What is a
Texas Workers’ Compensation Health Care Certified Network?
It is a
program that has been certified by the State of Texas to provide health
care services to you if you become injured at work.
What is
Injury Management Organization®(IMO)?
IMO is a
Certified Utilization Review agent and the parent company to IMO
Med-Select Network®. IMO provides preauthorization, case
management, and medical bill review.
How do I
find out more about the IMO Med-Select Network®?
A service
area is any county where the network operates with physicians and other
health care providers to care for injured employees. If the Network
lists a county as part of its service area there will be providers for
all zip codes in that county ready to provide health care services to
the injured employees.
What
should I do if I move to a different zip code?
Notify your
employer immediately to assist them in making sure that the Network has
service area coverage for you.
May I use
a PO Box for my official address when I participate in the Network?
No. The
Network requires a physical address in order to ensure all
communications reach the injured worker.
Where
does the Network operate?
The Network operates in the following counties or service areas:
Cameron
Collin
Dallas
Denton
Ellis
El Paso
Grayson
Henderson
Hidalgo
Hill
Hood
Hunt
Johnson
Kaufman
Navarro
Parker
Rains
Rockwall
Smith
Starr
Tarrant
Wise
Wood
Van Zandt
(a) Will I need to sign any forms to participate in the Network?
Yes. Your
employer will provide you with a Notice of Network Requirements
and an Acknowledgement form that shall be completed
and signed by you before your injury, in order for you to participate in
the network.
(b) What will happen if I choose not to sign the
acknowledgement form?
If an employee receives the Notice of Network
Requirements and refuses to sign the Acknowledgement form, they are still required to use the network.
Who is
responsible for paying for my medical care if I receive treatment
outside of the Network?
If you
receive care from an out-of-network provider, you may have to pay the
bill for health care services if it is determined that you live in the
Network service area.
Who can
be a Network Treating Doctor?
The IMO
Med-Select Network® requires your Treating Doctor to be a
physician chosen from the Network directory who is licensed as a Medical
Doctor or a Doctor of Osteopathy. The Treating Doctor must be a
specialist in Family Practice, General Practice, Internal Medicine, or
Occupational Medicine.
How do I
choose my Treating Doctor?
After an
injury, you must choose your Treating Doctor from the Network Provider
list and complete Request for Initial or Alternate Treating Doctor form # IMO MSN-1. To obtain form please contact IMO Med-Select
Network® at (888)466-6381 or email at
netcare@injurymanagement.com. If you need help choosing a Treating
Doctor, you may call the Customer Care Coordinator for assistance. There
is a list of providers on the website @
www.injurymanagement.com.
(a) May I select my HMO Primary Care Doctor for my Network Treating
Doctor?
Yes.
Prior to your injury the selection and following steps must occur:
If your
employer is participating in an HMO program, you will be asked to
complete the Workers’ Compensation Network Acknowledgement form provided
by your employer.
Once you
have completed the Network Acknowledgement form your employer will
provide you with the Selection of HMO Primary Care Physician as
Workers’ Compensation Treating Doctor form # IMO MSN-5. You will
complete this form and send to the Network.
The
Network will contact your HMO doctor to participate in the Network. If
your doctor does not agree or does not meet the Certified Network
qualification requirements to participate in the Network you must choose
a Treating Doctor from the Network list.
(b) Is an EPO Plan the same as a HMO Plan?
No. These
are two different health plans; an EPO does not qualify for the
Selection of HMO Primary Care Physician as Workers’ Compensation
Treating Doctor.
(c) If
employer is not participating in an HMO Program, but you would like to
nominate a doctor:
The
Network has a nomination form and credentialing process that must be
completed prior to any doctor being considered as a network provider.
The first step is to fill out the form which can be acquired from the
IMO website
www.injurymanagement.com or contact your employer.
The
Network will contact your doctor to participate in the Network. If your
doctor does not agree or does not meet the Certified Network
qualification requirements to participate in the Network, you must
choose a Treating Doctor from the Network list.
If you are uncertain of your company’s plan, please contact
your Workers’ Compensation Coordinator or Human Resources for
clarification.
Am I
required to see a doctor close to my residence?
Although
the Network must provide you with access to a Treating Doctor within a
30 mile radius of your residence, you can choose any Treating Doctor on
the list of Treating Doctors in the Network.
Can my
chiropractor or my orthopedic surgeon be my Treating Doctor?
No. The
Treating Doctor must be a specialist in Family Practice, General
Practice, Internal Medicine, or Occupational Medicine. For treatment by
any other type of specialist, including a chiropractor or orthopedic
surgeon, you must be referred by your Treating Doctor.
Do you
have Physicians Assistants or Advanced Nurse Practitioner (ANP) in the
Certified Network?
No. The
Certified Network does not have Physician Assistants or Advanced Nurse
Practitioner (ANP) contracted to treat injured employees at this time.
You may be treated by one of the above, if it is under the direction of
a MD in the Certified Network.
Can I
change my Treating Doctor?
You are
limited to the changes that you can make. These limits are set to ensure
that you have quality and continuity in your care.
Change #1
is called the alternate choice. When you call the Network you will be
asked to complete the Request for Initial or Alternate Treating
Doctor # IMO MSN-1. The Network will not deny your request for
your selection of an alternate choice
Change #2
and is called your subsequent change. If you have used your alternate
choice of Treating Doctor and you are still dissatisfied, you must
request and receive permission from the Network for the subsequent
change of Treating Doctor.
What do I
do if my Treating Doctor dies, retires, or leaves the Network
If your
current Treating Doctor dies, retires or leaves the Network you are
allowed a change of Treating Doctor at any time during your care.
What if I
don’t live in the service area?
If you do
not live in the service area, you are not required to receive health
care from the certified Network. You should contact ____INSURANCECARRIER____ to discuss this matter. ____INSURANCE CARRIER____ will
review your information and, within seven days, will contact you by
phone and in writing to advise you on the handling of your care.
The
Notice of Network Requirements states that I must receive medical care
from the Network if I live in the Network service area. How is “live”
defined?
Where an
employee lives includes:
the
employee’s principal residence for legal purposes, including the
physical address which the employee represented to the employer as the
employee’s address;
a
temporary residence necessitated by employment; or
a
temporary residence taken by the employee primarily for the purpose of
receiving assistance with routine daily activities because of the
compensable injury
28 Texas Administrative Code
§10.2(a) (14)
When do I
contact my claims adjuster?
You will
receive information from your employer in a separate handout to answer
this question.
What if I
need to be referred to a specialist?
If you need
a specialist, your Treating Doctor will refer you. You must go to the
health care providers in the network, except in emergencies and some
other cases. All referrals to a specialist must be approved by your
Treating Doctor. Appointments with Specialists’ are to be set no later
than 21 days after the date of the request. If there is an urgent
medical need, a shorter time period may be appropriate.
What if I
need a specialist that is not in the Network?
If your
Treating Doctor decides there is no provider or facility in the Network
that can provide the treatment you need for your compensable injury, he
or she will contact the Network for permission to send you to a provider
outside of the Network.
Your
Treating Doctor is required to submit to the Network a completed
referral form called Request for Out-of-Network Specialist form # IMO MSN- 4. The Network will approve or deny the referral
request within seven (7) days of receiving this form from the
Treating Doctor.
You and
your Treating Doctor will be notified by telephone and in writing if the
request is not approved. The notice will also explain the appeal
process.
What is
Medical Case Management?
When you
are injured at work you will be provided with a Telephonic Case Manager
(TCM) to assist with coordination of your medical needs. A TCM is a
Licensed Nurse Case Manager that will help coordinate the medical
services that your doctor recommends. The TCM will also provide
education and help with communication between you and your doctor and
employer. The Network wants you to have the best quality of care and a
safe stay at work/return to work.
What is
considered to be an emergency?
As defined by the Texas Insurance Code:
“Medical
Emergency” – means the sudden onset of a medical condition manifested by
acute symptoms of sufficient severity, including severe pain, that the
absence of immediate medical attention could reasonably be expected to
result in:
placing
the patient’s health or bodily functions in serious jeopardy; or
serious
dysfunction of any body organ or part
How do I
receive emergency care?
You should
seek treatment from the nearest urgent care facility or hospital
emergency room if emergency care is necessary. The Network provider
directory will list urgent care centers and hospitals that participate
in the Network.
How can I
get a Network provider directory?
Your
employer will have a Network provider directory available. A Network
provider directory also will be available at:
Some
medical services must be approved in advance. Unless there is an
emergency need, the Network must approve all of the following health
care services before they are provided to you:
Preauthorization List
Hospital
and Surgical Care
Inpatient
admissions including length of stay and, when necessary, extending the
authorized length of stay
Inpatient
length of stay for an emergency admission, starting with the first
business day after the admission
Inpatient
and outpatient surgical procedures performed in a hospital or ambulatory
surgical center (ASC)
Mental
Health Care
Psychiatric and repeat psychological evaluations
Psychological testing or psychotherapy
Biofeedback
Physical
Medicine, regardless of place of service
Osteopathic or chiropractic manipulations
Physical
or occupational therapy
Diagnostic Testing
CT myelograms and discogram CTs
Electromyelograms (EMGs) and nerve conduction velocity studies (NCVs)
Some
initial MRI’s and repeat diagnostic tests billed at $350 or greater.
Work
hardening, work conditioning, and outpatient rehabilitation regardless
of accreditation
Pain
management, chemical dependency, and weight loss
Durable
Medical Equipment (DME) billed at $500 or greater per item, either
cumulative rental or purchased. All electrical and/or neuromuscular
stimulators including transcutaneous electrical stimulators (TENS) or
interferential stimulators
Nursing
home, convalescent, and residential care and all home health care
services
Any
investigational or experimental services or devices
Treatments, services, medications, diagnostic testing or DME that falls
outside of or not recommended or not addressed by Official Disability
Guidelines (ODG)
What
happens if I am unable to work?
Your Case
Manager will work with your doctor and employer to coordinate possible
work programs to accommodate your restrictions while you are
rehabilitating.
How do I
file a complaint?
If you
are dissatisfied with any part of the Network, you may file a complaint
by completing the Complaint Form # IMO MSN- 3
You must
file the complaint within 90 days of the event about which you are
dissatisfied.
To obtain and submit this form you can contact the
NetComplaint Dept.
by:
Writing:
4100 Midway Road, Suite 1145,Carrollton, TX 75007
The
Network will respond to your complaint with a letter of acknowledgment
within seven (7) calendar days after receipt of the complaint.
Every
complaint will be investigated and resolved within (30) calendar days
after receipt of the complaint.
The
Network will send a letter to you explaining its decision and
recommendations.
How do I
file an appeal?
If you are dissatisfied with
the complaint response, you must submit your appeal either by calling the
Network at (877) 870–0638 or writing to the Network. This process does not
require a form completion, but you may use the Complaint Form # IMO MSN- 3 and
check the appropriate box to indicate that you are filing an appeal:
File the
appeal within 15 days of receiving the decision letter.
The Network will send a letter when it receives the appeal
and once again when the decision is made.
What
should I do next, if I do not agree with the Network’s complaint or
appeal resolution?
If you are dissatisfied
with the Network’s complaint or appeal resolution, you may file a
complaint with the Texas Department of Insurance (TDI). A complaint form
can be accessed at:
