(a) This section applies to all case management services as defined by Labor Code § 401.011(5-a) that are provided under Labor Code Title 5 to injured employees by an insurance carrier on or after September 1, 2011.
(b) This section does not apply to case management services:
(1) subject to Insurance Code Chapter 1305;
(2) subject to Labor Code § 504.053(b)(2); or
(3) of a health care provider subject to § 134.204 of this title (relating to Medical Fee Guideline for Workers’ Compensation Specific Services).
(c) Case managers who are certified must be certified by an established accredited organization including the National Commission for Certifying Agencies, the American Board of Nursing Specialties, or other national accrediting agencies with similar standards for case management certification. Case managers must be certified in one or more of the following areas:
(1) case management;
(2) case management administration;
(3) continuity of care;
(4) disability management;
(5) occupational health; or
(6) rehabilitation case management.
(d) When conducting evaluations to determine if case management services are required, insurance carriers shall utilize case managers who are certified in accordance with subsection (c) of this section.
(e) When providing case management services other than those specified in subsection (d) of this section, an insurance carrier shall utilize case managers who are:
(1) appropriately certified in accordance with subsection (c) of this section; or
(2) skilled, non-certified case managers as specified in subsection (f) of this section.
(f) Skilled, non-certified case managers are eligible to provide services other than those identified in subsection (d) of this section if:
(1) they meet all of the requirements of subsection (c) to sit for a case management certification examination, with the exception of work experience; and
(2) they are working under the direct supervision of an identified case manager that is certified in accordance with subsection (c) of this section in order to meet the experience requirements to sit for a case management certification examination.
(g) Individuals may only be employed or contracted as skilled, non-certified case managers as specified in subsection (f) of this section for an aggregate total of 24 months, beginning with the first month in which the individual first performs case management related services that occurs after the effective date outlined in subsection (a) of this section. After accrual of the 24 months, these individuals shall not conduct case management services until a certification is obtained in accordance with subsection (c) of this section.
(h) Insurance carriers shall be responsible for verifying and documenting in writing compliance with the requirements of subsections (d), (e) and (f) of this section. Insurance carriers shall provide this verification and documentation information to the division upon request.
(i) Claims adjusters shall not be used as case managers. This does not prohibit claims adjusters from performing claims services that are within the scope of licensure in accordance with the Insurance Code Chapter 4101.
(j) Reimbursement policies and maximum allowable reimbursement rates set forth in the adopted fee guidelines under § 134.204 of this title between the treating doctor and other health care providers does not apply to the reimbursement of case managers employed or contracted by insurance carriers under this section.
(k) If the requirements of this section are not met, the insurance carrier may be held liable for administrative violations in accordance with Labor Code provisions and division rules.
The provisions of this §137.5 adopted to be effective September 1, 2011, 35 TexReg 11378.