Transcript Document
Bunch’s Texas Workers’ Compensation Health Care Network (HCN) Employee Presentation Responsive. Caring. Committed. Created 3-07 What is a Workers’ Compensation Health Care Network? On June 1, 2005, Texas House Bill 7 was signed into law allowing for the implementation of Health Care Networks (HCNs) for work-related injuries and illnesses. A Health Care Network (HCN) is a network of providers that has been certified by the Texas Department of Insurance (TDI) to provide workers’ compensation health care to injured workers. The network is certified by counties within a Geographic Service Area (GSA). MSIG partnered with Bunch and Associates’ certified Texas Workers’ Compensation Health Care Network to supply a panel of providers for your work-related medical care and disability needs. Responsive. Caring. Committed. 2 What does this mean to me? If you live within the approved GSA, you must use network doctors and services. Bunch’s certified HCN contains doctors, hospitals and other medical providers to provide treatment and return-to-work programs for employees injured on the job. You have access to the following: - Treating doctors and hospitals – within 30 miles non-rural areas, 60 miles in rural areas Specialty Care within 75 miles A case manager to assist with extensive treatment plans and work restrictions Choice of treating doctors from the network list You may change treating doctors once without approval. If you wish to change treating doctors again, you must get approval from Bunch. If you are enrolled in an HMO, you may request to be treated by your HMO Primary Treating Physician (PTP) if you “pre-designate” your PTP prior to your work-related injury. Your physician must agree to follow all terms and conditions of the HCN contract and comply with the Workers’ Compensation Healthcare Network Act (Chapter 1305, Insurance Code) and all applicable rules. Responsive. Caring. Committed. 3 What is a treating doctor? A treating doctor is usually the first doctor that you see for an injury that is not an emergency. The treating doctor may be any of the following: - Family Practice General Practice Internal Medicine Occupational Medicine Physical Medicine and Rehabilitation A doctor who practices in an occupational clinic or urgent care center The treating doctor will direct your treatment plan and arrange for any referrals for specialty care or services that may be needed for your injury. Some treatments or services may need to be preauthorized and your treating doctor will arrange that process with the network. (See list of medical services in your enrollment package). Responsive. Caring. Committed. 4 Exceptions You do not have to go to a network treating doctor for the following reasons: - Emergency Elect to use your pre-designated HMO Primary Care Doctor Referred by your treating doctor to a specialty not available in the network* Live outside the approved GSA area * In this instance, your treating doctor will need to obtain approval from the network. Responsive. Caring. Committed. 5 What must you do? Your employer will provide you with the enrollment materials - Read, sign the acknowledgment form and return it to your employer Procedures if you are injured at work - If you require emergency care, go to the closest emergency facility. Otherwise, report your injury to your supervisor as soon as possible. - Select a treating doctor from the certified network list - If you go to a non-network doctor, you may be responsible for the payments to that doctor. Assistance with finding an appointment with a network doctor - Check the online medical provider search at www.bunchcare.net User name: MSIG Password: msi492 - Call Bunch at 800-853-4735 ext. 1224 Responsive. Caring. Committed. 6 HCN Service Area (GSA) How do I know if I live within the approved GSA? - Your enrollment package contains a listing and map showing all counties that are in the approved HCN area. How do I find a doctor, hospital or other health care service in my area? - Your employer will be able to assist you in receiving a hard copy listing of doctors in your area - Go to the online medical provider search at www.bunchcare.net - Call the Network Referral Unit at 1-800-238-6288 and ask for the Aetna Provider Relations Department What if I do not live within the approved GSA? - You will continue to choose any treating provider regardless if the provider is in or out of network. Provider must be certified by TX Department of Workers’ Compensation as a provider in the Approved Doctor List (ADL) - As the list of approved counties increases, your location may be in an approved GSA in the future. Responsive. Caring. Committed. 7 Texas HCN Complaints If you are not happy with the care you receive under the certified HCN, you may submit a complaint. The process is outlined in the complaint attachment of your enrollment package. Your complaint will be recorded and acknowledged within 7 working days and you will receive a resolution letter within 30 calendar days. The resolution contains: - Explanation of how the complaint was resolved - Specific reasons for the resolution - Specialty of any healthcare provider who was consulted - Process to follow if you are not satisfied with the resolution It is important for you to know that the certified network cannot retaliate against anyone who files a complaint. Responsive. Caring. Committed. 8