General Information about health care networks:

1. What is a health care network?
2. The Service Lloyds network option
3. What are the benefits of choosing a network?
4. In-network and non-network comparison
5. Employer responsibilities
6. Employee responsibilities
7. Service areas
8. Downloadable forms

1. What is a health care network?

A network is an organization formed as a health care provider network by an organization or insurance carrier. The network is comprised of a group of doctors, hospitals, and other health care providers working together to provide health care services to injured employees.

Networks must be certified by the Texas Department of Insurance (TDI) pursuant to Chapter 1305, Insurance Code, and rules adopted by the Commissioner of Insurance.

2. The Service Lloyds network option

Service Lloyds is pleased to have partnered with CorVel® to offer Texas employers a network option through the Texas CorCare® Workers' Compensation Network, TDI certificate number 6016. Determining network eligibility will be based on the accessibility of the certified network coverage area by the employer and employees.

CorVel was founded as FORTIS in 1988 and is now publicly traded on the NASDAQ National Market System under the stock symbol CRVL. The CorVel Corporation generated over $266 million in revenue for the year ended March 31, 2006. To find out more about CorVel Corporation or CorCare, visit their website at: www.corvel.com.

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3. What are the benefits of choosing a network?

Health care networks are one of many components within HB 7 designed to remove cost drivers from the workers' compensation system while providing better care for injured employees.

Although it will take time for reforms to impact the base rates published by TDI, Service Lloyds will provide premium discounts based on eligibility requirements. If eligible, an employer may choose a network option at any point during the existing policy period, or upon renewal. If chosen mid-term during the policy, a pro rate discount will be applied to the policy.

The primary focus of networks is to provide injured employees with quality care focused on returning injured employees to work as soon as possible. Network health care providers are chosen based on their experience and ability to provide occupational care.

In some cases it had become difficult to find a provider willing to handle a work related injury, or employees were unsure about where to seek medical treatment. By participating in a health care network, employees are provided with a list of pre-approved health care providers that have agreed to network treatment protocols focused on quality care, efficient delivery of care, and return-to-work as the final goal.

Networks will ultimately be graded by TDI for effectiveness pursuant to requirements of HB7. Overall effectiveness will be based on employee access to care; return-to-work outcomes; health-related outcomes; employee satisfaction with care; health care costs and utilization of health care.

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4. 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

This is for information purposes only. Texas rules and regulations continue to change. Should this document differ from the rules and regulations of Texas those rules apply.

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5. Employer responsibilities

Failure to notify employees as prescribed by TDI will result in the loss of network enforceability for work related injuries and removal of any network premium discounts if not corrected.

Employers are required to obtain signed acknowledgement forms by each covered employee within 3 days of choosing a network option within 3-days of hire; and, at time of injury. Failure of an employer to obtain acknowledgements will result in the inability to enforce network requirements; employees are not required to comply with network requirements until receipt of this notice.

Each employer must develop a standardized process to ensure that delivery of network requirements and acknowledgement forms is accomplished. The delivery process should include to whom the information was provided; date of delivery; how delivered; and location of delivery. If an employee refuses to sign a network acknowledgement form, the employer should document the time, date, and delivery method.

All employees must be provided with the Workers' Compensation Network Employee 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 provided in the language of the employees where that language is spoken by 10% of the employees. Service Lloyds will provide both an English and Spanish version of applicable forms.

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6. Employee responsibilities

If your employer has elected to purchase workers' compensation coverage with a network option, you will be asked to sign an Acknowledgement Form outlining your responsibilities if you incur a work related injury. You will be required to use network providers even if you do not sign and return the Acknowledgement Form. Failure to ahere to the network requirements may result in you having to pay for your medical care.

In the event of an emergency, you may seek treatment for the injury at any hospital or emergency care facility. However, you will be required to utilize network providers for subsequent treatment after the emergency situation has passed. Failure to ahere to the network requirements may result in you having to pay for your medical care.

If you live within the network service area, you will be required to obtain medical treatment from a provider in the network. Network services must be sufficiently accessible and available as necessary to ensure the distance from any point in the network's service area to a point of service by a treating doctor or general hospital is not greater than 30 miles in nonrural areas and 60 miles in rural areas. The distance from any point in the network's service area to a point of service by a specialist or specialty hospital is not greater than 75 miles in nonrural areas and 75 miles in rural areas. A "rural area" is defined as a county with a population of 50,000 or less; an area that is not designated as an urbanized area by the United States Census Bureau; or any other area designated as rural under rules adopted by the commissioner.

Your employer will provide a list of providers in your area, or you may search for providers by calling CorVel or via the CorVel website at: www.corvel.com,. For more information regarding service areas, see the Service Area section.

If you incurred a work related injury prior to September 1, 2005 and the insurance carrier contracts with, or maintains a certified workers' compensation network, your insurance carrier will provide you with the notice describing network requirements and the acknowledgement form. If you live in the a service area in which the network is available, you are required to obtain future treatment from network providers.

Regardless of when your work related injury occurred, you are not required to seek medical treatment within the network if you do not live in the network's service area. Determining whether or not you live in a service area is based on:

a) employee's principal residence for legal purposes, including the physical address that the employee represented to the employer as the employee's address;
b) a temporary residence necessitated by employement; 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 work-related injury.

[28 TAC §10.2 (14)]

In the event your health insurance is provided by a maintenance organization (HMO), you may request the network allow your primary care physician (PCP) to be your treating doctor. However, your PCP must agree to follow all the terms and conditions of the network's contract and comply with the Workers' Compensation Health Care Network Act (Chapter 1305, Insurance Code) and applicable rules.

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7. Service areas

Network services must be sufficiently accessible and available as necessary to ensure the distance from any point in the network's service area to a point of service by a treating doctor or general hospital is not greater than 30 miles in nonrural areas and 60 miles in rural areas. The distance from any point in the network's service area to a point of service by a specialist or specialty hospital is not greater than 75 miles in nonrural areas and 75 miles in rural areas.

CorCare®'s Service Areas

Service Area 1 includes the following counties: Cooke, Fannin, Wise*, Denton*, Collin*, Tarrant*, Dallas*, Rockwall*, Kaufman*

Service Area 2 includes the following counties: Kendall, Medina, Comal*, Bexar*, Guadalupe*, Wilson, Atascosa

Service Area 3 includes the following counties: Washington, Austin, Waller, Montgomery*, Harris*, Fort Bend*, Chambers, Hardin*, Jefferson* Galveston*

Service Area 4 includes the following counties: Bee, Refugo, Aransas, San Patricio* , Nueces*, Kleberg, Jim Wells

Service Area 5 includes the following counties: Brooks, Kenedy, Hidalgo*, Willacy

* indicates counties with a population > 50,000

Network service areas are subject to change. To obtain more up-to-date information about a specific area, please go to the CorVel website:

. www.corvel.com
. Select Texas CorCare Network
. Ender your search criteria and click Find Providers

CorCare®'s Área De Servicio

Descripción de Área De Servicio: Son 5 áreas de servicio.
Área De Servicio # 1 Abarca los siguientes condados Cooke, Fannin, Wise*, Denton*, Collin*, Tarrant*, Dallas*, Rockwall*, Kaufman*

Área De Servicio # 2 Abarca los siguientes condados: Kendall, Medina, Comal*, Bexar*, Guadalupe*, Wilson, Atascosa

Área De Servicio # 3 Abarca los siguientes condados: Washington, Austin, Waller, Montgomery*, Harris*, Fort Bend*, Chambers, Hardin*, Jefferson* Galveston

Área De Servicio # 4 Abarca los siguientes condados: Bee, Refugo, Aransas, San Patricio*, Nueces*, Kleberg, Jim Wells

Área De Servicio # 5 Abarca los siguientes condados: Brooks, Kenedy, Hidalgo*, Willacy

* indica condados con una población > 50,000

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

Toll Free Number: 1-866-353-9768

E-mail: Texas_corcare@corvel.com

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8. Downloadable forms

. Workers' Compensation Network Employee Acknowledgement Form
      (English & Spanish)

. Notice Of Network Requirements
      (English & Spanish)

. Service Areas

o By County
o By Zip Code
o By Map

. Employer Log / Register

. Employer Network Implementation

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