28 Tex. Admin. Code § 10.41 - Network-Carrier Contracts
(a) A network's
contract with a carrier must include the following:
(1) a description of the functions to be
performed by the network or its delegated entity, consistent with the
requirements of Insurance Code §
1305.154(b),
concerning Network-Carrier Contracts, and the reporting requirements for each
function;
(2) a statement that the
network will perform all delegated functions in full compliance with all
requirements of the Workers' Compensation Health Care Network Act, Insurance
Code Chapter 1305, concerning Workers' Compensation Health Care Networks; the
Texas Workers' Compensation Act, Labor Code Title 5, Subtitle A, concerning
Workers' Compensation; and the rules of the department and the Division of
Workers' Compensation;
(3) a
provision that the contract:
(A) may not be
terminated without cause by either party without 90 days' prior written notice;
and
(B) must be terminated
immediately if cause exists;
(4) a hold-harmless provision stating that
the network, a management contractor, a third party to which the network
delegates a function, and the network's contracted providers are prohibited
from billing or attempting to collect any amounts from an employee for health
care services for compensable injuries under any circumstances, including the
insolvency of the carrier or the network;
(5) a statement that the carrier and the
network retain ultimate responsibility for ensuring that all delegated
functions and all management contractor functions are performed in accordance
with applicable statutes and rules, and that the contract may not be construed
to limit in any way the carrier's or network's responsibility, including
financial responsibility, to comply with all statutory and regulatory
requirements;
(6) a statement that
the network's role is to provide the services listed in Insurance Code §
1305.154(b)
as well as any other services or functions the carrier delegates, including
functions delegated to a management contractor, subject to the carrier's
oversight and monitoring of the network's performance;
(7) a requirement that the network provide
the carrier, on at least a monthly basis and in a form that is usable for audit
purposes, the data necessary for the carrier to comply with reporting
requirements of the department and the Division of Workers' Compensation of the
department with respect to any services provided pursuant to the
carrier-network contract, including the following data:
(A) last name, first name, date of injury,
date of birth, sex, address, telephone number, claim number, and social
security number of each injured employee who is being served by the network,
and name and license number of the injured employee's treating
doctor;
(B) initial date of health
care services delivered by the network for each employee; and
(C) any other data, as determined by the
contract, necessary to assure proper monitoring of functions delegated to the
network by the carrier;
(8) a requirement that the carrier, the
network, any management contractor, and any third party to which the network
delegates a function comply with a provision that requires the network to
provide to the insurance carrier and department the license number of a
management contractor or any delegated third party performing any function that
requires a license under the Insurance Code or another insurance law of this
state, including a license as a utilization review agent under Insurance Code
Chapter 4201, concerning Utilization Review Agents;
(9) a contingency plan under which the
carrier would, in the event of termination of the contract or a failure to
perform, reassume one or more functions of the network under the contract,
including functions related to:
(A) payment to
providers and notification to employees, as applicable;
(B) quality of care;
(C) utilization review;
(D) continuity of care, including a plan for
identifying and transitioning employees to new providers; and
(E) collecting and reporting of data
necessary to comply with the reporting requirements described in paragraph (7)
of this subsection;
(10)
a provision that requires that any agreement by which the network delegates any
function to a third party be in writing, and that such agreement require the
delegated third party to be subject to all the requirements under Insurance
Code Chapter 1305 and this chapter;
(11) a provision that requires the network to
provide to the department the license number of a management contractor or any
delegated third party performing any function that requires a license under the
Insurance Code or another insurance law of this state, including a license as a
utilization review agent under Insurance Code Chapter 4201;
(12) an acknowledgment that:
(A) any management contractor or third party
to whom the network delegates a function must comply with this chapter and
other applicable statutes and rules, and that the management contractor or
third party is subject to the carrier's and the network's oversight and
monitoring of its performance; and
(B) if the management contractor or third
party fails to meet monitoring standards established to ensure that functions
delegated or assigned to the management contractor or third party under the
delegation contract are in full compliance with all statutory and regulatory
requirements, the carrier or network may cancel delegation of any or all
delegated functions;
(13)
a requirement that the network and any management contractor or third party to
which the network delegates a function provide all necessary information to
allow the carrier to provide the information required by §
10.60 of this title (relating to
Notice of Network Requirements; Employee Information) to employers or
employees;
(14) a provision that
requires the network to require any third party with which it contracts,
whether directly or through another third party, to permit the Commissioner to
examine at any time any information the Commissioner believes is relevant to
the third party's financial condition or the ability of the network to meet the
network's responsibilities in connection with any function the third party
performs or that has been delegated to the third party.
(15) a requirement that if the network
delegates the complaint function, the delegate must:
(A) implement and maintain a complaint system
in accordance with requirements under Insurance Code §
1305.401, concerning
Complaint System Required, and §
10.120 of this title (relating to
Complaint System Required); and
(B)
make the complaint log and complaint files available to the carrier and the
network upon request to the extent permitted by law;
(16) a statement that the contract and any
network contract with a provider, management contractor, or other third party
must not be interpreted to involve a transfer of risk as defined under
Insurance Code §
1305.004(a)(26),
concerning Definitions;
(17) a
statement that any network contract with a provider or third party must allow
the carrier to effect a contingency plan in the event that the carrier is
required to reassume functions from the network as contemplated under Insurance
Code §
1305.155, concerning
Compliance Requirements;
(18) a
statement that any network contract with a provider or third party must comply
with all applicable statutory and regulatory requirements under federal and
state law, including Insurance Code §
1305.152, concerning
Network Contracts with Providers, and §
10.42 of this title (relating to
Network Contracts with Providers); and
(19) a statement that if a network's delegate
subdelegates a network function, the delegate must first obtain the network's
consent to the subdelegation and have a delegation agreement that complies with
this section.
(b) Except
for the functions described under Insurance Code §
1305.154(b)
and §
10.121 of this title (relating to
Complaints; Deadlines for Responses and Resolution), a network's authority to
perform a function under a network-carrier contract is conditioned upon
whether:
(1) the carrier has delegated the
function to the network by contract; and
(2) the network is appropriately licensed to
perform the function.
(c)
A network must not act as a network for any entity regarding an insurance plan
being operated in violation of Insurance Code §
101.102, concerning
Unauthorized Insurance Prohibited.
Notes
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