LIFE, HEALTH

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LIFE, HEALTH LICENSING
How to apply to modify service area or network
configuration
2007 Workers Compensation Health
Care Network Workshop
Debra Diaz-Lara, Manager, Health Workers
Compensation Network QA
Texas Department of Insurance
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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Network Modifications
Service Area or Network Configuration

What is a Service Area or Network Configuration
Modification? Any additional zip codes or
counties added to the currently
certified service area. Any zip codes or
counties removed from the currently certified
service area.
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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Network Modifications
Why would I do a Service Area or Network
Configuration Modification?
Changes required by Business growth An
employer requests additional areas of coverage
for expansion into other regions within Texas
The network wishes to seek employers in other
regions in Texas to expand the network The
provider panel is less stable and complete in
specified areas within the network Providers
are no longer available within a service area or
Additional Providers become available within a
service area
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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Network Modifications
When is a Service Area or Network
Configuration Modification Done?
28 TAC10.26 (a) A network must file a
modification request with and receive approval
from the department before the network may
expand, eliminate, or reduce an existing service
area, or add a new service area. The modification
request must be filed not later than 30 days
before implementation of the modification. 28
TAC 10.27 (a) A network must file a modification
request with and receive approval from the
department before the network makes a material
modification to its network configuration. The
modification request must be filed not later than
30 days prior to implementation of the material
modification.
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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Network Modifications
Who requests a Service Area or Network
Configuration Modification?
The network contact or compliance person may
submit the service area modification request,
however, 28 TAC 10.26 (a) requires An officer
or other authorized representative of the network
must verify the modification request by attesting
to the truth and accuracy of the information in
the modification request.
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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Network Modification
How do I request a Service Area or Network
Configuration Modification?
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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance

• The application form must be used for Service
  Area Modifications.
• The Applicant must complete Items I-IV of the
  application as applicable (i.e. contact name has
  changed since issuance of the certificate.)
• Utilize the Modifications to Service Area
  checklist to facilitate the filing.
• An officer or other authorized representative
  of the applicant must verify the application by
  attesting to the truth and accuracy of the
  information in the application.

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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Network Modification
Network Application
Item I
TYPE OF APPLICATION - CHECK THE BOX THAT
APPLIES Original application Filing Fee (5000)
? Update/Change to Original Application
? Modifications to Service Area
? Modifications to Network Configuration ?
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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Network Modifications
Network Application
Item II
ORGANIZATIONAL INFORMATION (Only if changes have
occurred. Please submit a redline version if
changes have occurred, i.e. contact name has
changed since issuance of certificate.)
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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Network Modifications
Network Application
Item III

• CONTACT INFORMATION (Only if changes have
  occurred. Please submit a redline version if
  changes have occurred.)
• Company contact for application
• Name ____________________________
• Title _____________________________
• Mailing Address___________________
• E-Mail Address ___________________
• Phone _________________ Fax ________________

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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Network Modifications
Network Application
Item IV
IV SERVICE ARRANGEMENTS (Only if changes have
occurred. Please submit a redline version if
changes have occurred.) Provide information
regarding entities performing services or
functions on behalf of the Workers Compensation
Health Care Network. If the Workers
Compensation Health Care Network is using more
than one unique arrangement of contracted
entities, please attach a separate table for each
distinct plan of operation.
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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Network Modifications
EXHIBIT 9
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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Network Modifications
Service Area and Network Configuration
Modifications - Exhibit 9
28 TAC 10.26(b) (1) requires a description and a
map of the applicants service area or areas,
with key and scale, that identifies each county,
ZIP code, partial ZIP code, or part of a county
to be served. The geographical service area (GSA)
map must include the currently approved service
area and the proposed service area. Each should
be represented in different shades or colors with
a legend describing each shade or color.
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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Network Modifications
Exhibit 11
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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Network Modifications
Exhibit 11
Maps that demonstrate the compliance with access
and availability standards are required. One
Map for each Specialty Each specialty map
displays the entire service area (i.e. If the GSA
includes 10 counties, then each specialty map
displays all 10 counties) Each Map includes the
30/60/75 mile radii or circles, as applicable
Each individual provider location shown on each
specialty map is at the center point of the radii
circle
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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Network Modifications
Exhibit 11
Provider Lists of Contracted, Credentialed
Providers for the Proposed Service Area Excel
format to allow sorting by provider specialty,
county, location of admitting privileges Access
Plans if applicable Narrative Provider
Lists Maps
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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Network Modifications
Exhibit 13
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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Network Modifications
Service Area Modifications Exhibit 13
28 TAC10.26 (b) (2) requires separate and
consolidated projections (business plan) for the
existing network, the proposed new service area
and the proposed network. The business plan is
described in 28 TAC10.22 (13).
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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Network Modifications
Exhibit 18
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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Network Modifications
Service Area or Network Configuration
Modifications Exhibit 18
A corrected Notice of Network Requirements and
Employee Information and Acknowledgement Form
must be provided to affected employees Approval
of Exhibit 18 is contingent upon approval of
Exhibits 9 and 11 and the maps and provider
lists attached to the notice must be identical as
the maps and lists provided under Exhibits 9 and
11 Please furnish a redline version that is,
strike through deleted language and underline and
bold new language. Please use black font for
changes. Please submit an attestation that no
other changes have been made to previously
approved Exhibit 18 Spanish Version
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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Network Modifications

• Service Area and Network Configuration
  Modifications
• Additional Exhibits May be Required

If there are any changes to contracts,
administrative arrangements, organizational
charts, biographical data, or management
contracts The new contracts, amendments or
charts must be filed with the Service Area or
Network Configuration Modification request.
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LIFE, HEALTH LICENSING2007
Workers Compensation Health Care Network
WorkshopTexas Department of Insurance
Network Modification
Service Area or Network
Configuration Modifications
A network must be in good standing with the
department and in compliance with all applicable
requirements under 28 TAC 10, the Insurance Code
Chapter 1305 and the Labor Code Title 5 before
the department considers the modification
request. A modification request is not
considered complete and reviewable until the
department has received all information required
by statute and rule , including any additional
information the department requests as needed to
make that determination.