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. C N A . .& C 4 2 0 2 3 9 . J _ _ _ P P T 9 , z @ ? @ + , I n d i c a t o r i f N e c e s s a r y O = V/
T J W h a t s N e w T e x a s H o u s e B i l l 7 ( H B - 7 )
H e a l t h C a r e N e t w o r k s
C o v e n t r y W o r k e r s C o m p N e t w o r k
O u t o f N e t w o r k C a r e
E m p l o y e r a n d E m p l o y e e R o l e s a n d R e s p o n s i b i l i t i e s
C l a i m R o l e s a n d R e s p o n s i b i l i t i e s
C a s e M a n a g e m e n t R o l e s a n d R e s p o n s i b i l i t i e s
E m p l o y e e a n d E m p l o y e r T o o l B o x
X HB-7 V A b o l i s h e s T W C C .
C r e a t e s t h e D i v i s i o n o f W o r k e r s C o m p e n s a t i o n ( D W C ) a d m i n i s t e r e d a s a d i v i s i o n o f t h e T e x a s D e p a r t m e n t o f I n s u r a n c e ( T D I ) .
T D I a p p r o v e s a n d r e g u l a t e s t h e u s e o f m e d i c a l p r o v i d e r n e t w o r k s .
R e q u i r e s n e t w o r k s t o s e l e c t m e d i c a l t r e a t m e n t g u i d e l i n e s w h i c h n e t w o r k p h y s i c i a n s m u s t f o l l o w .
Y Health Care Networks z A l l o w s i n s u r a n c e c a r r i e r s t o c r e a t e o r c o n t r a c t w i t h a n e t w o r k .
A l l o w s v o l u n t a r y p a r t i c i p a t i o n i n a c e r t i f i e d n e t w o r k a t t h e e m p l o y e r l e v e l .
L i m i t s c h o i c e o f p h y s i c i a n t o d o c t o r s s e l e c t e d b y t h e n e t w o r k .
E m p l o y e e s r e c e i v e c a r e f o r w o r k p l a c e i n j u r i e s t h r o u g h t h e n e t w o r k I F t h e y l i v e i n t h e n e t w o r k s s e r v i c e a r e a .
Z ) Why participate in a Health Care Network? Employee selects treating doctor at time of injury.
Employer and carrier have more control over direction of care and medical treatment.
Referral to appropriate specialty care is channeled within network.
Network providers and emergency care must be available and accessible 24 hours a day, seven days a week.
Focus on treatment and return-to-work outcomes.
Improved quality of care. [ < C o v e n t r y W o r k e r s C o m p N e t w o r k C N A h a s c o n t r a c t e d w i t h C o v e n t r y t o u t i l i z e t h e C o v e n t r y W o r k e r s C o m p N e t w o r k .
T h e C o v e n t r y W o r k e r s ' C o m p N e t w o r k m e e t s a l l s t a t e a c c e s s a n d a v a i l a b i l i t y r e q u i r e m e n t s . P r i m a r y c a r e w i l l b e a v a i l a b l e w i t h i n 3 0 m i l e s i n n o n r u r a l a r e a s , a n d 6 0 m i l e s i n r u r a l a r e a s . S p e c i a l t y a n d h o s p i t a l c a r e w i l l b e a v a i l a b l e w i t h i n 7 5 m i l e s .
T h e C o v e n t r y W o r k e r s C o m p N e t w o r k i n c l u d e s a c o n t i n u o u s a n d c o m p r e h e n s i v e Q u a l i t y I m p r o v e m e n t p r o g r a m t h a t i s i n a c c o r d a n c e w i t h s t a t e s p e c i f i c r e q u i r e m e n t s . \ N C o v e n t r y W o r k e r s C o m p N e t w o r k c o n t d T h e C o v e n t r y W o r k e r s C o m p N e t w o r k i n c l u d e s a c o m p l a i n t p r o c e s s a c c e s s i b l e t o a l l i n j u r e d w o r k e r s .
T h e C o v e n t r y W o r k e r s C o m p N e t w o r k p r o v i d e s a t o l l f r e e 8 0 0 n u m b e r t o a s s i s t i n j u r e d w o r k e r s i n f i n d i n g a n e t w o r k p h y s i c i a n .
N e t w o r k s e r v i c e a r e a c u r r e n t l y c o v e r s t h e g r e a t e r T e x a s m e t r o p o l i t a n a r e a s , w i t h a n t i c i p a t e d e x t e n d e d c o v e r a g e t o i n c l u d e 9 7 % o f t h e w o r k f o r c e p o p u l a t i o n .
] Out of Network Care C a r r i e r s a r e r e s p o n s i b l e f o r o u t o f n e t w o r k c a r e i n v o l v i n g :
E m e r g e n c y c a r e .
C a r e o u t s i d e t h e s e r v i c e a r e a .
C a r e t h a t h a s b e e n r e f e r r e d a n d a p p r o v e d b y t h e c a r r i e r .
C a r e w h e r e t h e e m p l o y e e h a s n o t r e c e i v e d a p p r o p r i a t e n o t i c e o f n e t w o r k r e q u i r e m e n t s .
T h e A p p r o v e d D o c t o r s L i s t ( A D L ) r e m a i n s i n e x i s t e n c e a t l e a s t u n t i l S e p t e m b e r 1 , 2 0 0 7 f o r n o n - n e t w o r k c a r e . ^ # Role and Responsibility of Employer P r i o r t o i m p l e m e n t a t i o n , t h e e m p l o y e r m u s t p r o v i d e e a c h e m p l o y e e w i t h a l e t t e r a n d h a n d b o o k e n t i t l e d E m p l o y e e N o t i f i c a t i o n o f N e t w o r k R e q u i r e m e n t s .
E a c h e m p l o y e e m u s t s i g n a n a c k n o w l e d g e m e n t f o r m t h a t s t a t e s t h e i n f o r m a t i o n w a s r e c e i v e d .
E m p l o y e r s s h o u l d d o c u m e n t t o w h o m t h e n o t i c e w a s d e l i v e r e d , t h e m e t h o d o f d e l i v e r y , t h e l o c a t i o n o f d e l i v e r y a n d t h e d a t e o f d e l i v e r y .
A n e m p l o y e e w h o d o e s n o t s i g n t h e a c k n o w l e d g e m e n t f o r m s t i l l m u s t c o m p l y w i t h t h e n e t w o r k r e q u i r e m e n t s .
T h e e m p l o y e e h a n d b o o k i n c l u d e s i n f o r m a t i o n a b o u t t h e e m p l o y e e s r i g h t t o r e c e i v e c a r e f r o m t h e i r H M O p r i m a r y c a r e d o c t o r i f t h e y r e c e i v e g r o u p h e a l t h b e n e f i t s f r o m a n H M O . T h e H M O d o c t o r m u s t a g r e e t o a b i d e b y t h e n e t w o r k s t e r m s a n d c o n d i t i o n s . _ Z R o l e a n d R e s p o n s i b i l i t y o f E m p l o y e r c o n t d : Post notice of network requirements at each place of employment.
Provide the employee acknowledgement letter and handbook to new employees no later than the third day after the date of hire.
Provide the employee acknowledgement letter and handbook to an injured employee at the time the employer receives actual or constructive notice of an injury.
If the employee refuses to use the network, any out of network expenses may be the liability of the employee.
` ' Role and Responsibility of the Employee b R e a d a n d a c k n o w l e d g e r e c e i p t o f t h e E m p l o y e e N o t i f i c a t i o n o f N e t w o r k R e q u i r e m e n t s .
I f e m p l o y e e s w o u l d l i k e t o u s e t h e i r H M O p r i m a r y t r e a t i n g p h y s i c i a n a s t h e i r n e t w o r k t r e a t i n g d o c t o r , t h e y m u s t f i l l i n t h a t d o c t o r s n a m e a t t h e t i m e o f n o t i f i c a t i o n .
I f t h e y h a v e a n e m e r g e n c y , t h e y s h o u l d b e i n s t r u c t e d t o g e t i m m e d i a t e m e d i c a l c a r e .
W h e n a n i n j u r y o c c u r s , t h e y s h o u l d c h o o s e a t r e a t i n g d o c t o r f r o m t h e n e t w o r k l i s t .
F o r e x i s t i n g c l a i m s , t h e y s h o u l d s e l e c t a t r e a t i n g d o c t o r f r o m t h e n e t w o r k l i s t w i t h i n 1 4 d a y s o r a t r e a t i n g d o c t o r w i l l b e s e l e c t e d f o r t h e m .
2 2 a ` R o l e a n d R e s p o n s i b i l i t y o f t h e E m p l o y e e c o n t d If they wish to change a treating doctor, they must choose a doctor from the network list. Change to a third doctor requires permission from CNA.
Employees may have to pay for medical expenses if they do not use a network doctor.
V ) Role and Responsibility of Claim Adjuster D i r e c t c a r e i n t o t h e C o v e n t r y W o r k e r s C o m p N e t w o r k .
C o o r d i n a t e r e t u r n - t o - w o r k w i t h e m p l o y e r .
R e f e r o u t o f n e t w o r k r e f e r r a l r e q u e s t t o N u r s e C a s e M a n a g e r f o r r e v i e w .
D o c u m e n t s e l e c t i o n o f a l t e r n a t e t r e a t i n g d o c t o r .
A p p r o v e s u b s e q u e n t t r e a t i n g d o c t o r r e q u e s t s .
W , Role and Responsibilities of Case Management N D i r e c t c a r e i n t o t h e C o v e n t r y W o r k e r s C o m p N e t w o r k .
C o o r d i n a t e r e t u r n t o w o r k w i t h e m p l o y e r .
R e v i e w o u t o f n e t w o r k r e f e r r a l r e q u e s t s .
P r o v i d e i n - n e t w o r k a l t e r n a t i v e s t o r e q u e s t i n g p r o v i d e r o r i n j u r e d w o r k e r .
C o n t a c t H M O p r o v i d e r s , w h e n a p p l i c a b l e , t o i n f o r m t h e m o f n e t w o r k r e q u i r e m e n t s .
c l R o l e a n d R e s p o n s i b i l i t i e s o f C a s e M a n a g e m e n t c o n t d . 7 7 n Review continuity of care impact on existing claims in determining whether to transfer care into the HCN.
Facilitate selection of a network treating doctor on existing claims.
Document selection of alternate treating doctor.
Approve subsequent treating doctor requests.
Coordinate health care services and facilitate return to modified duty and full duty work.
b Employer and Employee Tool Box Visit the CLAIM page withinhttp://www.cna.comtoaccess:
Employee Communication Materials.
Frequently Asked Questions.
Agent and Employer Presentations.
Provider Look up - http://www.geoaccess.com/cvty/Client.asp; Client ID: TXHCN.
Single point of contact for provider search, provider list or provider nominations through Case Management Provider Coordinator: Alyson Arguijo 866-401-9667.
800-873-0055 for network questions.
Your CNA Client Service Director, Claim Consultant, or Case Manager.
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Avenir 65 cna_preliminal Slide 1 Whats New HB-7 Health Care Networks * Why participate in a Health Care Network? Coventry Workers Comp Network ( Coventry Workers Comp Network contd Out of Network Care $ Role and Responsibility of Employer . Role and Responsibility of Employer contd: ( Role and Responsibility of the Employee 1 Role and Responsibility of the Employee contd * Role and Responsibility of Claim Adjuster - Role and Responsibilities of Case Management 7 Role and Responsibilities of Case Management contd. Employer and Employee Tool Box Slide 17 Fonts Used Design Template
Slide Titles \ ( X ` P _PID_HLINKS _NewReviewCycle A h t t p : / / w w w . c n a . c o m / ) h t t p : / / w w w . g e o a c c e s s . c o m / c v t y / C l i e n t . a s p _㓵 CNA C N A
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. C N A . .& C 4 2 0 2 3 9 . J _ _ _ P P T 9 , z @ ? @ + , I n d i c a t o r i f N e c e s s a r y O = V/
T J W h a t s N e w T e x a s H o u s e B i l l 7 ( H B - 7 )
H e a l t h C a r e N e t w o r k s
C o v e n t r y W o r k e r s C o m p N e t w o r k
O u t o f N e t w o r k C a r e
E m p l o y e r a n d E m p l o y e e R o l e s a n d R e s p o n s i b i l i t i e s
C l a i m R o l e s a n d R e s p o n s i b i l i t i e s
C a s e M a n a g e m e n t R o l e s a n d R e s p o n s i b i l i t i e s
E m p l o y e e a n d E m p l o y e r T o o l B o x
X HB-7 V A b o l i s h e s T W C C .
C r e a t e s t h e D i v i s i o n o f W o r k e r s C o m p e n s a t i o n ( D W C ) a d m i n i s t e r e d a s a d i v i s i o n o f t h e T e x a s D e p a r t m e n t o f I n s u r a n c e ( T D I ) .
T D I a p p r o v e s a n d r e g u l a t e s t h e u s e o f m e d i c a l p r o v i d e r n e t w o r k s .
R e q u i r e s n e t w o r k s t o s e l e c t m e d i c a l t r e a t m e n t g u i d e l i n e s w h i c h n e t w o r k p h y s i c i a n s m u s t f o l l o w .
Y Health Care Networks z A l l o w s i n s u r a n c e c a r r i e r s t o c r e a t e o r c o n t r a c t w i t h a n e t w o r k .
A l l o w s v o l u n t a r y p a r t i c i p a t i o n i n a c e r t i f i e d n e t w o r k a t t h e e m p l o y e r l e v e l .
L i m i t s c h o i c e o f p h y s i c i a n t o d o c t o r s s e l e c t e d b y t h e n e t w o r k .
E m p l o y e e s r e c e i v e c a r e f o r w o r k p l a c e i n j u r i e s t h r o u g h t h e n e t w o r k I F t h e y l i v e i n t h e n e t w o r k s s e r v i c e a r e a .
Z ) Why participate in a Health Care Network? Employee selects treating doctor at time of injury.
Employer and carrier have more control over direction of care and medical treatment.
Referral to appropriate specialty care is channeled within network.
Network providers and emergency care must be available and accessible 24 hours a day, seven days a week.
Focus on treatment and return-to-work outcomes.
Improved quality of care. [ < C o v e n t r y W o r k e r s C o m p N e t w o r k C N A h a s c o n t r a c t e d w i t h C o v e n t r y t o u t i l i z e t h e C o v e n t r y W o r k e r s C o m p N e t w o r k .
T h e C o v e n t r y W o r k e r s ' C o m p N e t w o r k m e e t s a l l s t a t e a c c e s s a n d a v a i l a b i l i t y r e q u i r e m e n t s . P r i m a r y c a r e w i l l b e a v a i l a b l e w i t h i n 3 0 m i l e s i n n o n r u r a l a r e a s , a n d 6 0 m i l e s i n r u r a l a r e a s . S p e c i a l t y a n d h o s p i t a l c a r e w i l l b e a v a i l a b l e w i t h i n 7 5 m i l e s .
T h e C o v e n t r y W o r k e r s C o m p N e t w o r k i n c l u d e s a c o n t i n u o u s a n d c o m p r e h e n s i v e Q u a l i t y I m p r o v e m e n t p r o g r a m t h a t i s i n a c c o r d a n c e w i t h s t a t e s p e c i f i c r e q u i r e m e n t s . \ N C o v e n t r y W o r k e r s C o m p N e t w o r k c o n t d T h e C o v e n t r y W o r k e r s C o m p N e t w o r k i n c l u d e s a c o m p l a i n t p r o c e s s a c c e s s i b l e t o a l l i n j u r e d w o r k e r s .
T h e C o v e n t r y W o r k e r s C o m p N e t w o r k p r o v i d e s a t o l l f r e e 8 0 0 n u m b e r t o a s s i s t i n j u r e d w o r k e r s i n f i n d i n g a n e t w o r k p h y s i c i a n .
N e t w o r k s e r v i c e a r e a c u r r e n t l y c o v e r s t h e g r e a t e r T e x a s m e t r o p o l i t a n a r e a s , w i t h a n t i c i p a t e d e x t e n d e d c o v e r a g e t o i n c l u d e 9 7 % o f t h e w o r k f o r c e p o p u l a t i o n .
] Out of Network Care C a r r i e r s a r e r e s p o n s i b l e f o r o u t o f n e t w o r k c a r e i n v o l v i n g :
E m e r g e n c y c a r e .
C a r e o u t s i d e t h e s e r v i c e a r e a .
C a r e t h a t h a s b e e n r e f e r r e d a n d a p p r o v e d b y t h e c a r r i e r .
C a r e w h e r e t h e e m p l o y e e h a s n o t r e c e i v e d a p p r o p r i a t e n o t i c e o f n e t w o r k r e q u i r e m e n t s .
T h e A p p r o v e d D o c t o r s L i s t ( A D L ) r e m a i n s i n e x i s t e n c e a t l e a s t u n t i l S e p t e m b e r 1 , 2 0 0 7 f o r n o n - n e t w o r k c a r e . ^ # Role and Responsibility of Employer P r i o r t o i m p l e m e n t a t i o n , t h e e m p l o y e r m u s t p r o v i d e e a c h e m p l o y e e w i t h a l e t t e r a n d h a n d b o o k e n t i t l e d E m p l o y e e N o t i f i c a t i o n o f N e t w o r k R e q u i r e m e n t s .
E a c h e m p l o y e e m u s t s i g n a n a c k n o w l e d g e m e n t f o r m t h a t s t a t e s t h e i n f o r m a t i o n w a s r e c e i v e d .
E m p l o y e r s s h o u l d d o c u m e n t t o w h o m t h e n o t i c e w a s d e l i v e r e d , t h e m e t h o d o f d e l i v e r y , t h e l o c a t i o n o f d e l i v e r y a n d t h e d a t e o f d e l i v e r y .
A n e m p l o y e e w h o d o e s n o t s i g n t h e a c k n o w l e d g e m e n t f o r m s t i l l m u s t c o m p l y w i t h t h e n e t w o r k r e q u i r e m e n t s .
T h e e m p l o y e e h a n d b o o k i n c l u d e s i n f o r m a t i o n a b o u t t h e e m p l o y e e s r i g h t t o r e c e i v e c a r e f r o m t h e i r H M O p r i m a r y c a r e d o c t o r i f t h e y r e c e i v e g r o u p h e a l t h b e n e f i t s f r o m a n H M O . T h e H M O d o c t o r m u s t a g r e e t o a b i d e b y t h e n e t w o r k s t e r m s a n d c o n d i t i o n s . _ Z R o l e a n d R e s p o n s i b i l i t y o f E m p l o y e r c o n t d : Post notice of network requirements at each place of employment.
Provide the employee acknowledgement letter and handbook to new employees no later than the third day after the date of hire.
Provide the employee acknowledgement letter and handbook to an injured employee at the time the employer receives actual or constructive notice of an injury.
If the employee refuses to use the network, any out of network expenses may be the liability of the employee.
` ' Role and Responsibility of the Employee b R e a d a n d a c k n o w l e d g e r e c e i p t o f t h e E m p l o y e e N o t i f i c a t i o n o f N e t w o r k R e q u i r e m e n t s .
I f e m p l o y e e s w o u l d l i k e t o u s e t h e i r H M O p r i m a r y t r e a t i n g p h y s i c i a n a s t h e i r n e t w o r k t r e a t i n g d o c t o r , t h e y m u s t f i l l i n t h a t d o c t o r s n a m e a t t h e t i m e o f n o t i f i c a t i o n .
I f t h e y h a v e a n e m e r g e n c y , t h e y s h o u l d b e i n s t r u c t e d t o g e t i m m e d i a t e m e d i c a l c a r e .
W h e n a n i n j u r y o c c u r s , t h e y s h o u l d c h o o s e a t r e a t i n g d o c t o r f r o m t h e n e t w o r k l i s t .
F o r e x i s t i n g c l a i m s , t h e y s h o u l d s e l e c t a t r e a t i n g d o c t o r f r o m t h e n e t w o r k l i s t w i t h i n 1 4 d a y s o r a t r e a t i n g d o c t o r w i l l b e s e l e c t e d f o r t h e m .
2 2 a ` R o l e a n d R e s p o n s i b i l i t y o f t h e E m p l o y e e c o n t d If they wish to change a treating doctor, they must choose a doctor from the network list. Change to a third doctor requires permission from CNA.
Employees may have to pay for medical expenses if they do not use a network doctor.
V ) Role and Responsibility of Claim Adjuster D i r e c t c a r e i n t o t h e C o v e n t r y W o r k e r s C o m p N e t w o r k .
C o o r d i n a t e r e t u r n - t o - w o r k w i t h e m p l o y e r .
R e f e r o u t o f n e t w o r k r e f e r r a l r e q u e s t t o N u r s e C a s e M a n a g e r f o r r e v i e w .
D o c u m e n t s e l e c t i o n o f a l t e r n a t e t r e a t i n g d o c t o r .
A p p r o v e s u b s e q u e n t t r e a t i n g d o c t o r r e q u e s t s .
W , Role and Responsibilities of Case Management N D i r e c t c a r e i n t o t h e C o v e n t r y W o r k e r s C o m p N e t w o r k .
C o o r d i n a t e r e t u r n t o w o r k w i t h e m p l o y e r .
R e v i e w o u t o f n e t w o r k r e f e r r a l r e q u e s t s .
P r o v i d e i n - n e t w o r k a l t e r n a t i v e s t o r e q u e s t i n g p r o v i d e r o r i n j u r e d w o r k e r .
C o n t a c t H M O p r o v i d e r s , w h e n a p p l i c a b l e , t o i n f o r m t h e m o f n e t w o r k r e q u i r e m e n t s .
c l R o l e a n d R e s p o n s i b i l i t i e s o f C a s e M a n a g e m e n t c o n t d . 7 7 n Review continuity of care impact on existing claims in determining whether to transfer care into the HCN.
Facilitate selection of a network treating doctor on existing claims.
Document selection of alternate treating doctor.
Approve subsequent treating doctor requests.
Coordinate health care services and facilitate return to modified duty and full duty work.
b Employer and Employee Tool Box Visit the CLAIM page withinhttp://www.cna.comtoaccess:
Employee Communication Materials.
Frequently Asked Questions.
Agent and Employer Presentations.
Provider Look up - http://www.geoaccess.com/cvty/Client.asp; Client ID: TXHCN.
Single point of contact for provider search, provider list or provider nominations through Case Management Provider Coordinator: Alyson Arguijo 866-401-9667.
800-873-0055 for network questions.
Your CNA Client Service Director, Claim Consultant, or Case Manager.
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/ One or more of the CNA companies provide the products and/or services described. The information is intended to present a general overview for illustrative purposes only. It is not intended to substitute for the guidance of retained legal or other professional advisors or to constitute a binding contract. Please remember that only the relevant insurance policy or claim service agreement can provide the actual terms, coverages, amounts, conditions and exclusions. Use of the term "partnership" and/or "partner" should not be construed to represent a legally binding partnership. All products and services may not be available in all states and may be subject to change without notice. CNA is a service mark registered with the United States Patent and Trademark Office. Copyright 2008 CNA. All rights reserved. 0 Z 0 @a
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Avenir 65 cna_preliminal Slide 1 Whats New HB-7 Health Care Networks * Why participate in a Health Care Network? Coventry Workers Comp Network ( Coventry Workers Comp Network contd Out of Network Care $ Role and Responsibility of Employer . Role and Responsibility of Employer contd: ( Role and Responsibility of the Employee 1 Role and Responsibility of the Employee contd * Role and Responsibility of Claim Adjuster - Role and Responsibilities of Case Management 7 Role and Responsibilities of Case Management contd. Employer and Employee Tool Box Slide 17 Fonts Used Design Template
Slide Titles \ ( X ` P _PID_HLINKS _NewReviewCycle A h t t p : / / w w w . c n a . c o m / ) h t t p : / / w w w . g e o a c c e s s . c o m / c v t y / C l i e n t . a s p _
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