Employee Notification Regarding the Texas Workers Compensation Health Care Network (HCN) (Title 28, Insurance, Chapter 10, Subchapter D)

Transcription

1 Employee Notification Regarding the Texas Workers Compensation Health Care Network (HCN) (Title 28, Insurance, Chapter 10, Subchapter D) Important Information about Medical Care if you have a Work-Related Injury or Illness Your employer, Mitsui Sumitomo, has chosen to provide medical care for work-related injuries and/or illnesses by using a workers compensation program certified by the Texas Department of Insurance (TDI) called a health care network (HCN). The Bunch Texas HCN is a network certified by TDI. Workers compensation carrier: Claims Management: Certified HCN: Mitsui Sumitomo Mitsui Sumitomo Bunch Texas HCN This notice tells you what you need to know about the Bunch HCN program. It describes your rights in choosing medical care if you get injured at work. At the time of an injury, you will be sent this information again to help you understand the program. What is a HCN? A workers compensation health care network (HCN) is a program that has been certified by the state. The HCN program helps manage medically necessary care through hospitals and doctors when you become injured on the job. Each HCN must include enough doctors in your area that specialize in work-related injuries. The HCN doctors must meet quality standards and provide care according to standard treatment guidelines. HCN providers agree to bill the insurance carrier for the care provided for your injury. They should not look to obtain payment from you. How do I find out more information about the network or which doctors are in my HCN? You may contact the following person for all questions or concerns: HCN Liaison Address: P.O. Box 32037, Lakeland, FL Telephone number: ext Fax number: address: TXHCN@bunchcare.com

2 This 800 number is available 24 hours a day. The contact person will be available during normal business hours. They can answer your questions about the program and how to gain access to the names of the doctors in the program. After normal business hours, you may leave a message and you will be contacted during the next business day. If you need emergency medical care, or need care after normal business hours, go to the nearest hospital or urgent care center. If you need a list of doctors, call your contact person or go to the following website: User name: MSIG Password: msi492 What happens if I get injured at work? In case of an emergency or if you need care after normal business hours, you should call 911 or go to the closest emergency room or urgent care center. As soon as possible, tell your employer that you have had an injury at work. If you do not have an emergency, you will need to choose a treating provider within the HCN. If it is not an emergency, but you need after hour care, you can get a listing of hospitals and urgent care centers by calling ext You can also access a list on the following website: User name: MSIG Password: msi492 How do I select a treating doctor? You may choose an initial treating doctor from the list of all treating doctors under contract with the HCN who provide services within the network service area. Treating doctors have been identified as, 1) the primary doctor who will give care for your workers compensation injury, 2) the primary doctor who will refer within the network for specialty care, 3) the primary doctor who will participate in case management activities with the HCN, 4) doctors who have special training to provide maximum medical improvement and impairment ratings, and 5) doctors who have agreed to provide workers compensation services under the HCN. Treating doctors include family practitioners, general practitioners, internal medicine specialists, occupational medicine specialists and clinics and urgent care clinics. If you need help in locating a treating doctor, call the toll free number listed above. You may use your HMO primary care doctor if you have pre-designated your doctor prior to your injury. Your HMO doctor must agree to give care according to the terms of the network s contract. Contact your HCN to obtain a form or you can ask your doctor to put it in writing. In order to use your HMO doctor, you must designate him or her prior to an injury. If, at any time in the future, you request a change of your doctor, you must select a provider in the HCN. If you need any help in choosing a treating doctor, contact the HCN at the following toll free number, ext

3 What happens if I already have a workers compensation injury how do I choose a treating doctor? If you already have an injury, this information is your notice that your employer or carrier will be using a HCN. You need to select a new treating doctor within 14 days of receiving this notice. If you do not make a choice within 14 days, the HCN will select a treating doctor for you. All future care must be with the new treating doctor. What if I need to get other health care services or see a specialist? Except for emergency services, your treating doctor will provide all your health care. If necessary, your treating doctor may also refer you to a HCN specialist. You will have access to timely health care services that are appropriate to your injury no later than 21 days after the date of the original request. Your HCN contact will assist you in setting up the appointment with a service provider or specialist. What if there are no doctors in my area? We do not believe there will be a problem with access to care for your injury. However, the following are situations where you may receive approval to get care with a non-network doctor: If you are temporarily not living in the network s service area If you need medical services or a specialist who is not available within the network s service area If you are an injured employee who decides to temporarily reside outside of the HCN service area If you have one of these situations, call the Workers Compensation Insurance Carrier listed on page one to receive approval for non-network care. Except for emergency situations, you should not obtain services outside of the HCN without approval. Doctors must make referrals to other HCN doctors, or request approval for non-network doctors if services are not available within the network. Non-network referrals require prior approval. The Carrier will provide a decision on access to a non-network doctor within 7 days of the request. If denied, you may appeal the decision through the HCN s complaint process. If you decide to receive health care services outside of the HCN during the Carrier s review, you may be liable for payment of those health care services if it is ultimately determined that you do live within the network service area. How is it decided whether or not I live outside of the HCN service area? Your contact will identify the HCN service area where you live. Your HCN must provide access to treating doctors or hospitals within 30 miles in non-rural areas or 60 miles in rural areas. In addition, you must have access to specialists and specialty hospitals within 75 miles. If you believe you do not have enough access to these services within these areas, contact the Insurance Carrier to receive approval for nonnetwork care. For emergency care, you are not required to seek approval for services and should treat at the nearest hospital or treating facility. The HCN will approve access to non-network care for the following situations: For employees living permanently or temporarily outside the geographic service area When referrals to specialists are not available within the network Before receipt of HCN notice of network requirements and the employee information

4 The HCN will not approve access to non-network care involving the following situations: A referral request that is not medically necessary A referral where the provider specialty is available within the network The insurance carrier will review the information and supply a written decision within 7 days of your request. While the insurance carrier is reviewing your request, you may choose to receive these services from a non-network doctor. However, you may be liable for payment if it is determined that you live within the network s service area. If the insurance carrier does not approve your request, you will be given notice of the network requirements. You also have the right to obtain and independent review if referral request is denied because it is not medically necessary. Are there any medical services that require prior approval prior to the services or to continue the services? Yes, the following services require pre-authorization: All inpatient hospital stays All outpatient surgical, physical therapy, occupational therapy, speech therapy, or ambulatory surgical services excluding the first 6 visits of PT/OT/Chiropractic Psychological testing and psychotherapy, repeat interviews, and biofeedback unless the service is part of a preauthorized or exempt rehabilitation program All external and implantable bone growth stimulators All chemonucleolysis Repeat individual diagnostic study, unless otherwise specified Work conditioning programs and work hardening programs (not evaluations) Rehabilitation programs that include (a) outpatient medical rehabilitation and (b) chronic pain management / interdisciplinary pain rehabilitation and pain pump implantation and trials All purchased or rented durable medical equipment (DME) in excess of $500 and all transcutaneous electrical nerve stimulator (TENS) units and all rental items Nursing home, convalescent, residential and all home health care service, I.V. therapy and treatments Chemical dependency programs Weight loss programs outpatient or clinic Any investigational or experimental service or device Physical Medicine and Rehabilitation Non-emergency admissions to inpatient facilities of any type including, but not limited to skilled nursing facilities

5 Elective medical services performed in an ambulatory surgery center or the outpatient surgery department of a hospital or as part of an inpatient admission Dental non-emergency services of all types All diagnostic testing including but not limited to MRI and CT Ambulance services, non-emergency transport Naturopathy What happens if the HCN does not approve my medical care? Bunch will review your doctor s proposed care against standard guidelines and make a decision. If your care is reviewed and not certified as medically necessary by Bunch s Physician Advisor or Medical Director, you may request an appeal. If you receive an adverse determination notification, you will also be sent a copy of the appeal instructions. To request an appeal you will follow the appeal instructions that are attached to the adverse determination letter. The appeal instructions include the process and phone numbers to contact. This is the HCN s internal utilization review appeals process. You may call Bunch at ext. 1224, or send in writing a request for an appeal within 30 days of receipt of the adverse determination letter. Written requests should be sent to the following address: Bunch & Associates, Inc. Attention: Texas Utilization Review Appeal 1207 Washington Street Commerce, TX Telephone: ext Fax: If you disagree with the appeal decision you can file a complaint against the network or appeal the network decision through the complaint process with the Texas Department of Insurance. (See Attachment D Description of Complaint System ) If you receive notice that the adverse determination stands, you will also receive instructions on how to request a review with an independent review organization (IRO). IRO requests must be sent within 45 days after the date of the notification. If an IRO is requested, the department will assign the IRO. The carrier or employer will pay for the IRO and is responsible for health care while the IRO is completing its review. If the IRO makes its decision and the injured worker or doctor does not seek judicial review; the carrier/employer and HCN will comply with the IRO s decision. The division of workers' compensation and the department are not considered to be parties to the medical dispute. If you obtain health care services without the approval of the HCN for any care other than emergency services, the insurance carrier may not be liable for payment and you may be liable for payment for that health care. For all health care services other than emergency services that have been approved by the HCN the health care providers may not look to you for payment of any portion of that service.

6 How do I file a complaint? If you have a complaint about any services provided by the HCN or its providers, you may file a complaint by calling, writing or ing the HCN. The HCN cannot retaliate against you, your employer, doctor or any person filing for you regarding a complaint. To file a complaint, you must contact Bunch within 90 days after the event at: Bunch & Associates, Inc. Attention: Grievance Coordinator P.O. Box Lakeland, FL Phone (800) ext. 1224, Fax grievance@bunchcare.com Upon receipt of a complaint, you will be sent an acknowledgement letter within 7 days. The letter will describe the network s complaint procedures and deadlines. Bunch will review and resolve the complaint within 30 days of receipt of the request. If you disagree with the adverse determination based on medical necessity, you may also request an Independent Review through the Texas Department of Insurance. In the event you disagree with the HCN s resolution of your complaint, you may file a complaint to the Department by obtaining a copy of the complaint form at or calling Customer Service at Or you may submit a request to the following address: HMO Division, Mail Code 103-6A Texas Department of Insurance P.O. Box Austin, Texas To expedite your request, please include the following information: your name, current physical address, telephone number, copy of the carrier/employer or HCN s determination and any information you provided to make the determination. What if I want to change my treating doctor? If you wish to change treating doctors, you may select an alternate treating doctor within the HCN where you live. You may also choose an alternate doctor if, you want a second opinion, your provider dies, retires or leaves the network, or you move. In order to change to an alternate doctor, you must notify the HCN. The HCN cannot deny your request for an alternate treating doctor. If you are dissatisfied with the alternate treating doctor and want to change providers, you must receive approval to select a subsequent doctor. The HCN will approve your request for a subsequent doctor for the following reasons: Treatment by the current treating doctor is medically inappropriate Not receiving appropriate medical care to reach maximum medical improvement Medical care is not in compliance with the network s treatment guidelines A conflict exists between the employee and the current treating doctor to the extent that the doctor-patient relationship is jeopardized or impaired

7 If the HCN denies your request for a subsequent treating doctor, you may file an appeal using the complaint process described in this document. What if a HCN doctor leaves the HCN? Your HCN has a Continuity of Care plan to make sure you receive the necessary medical care if your provider terminates from the HCN. There are two primary reasons for provider terminations: At the doctor s request At the network s request because of quality related concerns involving a medical disciplinary cause or reason, fraud or criminal activity that could cause harm to you As soon as the HCN is aware of the doctor s termination, they will contact you to advise you of your options. If you have a life-threatening condition or an acute condition for which disruption of care could harm you, your HCN will allow you to continue treatment with the terminated doctor for 90 days. The HCN will continue to reimburse the provider at the HCN contracted rate during this time period. If the HCN terminated the doctor because of a medical disciplinary cause or reason, you will not be allowed to complete treatment with that doctor and will need to find an alternate doctor. How can I find the most up to date listing of doctors in my network? Access to a list of HCN doctors with a map of the services within your area is available by calling your HCN contact person or by going to the website: User name: MSIG Password: msi492 This listing is updated monthly and will contain doctors and their specialties. Providers can be selected by specialty or name or location. TDI Information If you have concerns, complaints or questions regarding the HCN, the notification process, or your medical care after an injury at work, you can call the Texas Department of Insurance at