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§ 133.4. Written Notification to Health Care Providers of Contractual Agreements for Informal and Voluntary Networks

(a) Applicability. This section applies to health care services that are rendered between August 1, 2008, and December 31, 2010, pursuant to an informal network or voluntary network fee agreement with a health care provider in accordance with Labor Code § 413.011 and § 413.0115.

(b) Person. Under this section “person” is defined as an individual, partnership, corporation, hospital district, insurance carrier, organization, business trust, estate trust, association, limited liability company, limited liability partnership or other entity to whom an informal network or voluntary network’s fee arrangement with a health care provider is sold, leased, transferred, or conveyed on behalf of an insurance carrier. This term does not include an injured employee.

(c) Required Notice. Each informal network or voluntary network, or the insurance carrier, or the insurance carrier’s authorized agent, as appropriate, shall notify each affected health care provider of any person that is given access to the informal or voluntary network’s fee arrangement with that health care provider within the time and manner provided by this section.

(d) Notice. Notice to each contracted health care provider:

(1) must include the contact information for the informal or voluntary network, including, but not limited to, the name, physical address, and a toll-free telephone number accessible to all contracted health care providers;

(2) must include the following information in the body of the notice:

(A) name, physical address, and telephone number of any person that is given access to the informal or voluntary network’s fee arrangement with a health care provider; and

(B) the start date and any end date during which any person has been given access to the health care provider’s contracted fee arrangement.

(3) may be provided in an electronic format provided a paper version is available upon request by the Texas Department of Insurance, Division of Workers’ Compensation (Division); and

(4) may be provided through a website link only if the website:

(A) contains the information stated in paragraphs (1), (2)(A) and (2)(B) of this subsection; and

(B) is updated at least monthly with current and correct information.

(e) Documentation. The informal or voluntary network, insurance carrier, or the insurance carrier’s authorized agent, as appropriate, shall document the information provided in the notice as required by subsection (d) of this section, the method of delivery, to whom the notice was delivered, and the date of delivery. For the purpose of this section, a notice is determined to be delivered in accordance with § 102.4(p) of this title (relating to General Rules for Non-Commission Communications). Failure to provide documentation upon the request of the Division or failure to provide notice that complies with the requirements of Labor Code § 413.011 and this section creates a rebuttable presumption in a Division enforcement action and in a medical fee dispute that the health care provider did not receive the notification.

(f) Time of notification. Under this section:

(1) for contracts with health care providers in effect on August 1, 2008, initial notification must be made no later than November 1, 2008, and subsequent notices provided to health care providers in accordance with this section thereafter on a quarterly basis; and

(2) for contracts with health care providers entered into after August 1, 2008, initial notification must be made no later than the 30th day after the effective date of the contract and subsequent notices provided to health care providers in accordance with this section thereafter on a quarterly basis.

(g) Noncompliance. The insurance carrier is not entitled to pay a health care provider at a contracted fee negotiated by an informal network or voluntary network if:

(1) the notice to the health care provider does not meet the requirements of Labor Code § 413.011 and this section; or

(2) there are no required contracts in accordance with Labor Code § 413.011(d-1) and § 413.0115.

(h) Application of Division Fee Guideline. If the insurance carrier is not entitled to pay a health care provider at a contracted rate as outlined in subsection (g) of this section and as provided in Labor Code § 413.011(d-1), the Division fee guidelines will apply pursuant to § 134.1(e)(1) of this title (relating to Medical Reimbursement), or, in the absence of an applicable Division fee guideline, reimbursement will be based on fair and reasonable reimbursement pursuant to § 134.1(e)(3) of this title.

(i) Administrative Violations. If notice to the health care provider does not meet the requirements of this section, the insurance carrier may be held liable for administrative violations in accordance with Labor Code provisions and Division rules.

(j) Severability Clause. If a court of competent jurisdiction holds that any provision of this section is inconsistent with any statutes of this state, are unconstitutional, or are invalid for any reason, the remaining provisions of this section shall remain in full effect.

(k) Expiration. In accordance with § 413.011(d-6), the provisions of this rule shall expire on January 1, 2011. This section will continue to apply to health care services that were rendered between August 1, 2008, and December 31, 2010, pursuant to an informal network or voluntary network fee agreement with a health care provider.

The provisions of this § 133.4 adopted to be effective July 27, 2008, 33 TexReg 5701.

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At a Glance:

Title:

§ 133.4. Written Notification to Health Care Providers of Contractual Agreements for Informal and Voluntary Networks

Title:

Title 28. Insurance

Status:

Current

Usage:

New Law Rule

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