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texas

The Benefits of utilizing a Health Care Network

Health Care Networks (HCNs) are utilized by workers’ compensation insurers and self-insured employers to provide injured workers appropriate, cost-effective medical treatment and disability management, and to ensure the claims process and medical care are moving forward.

Texas Administrative Rules and Regulation

Workers’ compensation is a state-regulated insurance program that pays medical bills and replaces some lost wages for employees who are injured at work or who have work-related diseases or illnesses.

Workers’ compensation will pay for the medical treatment of an injury or illness if:

  • The injury occurred at work or the disease or illness is job-related; and
  • The worker’s employer has workers’ compensation insurance or is certified by the Texas Department of Insurance, Division of Workers’ Compensation to self-insure.

For a complete list of administrative rules Texas Administrative codes (Chapters 102-180) visit http://www.tdi.texas.gov/wc/rules/index.html

Medical and Facility Fee Guidelines and Information

In the Texas workers compensation system, reimbursement of medical services and treatments for non-network care is determined by fee guideline rules.  These fee guideline rules are based on the Texas Worker’s Compensation Act and are adopted through the administrative rule making process.  Understanding the fee guideline rules and related resources is crucial to successful reimbursement for workers’ compensation claims. For a complete list of reimbursements for Medical, Hospital, Ambulatory Surgical Center, Pharmacy, and Dental visit https://www.tdi.state.tx.us/wc/fee/index.html .

Office of Injured Employee Counsel- Assistance to Injured Workers

The Office of Injured Employee Counsel (OIEC) is the state agency created to advocate for the injured employees of Texas. OIEC assists injured employees by: educating and providing general assistance to injured employees regarding the workers’ compensation system; providing an ombudsman once a dispute proceeding has been scheduled to assist the injured employee throughout the dispute process; referring injured employees complaints to the appropriate entities and licensing boards; and providing injured employee referrals to other local, state and federal agencies, including the Department of Assistive & Rehabilitative Services (DARS), as appropriate.

You may request assistance from the Office of Injured Employee Counsel by calling 1-866-EZE-OIEC (1-866-393-6432) or visiting their website at www.oiec.texas.gov

Complaint Form

Texas Department of Insurance has a single complaint form for worker’s compensation. A complaint may also be submitted to the Majoris® HCN by an injured worker, their representative, an employer, a health care provider, or an insurer. The complaint should include:

  • The complainant’s complete name, address, and phone number.
  • The complete name, address, and phone number of the party for which the complaint is being filed.
  • A concise description of the issue(s) with supporting documents.
  • The complete name and address of the patient, insured, or enrollee.

Complaints may be submitted via telephone, fax, mail, or email to the following:

MAJORIS

P.O. Box 1728

Lake Oswego, OR 97035

Phone:  800-525-0394   Fax:  888-353-5920

Email:  providerrelations@majorishealthsystems.com

Visit http://www.tdi.texas.gov/forms/consumer/cp012complform.pdf to print out a copy of the complaint form or submit a complaint online.