TEXAS
Provider Selection
Except in an emergency, the division shall require an employee to receive medical treatment from a doctor chosen from a list of doctors approved by the commissioner. A doctor may perform only those procedures that are within the scope of the practice for which the doctor is licensed. The employee is entitled to the employee's initial choice of a doctor from the division's list. (Tex. Lab. Code § 408.022(a))

The division shall develop a list of doctors licensed in this state who are approved to provide health care services under this subtitle. A doctor is eligible to be included on the division's list of approved doctors if the doctor: (1) registers with the division in the manner prescribed by commissioner rules; and (2) complies with the requirements adopted by the commissioner under this section.(Tex. Lab. Code § 408.023(a))

Note: This list is not the ADL, which expired 08/31/2007. TDI maintains an online listing of doctors licensed to practice in Texas through the TXCOMP Provider system. This listing can be used by injured employees to select treating doctors and other system participants to verify the status of providers. http://www.tdi.state.tx.us/wc/hcprovider/documents/healthcare9107.pdf

Change of Provider
If an employee is dissatisfied with the initial choice of a doctor from the division's list, the employee may notify the division and request authority to select an alternate doctor. The notification must be in writing stating the reasons for the change, except notification may be by telephone when a medical necessity exists for immediate change. (Tex. Lab. Code § 408.022(b))
If the injured worker is not covered by a certified workers' compensation network, the Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC) must first approve the injured worker's request to change treating doctor. To request a change of treating doctor, use DWC Form-053. (TX Dept of Insurance - Division of WC Website: http://www.tdi.state.tx.us/wc/hcprovider/locatedoctor.html )

Panels
Not addressed

Panel Provisions
See Direction of Care law.

TEXAS HCN
Employee Selects from Network
An injured employee is entitled to the employee's initial choice of a treating doctor from the list provided by the network of all treating doctors under contract with the network who provide services within the service area in which the injured employee lives. The following does not constitute an initial choice of treating doctor:
(1) a doctor salaried by the employer;
(2) a doctor providing emergency care; or
(3) any doctor who provides care before the employee is enrolled in the network, except for a doctor selected under Section 1305.105. (Tex. Ins. Code 1305.104(a))

A Service Area means a geographic area within which health care services from network providers are available and accessible to employees who live within that geographic area. (Tex. Ins. Code § 1305.004(24))

Each network shall provide that network services are sufficiently accessible and available as necessary to ensure that the distance from any point in the network's service area to a point of service by a treating doctor or general hospital is not greater than: (1) 30 miles in non-rural areas; and (2) 60 miles in rural areas. (e) Each network shall provide that network services are sufficiently accessible and available as necessary to ensure that the distance from any point in the network's service area to a point of service by a specialist or specialty hospital is not greater than: (1) 75 miles in non-rural areas; and (2) 75 miles in rural areas. (28 TAC § 10.80(d)-(e))

Change of Provider
An employee who is dissatisfied with the initial choice of a treating doctor is entitled to select an alternate treating doctor from the network's list of treating doctors who provide services within the service area in which the injured employee lives by notifying the network in the manner prescribed by the network. The network may not deny a selection of an alternate treating doctor.

(c) An employee who is dissatisfied with an alternate treating doctor must obtain authorization from the network to select any subsequent treating doctor. The network shall establish procedures and criteria to be used in authorizing an employee to select subsequent treating doctors. The criteria must include, at a minimum, whether: (1) treatment by the current treating doctor is medically inappropriate; (2) the employee is receiving appropriate medical care to reach maximum medical improvement or medical care in compliance with the network's treatment guidelines; and (3) a conflict exists between the employee and the current treating doctor to the extent that the doctor-patient relationship is jeopardized or impaired.
(d) Denial of a request for any subsequent treating doctor is subject to the appeal process for a complaint filed under Subchapter I.
(e) For purposes of this section, the following do not constitute the selection of an alternate or any subsequent treating doctor: (1) a referral made by the treating doctor, including a referral for a second or subsequent opinion; (2) the selection of a treating doctor because the original treating doctor: (A) dies; (B) retires; or (C) leaves the network; or (3) a change of treating doctor required because of a change of address by the employee to a location outside the service area distance requirements, as described by Section 1305.302(g). (f) A network shall provide that an injured employee with a chronic, life-threatening injury or chronic pain related to a compensable injury may apply to the network's medical director to use a non-primary care physician specialist that is in the network as the injured employee's treating doctor. (Tex. Ins. Code 1305.104(b)-(f)

Panels
Not addressed

Panel Provisions
See Direction of Care law for network access requirements.

Per previous discussions with TX regulators, the state has advised that if a panel posting is used, it must list all treating doctors (the network is required to identify the specialties that are treating doctors) in the approved service area.

The information on this website constitutes summary information only and does not constitute legal advice. Review of the full text of the referenced statutes and regulations may be necessary. Coventry Health Care Workers' Compensation, Inc. makes no representations or warranties about the accuracy of the information contained on this website.