1305.552
If under Section 1305.551 the commissioner determines that a network, insurance carrier, or other person or third party described under Section 1305.551 has violated or is violating this chapter, rules adopted by the commissioner under this chapter, or the Labor Code or rules adopted under that code, the commissioner may: (1) suspend or revoke a […]
1305.402
(a) If a complainant notifies a network of a complaint, the network, not later than the seventh calendar day after the date the network receives the complaint, shall respond to the complainant, acknowledging the date of receipt of the complaint and providing a description of the network’s complaint procedures and deadlines. (b) The network shall […]
1305.403
(a) Each network shall maintain a complaint and appeal log regarding each complaint. The commissioner shall adopt rules designating the classification of network complaints under this section. (b) Each network shall maintain a record of and documentation on each complaint, complaint proceeding, and action taken on the complaint until the third anniversary of the date […]
1305.404
A network may not engage in any retaliatory action against an employer or employee because the employer or employee or a person acting on behalf of the employer or employee has filed a complaint against the network. Added by Acts 2005, 79th Leg., ch. 265, § 4.02, eff. Sept. 1, 2005.
1305.405
(a) A contract between a network and a provider must require the provider to post, in the provider’s office, a notice to injured employees on the process for resolving complaints with the network. (b) The notice required under Subsection (a) must include the department’s toll-free telephone number for filing a complaint. Added by Acts 2005, […]
1305.401
(a) Each network shall implement and maintain a complaint system that provides reasonable procedures to resolve an oral or written complaint. (b) The network may require a complainant to file the complaint not later than the 90th day after the date of the event or occurrence that is the basis for the complaint. (c) The […]
1305.354
(a) A utilization review agent shall maintain and make available a written description of the reconsideration procedures involving an adverse determination. The reconsideration procedures must be reasonable and must include: (1) a provision stating that reconsideration must be performed by a provider other than the provider who made the original adverse determination; (2) a provision […]
1305.302
(a) All services specified by this section must be provided by a provider who holds an appropriate license, unless the provider is exempt from license requirements. (b) The network shall ensure that the network’s provider panel includes an adequate number of treating doctors and specialists, who must be available and accessible to employees 24 hours […]
1305.303
(a) A network shall develop and maintain an ongoing quality improvement program designed to objectively and systematically monitor and evaluate the quality and appropriateness of care and services and to pursue opportunities for improvement. The quality improvement program must include return-to-work and medical case management programs. (b) The network’s governing body is ultimately responsible for […]
1305.304
Each network shall adopt treatment guidelines, return-to-work guidelines, and individual treatment protocols. The treatment guidelines and individual treatment protocols must be evidence-based, scientifically valid, and outcome-focused and be designed to reduce inappropriate or unnecessary health care while safeguarding necessary care. Treatment may not be denied solely on the basis that the treatment for the compensable […]