Texas Workers’ Compensation uses two systems for providing medical care to injured workers: network and non-network.
The network system applies when an employer or their insurance carrier contracts with a certified Workers’ Compensation Health Care Network (HCN). In this case, injured workers must receive care from providers and facilities within the network (except in emergencies, when the injured worker resides outside any network service area, or when the network approves out-of-network care through a referral).
The non-network system applies when an employer does not contract with an HCN. In this case, injured workers are free to choose any authorized physician to treat their compensable injuries.
A list of certified workers’ compensation HCNs can be found here.
Impact on Providers
The difference between network and non-network systems directly affects how providers deliver care, bill for services, and resolve disputes.
Eligibility to Treat
Only providers who contract with an HCN may treat injured workers covered by that network. The exceptions to this rule include the following:
- Emergencies
- When the injured worker lives outside the network service area
- When the network approves an out-of-network referral
Providers who do not join the HCN generally cannot treat the injured workers within that network for work-related injuries.
Billing Differences
- Network: Refer to the network contract for information on billing procedures, fee schedules, and electronic submission requirements.
- Non-Network: For billing and payment rules, refer to the Medical Fee Guideline conversion factors.
Dispute Resolution
- Network: Providers resolve disputes through their network’s internal complaint and appeal process.
- Non-Network: Providers resolve billing and medical necessity disputes through the DWC Medical Fee Dispute Resolution (MFDR).
Texas |
Statute/Rule |
Statute |
|
Section |
Sec. 1305.005 - Participation in Network; Notice of Network Requirements |
Subsection Text |
(a) An employer that elects to provide workers' compensation insurance coverage under the Texas Workers' Compensation Act may receive workers' compensation health care services for the employer's injured employees through a workers' compensation health care network. (b) An insurance carrier may establish or contract with networks certified under this chapter to provide health care services under the Texas Workers' Compensation Act. If an employer elects to contract with an insurance company for the provision of health care services through a network, or if a self-insured employer under Chapter 407, Labor Code, a group of employers certified to self-insure under Chapter 407A, Labor Code, or a public employer under Subtitle C, Title 5, Labor Code, elects to establish or contract with a network, the employer's employees who live within the network's service area are required to obtain medical treatment for a compensable injury within the network, except as provided by Sections 1305.006(1) and (3). (c) Notwithstanding Subsection (b), the State Office of Risk Management shall have exclusive authority to establish or contract with networks certified under this chapter to provide health care services under Chapter 501, Labor Code. (d) The insurance carrier shall provide to the employer, and the employer shall provide to the employer's employees, notice of network requirements, including all information required by Section 1305.451. The employer shall: (1) obtain a signed acknowledgment from each employee, written in English, Spanish, and any other language common to the employer's employees, that the employee has received information concerning the network and the network's requirements; and (2) post notice of the network requirements at each place of employment. (e) The employer shall provide to each employee hired after the notice is given under Subsection (d) the notice and information required under that subsection not later than the third day after the date of hire. (f) An injured employee who has received notice of network requirements but refuses to sign the acknowledgment form required under Subsection (d) remains subject to the network requirements established under this chapter. (g) The employer shall notify an injured employee of the network requirements at the time the employer receives actual or constructive notice of an injury. (h) An injured employee is not required to comply with the network requirements until the employee receives the notice under Subsection (d), (e), or (g). An insurance carrier that establishes or contracts with a network is liable for the payment of medical care under the requirements of Title 5, Labor Code, for an injured employee who does not receive notice until the employee receives notice of network requirements under this section. (i) The commissioner may adopt rules as necessary to implement this section. |
Section |
Sec. 1305.006 - Insurance Carrier Liability for Out-of-Network Health Care |
Subsection Text |
An insurance carrier that establishes or contracts with a network is liable for the following out-of-network health care that is provided to an injured employee: (1) emergency care; (2) health care provided to an injured employee who does not live within the service area of any network established by the insurance carrier or with which the insurance carrier has a contract; and (3) health care provided by an out-of-network provider pursuant to a referral from the injured employee's treating doctor that has been approved by the network pursuant to Section 1305.103. |
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