10.120
(a) Each network must implement and maintain a complaint system compliant with Insurance Code Chapter 1305, Subchapter I, concerning Complaint Resolution, and this subchapter that provides reasonable procedures for resolving an oral or written complaint. (b) For purposes of this subchapter, a complaint relating to a fee dispute is a complaint from a provider regarding […]
10.121
(a) Not later than seven calendar days after receipt of an oral or written complaint, a network must: (1) acknowledge receipt of the complaint in writing; (2) acknowledge the date of receipt; and (3) provide a description of the network’s complaint procedures and deadlines. (b) A network must investigate each oral or written complaint received […]
10.100
In addition to the requirements under this subchapter, the requirements of Insurance Code Chapter 4201, concerning Utilization Review Agents, apply to utilization review conducted in relation to a workers’ compensation health care network. In the event Chapter 4201 conflicts with this chapter and Insurance Code Chapter 1305, concerning Workers’ Compensation Health Care Networks, this chapter […]
10.101
(a) Screening criteria used for utilization review related to a workers’ compensation health care network must be consistent with the network’s treatment guidelines, return-to-work guidelines, and individual treatment protocols. (b) The carrier’s utilization review program must include a process for a treating doctor or specialist to request approval from the network for deviation from the […]
10.102
Former Section, titled “Notice of Certain Utilization Review Determinations; Preauthorization and Retrospective Review Requirements”, had the following source: “The provisions of this §10.102 adopted to be effective December 5, 2005, 30 TexReg 8099.” Repealed by 47 TexReg 4534, effective August 2, 2022.
276.5
(a) All employers participating in the workers’ compensation system shall post notice of the Office of Injured Employee Counsel’s (OIEC) Ombudsman Program. This notice shall be posted in the workplace where each employee is likely to see the notice on a regular basis. (b) This notice of the Ombudsman Program shall be publicly posted in […]
276.1
The following words and terms when used in this chapter shall have the following meaning, unless the context clearly indicates otherwise: (1) Office of Injured Employee Counsel (OIEC)–An independent state agency created by the 79th Texas Legislature, Regular Session, 2005, to represent the interests of injured employees in the workers’ compensation system. (2) Ombudsman–A specially […]
276.12
Former Section, titled “Procedures for Private Meetings with Unrepresented Injured Employees Prior to a Workers’ Compensation Proceeding”, had the following source: “The provisions of this §276.12 adopted to be effective February 2, 1996, 21 TexReg 512; transferred effective March 1, 2006, as published in the Texas Register June 23, 2006, 31 TexReg 5147; amended to […]
102.4
(a) All written communications to a claimant (who is either an employee, an employee’s legal beneficiary, or a subclaimant) must be sent to the most recent address or fax number supplied by the claimant. If an address has not been supplied by the claimant, the most recent address provided by the employer must be used. […]
102.5
(a) After the division is notified in writing that a claimant is represented by an attorney or other representative, all copies of written communications to the claimant will be sent to the representative as well as the claimant. Copies of settlements, notices setting benefit review conferences and hearings, and orders of the division will always […]