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Subchapter A. General Provisions
Section 1305.001. Short Title - Sec. 1305.001. SHORT TITLE. This chapter may be cited as...
Section 1305.002. Purpose - Sec. 1305.002. PURPOSE. The purpose of this chapter is to:...
Section 1305.003. Limitations on Applicability - Sec. 1305.003. LIMITATIONS ON APPLICABILITY. (a) This chapter does not...
Section 1305.004. Definitions - Sec. 1305.004. DEFINITIONS. (a) In this chapter, unless the context...
Section 1305.005. Participation in Network; Notice of Network Requirements - Sec. 1305.005. PARTICIPATION IN NETWORK; NOTICE OF NETWORK REQUIREMENTS. (a)...
Section 1305.006. Insurance Carrier Liability for Out-of-Network Health Care - Sec. 1305.006. INSURANCE CARRIER LIABILITY FOR OUT-OF-NETWORK HEALTH CARE. An...
Section 1305.007. Rules - Sec. 1305.007. RULES. The commissioner may adopt rules as necessary...
Section 1305.008. Administrator Certificate of Authority Required - Sec. 1305.008. ADMINISTRATOR CERTIFICATE OF AUTHORITY REQUIRED. A person that...
Subchapter B. Certification
Section 1305.051. Certification Required - Sec. 1305.051. CERTIFICATION REQUIRED. (a) A person may not operate...
Section 1305.052. Certificate Application - Sec. 1305.052. CERTIFICATE APPLICATION. (a) A person who seeks to...
Section 1305.053. Contents of Application - Sec. 1305.053. CONTENTS OF APPLICATION. Each certificate application must include:...
Section 1305.054. Action on Application; Renewal of Certification - Sec. 1305.054. ACTION ON APPLICATION; RENEWAL OF CERTIFICATION. (a) The...
Section 1305.055. Use of Certain Insurance Terms by Network Prohibited - Sec. 1305.055. USE OF CERTAIN INSURANCE TERMS BY NETWORK PROHIBITED....
Section 1305.056. Restraint of Trade; Application of Certain Laws - Sec. 1305.056. RESTRAINT OF TRADE; APPLICATION OF CERTAIN LAWS. (a)...
Subchapter C. General Powers and Duties of Workers' Compensation Health Care Networks
Section 1305.101. Providing or Arranging for Health Care - Sec. 1305.101. PROVIDING OR ARRANGING FOR HEALTH CARE. (a) Except...
Section 1305.102. Management Contracts - Sec. 1305.102. MANAGEMENT CONTRACTS. (a) A network may not enter...
Section 1305.103. Treating Doctor; Referrals - Sec. 1305.103. TREATING DOCTOR; REFERRALS. (a) A network shall determine...
Section 1305.104. Selection of Treating Doctor - Sec. 1305.104. SELECTION OF TREATING DOCTOR. (a) An injured employee...
Section 1305.105. Treatment by a Primary Care Physician or Provider Under Chapter 843; Recommendations Regarding Use of Preferred Provider Plan - Sec. 1305.105. TREATMENT BY A PRIMARY CARE PHYSICIAN OR PROVIDER...
Section 1305.106. Payment of Health Care Provider - Sec. 1305.106. PAYMENT OF HEALTH CARE PROVIDER. Notwithstanding any other...
Section 1305.107. Telephone Access - Sec. 1305.107. TELEPHONE ACCESS. (a) Each network shall have appropriate...
Subchapter D. Contracting Provisions
Section 1305.151. Transfer of Risk - Sec. 1305.151. TRANSFER OF RISK. A contract under this subchapter...
Section 1305.152. Network Contracts With Providers - Sec. 1305.152. NETWORK CONTRACTS WITH PROVIDERS. (a) A network shall...
Section 1305.153. Provider Reimbursement - Sec. 1305.153. PROVIDER REIMBURSEMENT. (a) The amount of reimbursement for...
Section 1305.154. Network-Carrier Contracts - Sec. 1305.154. NETWORK-CARRIER CONTRACTS. (a) Except for emergencies and out-of-network...
Section 1305.1545. Restrictions on Payment and Reimbursement - Sec. 1305.1545. RESTRICTIONS ON PAYMENT AND REIMBURSEMENT. (a) An insurance...
Section 1305.155. Compliance Requirements - Sec. 1305.155. COMPLIANCE REQUIREMENTS. (a) An insurance carrier that becomes...
Subchapter E. Financial Requirements
Section 1305.201. Network Financial Requirements - Sec. 1305.201. NETWORK FINANCIAL REQUIREMENTS. (a) Each network shall prepare...
Subchapter F. Examinations
Section 1305.251. Examination of Network - Sec. 1305.251. EXAMINATION OF NETWORK. (a) As often as the...
Section 1305.252. Examination of Provider or Third Party - Sec. 1305.252. EXAMINATION OF PROVIDER OR THIRD PARTY. If requested...
Subchapter G. Provision of Services by Network; Quality Improvement Program
Section 1305.301. Network Organization; Service Areas - Sec. 1305.301. NETWORK ORGANIZATION; SERVICE AREAS. (a) The chief executive...
Section 1305.302. Accessibility and Availability Requirements - Sec. 1305.302. ACCESSIBILITY AND AVAILABILITY REQUIREMENTS. (a) All services specified...
Section 1305.303. Quality of Care Requirements - Sec. 1305.303. QUALITY OF CARE REQUIREMENTS. (a) A network shall...
Section 1305.304. Guidelines and Protocols - Sec. 1305.304. GUIDELINES AND PROTOCOLS. Each network shall adopt treatment...
Subchapter H. Utilization Review
Section 1305.351. Utilization Review in Network - Sec. 1305.351. UTILIZATION REVIEW IN NETWORK. (a) The requirements of...
Section 1305.353. Notice of Certain Utilization Review Determinations; Preauthorization Requirements - Sec. 1305.353. NOTICE OF CERTAIN UTILIZATION REVIEW DETERMINATIONS; PREAUTHORIZATION REQUIREMENTS....
Section 1305.354. Reconsideration of Adverse Determination - Sec. 1305.354. RECONSIDERATION OF ADVERSE DETERMINATION. (a) A utilization review...
Section 1305.355. Independent Review of Adverse Determination - Sec. 1305.355. INDEPENDENT REVIEW OF ADVERSE DETERMINATION. (a) The utilization...
Section 1305.356. Contested Case Hearing on and Judicial Review of Independent Review - Sec. 1305.356. CONTESTED CASE HEARING ON AND JUDICIAL REVIEW OF...
Subchapter I. Complaint Resolution
Section 1305.401. Complaint System Required - Sec. 1305.401. COMPLAINT SYSTEM REQUIRED. (a) Each network shall implement...
Section 1305.402. Complaint Initiation and Initial Response; Deadlines for Response and Resolution - Sec. 1305.402. COMPLAINT INITIATION AND INITIAL RESPONSE; DEADLINES FOR RESPONSE...
Section 1305.403. Record of Complaints - Sec. 1305.403. RECORD OF COMPLAINTS. (a) Each network shall maintain...
Section 1305.404. Retaliatory Action Prohibited - Sec. 1305.404. RETALIATORY ACTION PROHIBITED. A network may not engage...
Section 1305.405. Posting of Information on Complaint Process Required - Sec. 1305.405. POSTING OF INFORMATION ON COMPLAINT PROCESS REQUIRED. (a)...
Subchapter J. Employee Information and Responsibilities
Section 1305.451. Employee Information; Responsibilities of Employee - Sec. 1305.451. EMPLOYEE INFORMATION; RESPONSIBILITIES OF EMPLOYEE. (a) An insurance...
Subchapter K. Evaluation of Networks; Consumer Report Card
Section 1305.502. Consumer Report Cards - Sec. 1305.502. CONSUMER REPORT CARDS. (a) Not later than December...
Section 1305.503. Confidentiality Requirements - Sec. 1305.503. CONFIDENTIALITY REQUIREMENTS. (a) As necessary to implement this...
Subchapter L. Disciplinary Actions
Section 1305.551. Determination of Violation; Notice - Sec. 1305.551. DETERMINATION OF VIOLATION; NOTICE. (a) If the commissioner...
Section 1305.552. Disciplinary Actions - Sec. 1305.552. DISCIPLINARY ACTIONS. If under Section 1305.551 the commissioner...