Care

Employees in the network must choose a network doctor as treating doctor. ( There are special circumstances that allow the network to approve a specialist or the employee's HMO doctor as treating doctor.) The treating doctor is responsible for all medical care including referrals to specialists. CorCare® has chosen the following specialties to be treating doctors: Occupational Medicine, Physical Medicine Rehabilitation, Internal Medicine, General Practice and Family Practice MD's and DO's. All providers must follow the workers compensation state laws and the rules of the network.


Referrals to Specialists

The treating doctor is the provider who may refer to specialists. If the specialist is a network provider no further approval is needed. Preauthorization requirements still apply. If the specialist is not a network provider, the specialist must have approval from the network prior to treating the patient except for emergency services.

Change in Treating Doctors

In general the employee can make the first two choices of treating doctors and after that the network must approve any choices. All alternate and subsequent choices must be a network treating doctor and be pre-approved by the network.

Preauthorization

Networks choose what items require preauthorization so the list is different from non-network claims. Once a service is preauthorized it can not be denied based on medical necessity.

Payment of Providers

Network providers are paid according to the contract. Non-network providers will be reimbursed in accordance with the TDI/DWC fee schedule in effect on the date of service, unless there is a case by case agreement for fees with the network. Non-network providers providing services in conjunction with an approved service must be paid. Example: Hospitalization. Pay the radiologists, pathologists, anesthesiologist, etc.

Disputes

Compensability disputes for network and non-network claims are handled through the Division of Workers Compensation. The carrier who is disputing a network claim must notify the network providers in writing. This only applies in the network setting. The carrier may not deny payment until notice of dispute is issued. Carrier is liable for a maximum of $7000 total up to the point the denial is issued. Plain Language notices must also be provided to the employee and the DWC whenever the carrier is disputing a claim or the extent of injury. Medical necessity disputes once there have been 2 denials may proceed to the Independent Review Organization through the Texas Department of Insurance. Network fee disputes may be resolved by the network or if unresolved may proceed to judicial review. Non-network fee disputes are handled through the DWC dispute resolution process.


Return to Work Program

The network is required to have a program to assist injured employees in returning to work. CorVel Corporation's case managers are available to assist with this.

Quality Improvement Program

The network is required to have a quality improvement program. The quality improvement committee will be evaluating all aspects of the network's performance and developing strategies for improving the network. As needed a peer review committee will be formed to address provider quality of care issues. Annually, a report will be prepared and given to the state.


In Network and Non-network Comparison

	In Network	Non Network
Emergency Care	No Preauthorization required. Employee may go to nearest emergency facility. Defined in 28 TAC 10.2	No Preauthorization required. Employee may go to nearest emergency facility. Defined in 28  TAC §133.1
Preauthorization	Use Network List	28 TAC §134.600
Treatment Guidelines	Network chooses the guidelines. ODG & ACOEM	Commissioner decides. Rules are pending
Return to Work Guidelines	Network chooses the guidelines. ODG & ACOEM	Commissioner decides. Rules are pending
Treating Doctors	Network Determines who may be a treating doctor. Treating doctors must be in the network provider directory.	Legislature determines who is a treating doctor. Must be on the ADL unless there is a case by case exception
ADL (Approved Doctor List)	Not required for providers to be on the ADL but the DWC recommends all providers be on the ADL in case the provider sees a non-network patient unknowingly. Use provider directory for referrals	Provider is required to be on the ADL in order to get payment for all non-emergency services
Referrals to other providers	Network determines if approval is needed for in network referrals. CorCare® does not require pre-approval for referrals within the network. The treating doctor coordinates all referrals	The treating doctor coordinates the referrals to doctors on the ADL
DWC Required Reports (Report of Medical Evaluation DWC-69 and Work Status Report and DWC-73.)	Submit in accordance with rules	Submit in accordance with rules
Required Medical Exam (RME)	Carrier may not request RME on a network covered injury. Network Providers cannot do RME or DDE on patients within the network that they are contracting with. They may, if qualified, do these exams on non-network patients or on patients in networks that the provider is not contracted with	Carrier can request RME in accordance with DWC rules
Designated Doctor Exams	Carrier can request this exam. Network Providers cannot do RME or DDE on patients within the network that they are contracting with. They may, if qualified, do these exams on non-network patients or on patients in networks that the provider is not contracted with	Carrier can request DDE in accordance with DWC rules
Billing Forms	Use DWC required billing forms 28 TAC §133.10	Use DWC required billing forms 28 TAC §133.10
Medical Bill Documentation	Include the necessary documentation 28 TAC §133.210	Include the necessary documentation 28 TAC §133.210
Submission of Bills	Must submit bill within 95 days of the date of service or the carrier does not have to pay. 28 TAC §133.20	Must submit bill within 95 days of the date of service or the carrier does not have to pay. 28 TAC §133.20
Submission of Reconsiderations	Request must clearly indicate that this is a request for a RECONSIDERATION within 95 days of payment, reduction or denial. Provide a clear explanation that supports the health care provider's opinion. 28 TAC §133.250	Must submit in accordance with 28 TAC §133.250 within 11 months of the date of service
Payment amount	Paid in accordance with network provider contract	Paid in accordance with DWC Fee guidelines
Compensability Disputes	Carrier determines compensability. Carrier must notify health care provider in writing of compensability disputes and may not deny payment until notice of dispute is issued. Carrier is liable for a maximum of $7000 total.	Carrier determines compensability and must issue plain language notice. 28 TAC §124.3
Medical Necessity Disputes	Follow the provision of 28 TAC §10.103 & §10.104. File appeal with URA. IRO available after the second denial or immediately if a life threatening condition. TDI assigns the IRO.	Follows Rule §133.308. Provider must file a request for dispute resolution with TDI. TDI assigns the IRO.
Fee Disputes	Follows the network's process. After carrier has processed the reconsideration send complaint to CorCare® or may file complaint with TDI	Follows §133.307. If dissatisfied may request judicial review

Back to Top of Page

3. Texas CorCare® Network Call Center

The Texas CorCare® Network Call Center will be available to assist network participants in all aspects of the network process.

Still, reconsiderations (appeals) of bills should be sent to the carrier and appeals of preauthorizations should be sent to the carrier's utilization review agent.

When contacting the call center please provide the following information:

. Insurance Carrier's Name
. Employer's Name
. Employee's Name
. Employee's Social Security Number
. Employee's Date of Birth
. Employee's place of residence
. Workers' Compensation Claim Number
. Date of Injury
. Your contact information

As a network participant do not hesitate to contact the call center when questions or issues arise.

Texas CorCare® Network Call Center

Address:         CorVel Corporation, ATTN: CorCare®
                          15303 Dallas Parkway, Suite 300
                                  Addison, TX 75001

Toll Free Number:           866-353-9768

E-mail:         Texas_corcare@corvel.com

Provider List:               www.corvel.com

1. Go to www.corvel.com
2. Select Texas CorCare® Network
3. Enter your search criteria and click Find Providers

Back to Top of Page

4. Employer Network Implementation

Network Requirements

The network requirements include the document titled Network Requirements, Employee Information, Responsibilities, the service area maps, and the network provider list. Copies are available from your insurance carrier. This is to be provided to all employees and posted at the work site.

Acknowledgement Form

This form has a place for the employee to sign showing that your employees have received notice of the network requirements. Copies are available from your insurance carrier.

Forms Handling

. The forms must be in English, Spanish and any language common to 10% of employees

. Obtain a signed acknowledgement form from each employee. (This may be done with electronic signature provided that a paper version is available upon request.)

. Keep the signed acknowledgement forms. There must be a standardized process for delivering the notice of network requirements and the acknowledgement forms. Document to whom it was delivered, the method of delivery, the location of delivery and the date or dates of delivery

. Provide each employee with a copy of the Network Requirements. This must done:

o When the network is contracted

o Within 3 days of hire

o And at the time of injury

. Post the network requirements at each place of employment

Note: An injured employee is not required to comply with the network requirements until the injured employee receives the notice

Employees Who Are Under Care When Network Is Contracted

. An employee is presumed to live at the physical address given to the employer as his or her address, or if the employee no longer works for the employer, the physical address on file with the carrier

. An employee who is under care for a work injury must choose a network treating doctor when the carrier informs them that health care services are being provided through the network. This applies to employees who live within the service area of a network and who are being treated for an injury that occurred before the network contract

. The carrier shall provide the network requirements to the employee

. If the employee does not choose a treating doctor within 14 days after they receive the network requirements, the network may assign a treating doctor

Injured Employees Who Live Or May Live Outside The Service Area

. An injured employee who does not live within the service area may choose to participate in the network upon mutual agreement with the carrier

. Injured employees who state that they live outside of the network service area may notify the insurance carrier. The carrier will then review this and determine if the injured employee lives in the service area. The carrier will within 7 days send written notification to the injured employee and the employer. If the injured employee disagrees with the carrier's determination, the employee may file a complaint with the Texas Department of Insurance

Back to Top of Page

5. Network Requirements

The network requirements that must be given to the employees consists of the acknowledgement form, the document titled "Network Requirements, Employee Information, Responsibilities", the description of the network by county and zip codes, the service area map and the provider directory.

The network requirements must be provide in the language of the employees where that language is spoken by 10% of the employees. An English and Spanish version is provided.

Back to Top of Page