Kimberly Gonzales, Administrative Assistant Personnel
Phone (830) 569-1233
Information, Instructions, Rights and Obligations
If you are injured at work, tell your supervisor or employer immediately. The information in this notice will help you to seek medical treatment for your injury. Your employer will also help with any questions about how to get treatment. You may also contact your adjuster at the TASB Risk Management Fund (the Fund) for any questions about treatment for a work related injury. The Fund is your employer's workers' compensation coverage provider and they are working with your employer to ensure you receive timely and appropriate health care. The goal is to return you to work as soon as it is safe to do so.
How do I choose a treating doctor?
If you are hurt at work and you live in the Alliance service area, you are required to choose a treating doctor from the provider list. This is required for you to receive coverage of healthcare costs for your work related injury. A provider listing is available through the Alliance website at http://www.pswca.org
and a link to that site is also contained on the Fund's web site at http://www.tasbrmf.org
. It identifies providers who are taking new patients.
What if I live outside the service area?
If you believe you live outside of the service area, you may request a service area review by calling your adjuster.
How do I change treating doctors?
If you become dissatisfied with your first choice of a treating doctor, you can select an alternate treating doctor from the list of direct contract treating doctors in the service area where you live. The Fund will not deny a choice of an alternate treating doctor. Before you can change treating doctors a second time, you must obtain permission from your adjuster.
How are treating doctor referrals handled?
Referrals for health care services that you or your doctor request will be made available on a timely basis as required by your medical condition. Referrals will be made no later than 21 days after the request. Your doctor should refer you to another Alliance provider unless it becomes medically necessary to make a referral outside of the Alliance. You do not have to get a referral if you are in need of emergency care.
Who pays for the healthcare?
Alliance providers have agreed to seek payment from the Fund for your health care. They should not request payment from you. If you obtain health care from a doctor who is not in the Alliance without prior approval from your adjuster, you may have to pay for the cost of that care and your income benefits may be disputed. You may treat with medical providers that are not contracted with the Alliance only if one of the following situations occurs:
- Emergencies: You should go to the nearest hospital or emergency care facility.
- You do not live within an Alliance service area.
- Your treating doctor refers you to a provider or facility outside of the Alliance.
This referral must be approved by your adjuster.
How to file a complaint
You have the right to file a complaint with the Alliance. You may do this if you are dissatisfied with any aspect of direct contract program operations. This includes a complaint about the program and/or your Alliance doctor. It may also be a general complaint about the Alliance. A complainant can notify the Alliance Grievance Coordinator of a complaint by phone, from the Alliance web site http://www.pswca.org/ or in writing via mail or fax. Complaints should be forwarded to:
PSWCA (The Alliance)
Attention: Grievance Coordinator
P.O. Box 763
Austin, TX 78767-0763
A complaint must be filed with the program grievance coordinator no later than 90 days from the date the issue occurred. Texas law does not permit the Alliance to retaliate against you if you file a complaint against the program. Nor can the Alliance retaliate if you appeal the decision of the program. The law does not permit the Alliance to retaliate against your treating doctor if he or she files a complaint against the program or appeals the decision of the program on your behalf.
What to do when you are injured on the job?
If you are injured while on the job, tell your employer as soon as possible. A list of Alliance treating doctors in your service area may be available from your employer. A complete list of Alliance treating doctors is also available online at http://www.pswca.org/. Or, you may contact us directly at the following address and/or toll-free telephone number:
TASB Risk Management Fund
P.O. Box 2010
Austin, TX 78768
1 (800) 482-7276
In case of an emergency...
If you are hurt at work and it is a life threatening emergency, you should go to the nearest emergency room. If you are injured at work after normal business hours or while working outside your service area, you should go to the nearest care facility. After you receive emergency care, you may need ongoing care. You will need to select a treating doctor from the Alliance provider list. This list is available online at http://www.pswca.org/. If you do not have internet access call (800) 482-7276 or contact your employer for a list. The doctor you choose will oversee the care you receive for your work related injury. Except for emergency care you must obtain all health care and specialist referrals through your treating doctor.
Emergency care does not need to be approved in advance. "Medical emergency" is defined in Texas laws. It is a medical condition that comes up suddenly with acute symptoms that are severe enough that a reasonable person would believe that you need immediate care or you would be harmed. That harm would include your health or bodily functions being in danger or a loss of function of any body organ or part.
Report your injury to your employer as soon as you can.
Select a treating doctor from the Alliance provider list.
This list is available online at http://www.pswca.org/.
If you do not have internet access, call 800- 482-7276 or contact your employer for a list.
The following non-emergency healthcare treatment requests must be approved in advance:
- Inpatient hospital admissions
- Outpatient Surgical or ambulatory surgical services
- Spinal Surgery
- All non-exempted work hardening
- All non-exempted work conditioning
- Physical or occupational therapy except for the first six (6) visits if those six visits were done within the first 2 weeks immediately following date of injury or date of surgery
- Any investigational or experimental service
- All psychological testing and psychotherapy
- Repeat diagnostic studies greater than $350.
- All durable medical equipment (DME) in excess of $500Chronic pain management and interdisciplinary pain rehabilitation
- Drugs not included in the TDI Division of Workers' Compensation Formulary
- All narcotic medications dispensed greater than 60 days
- Any treatment or service that exceeds the Official Disability Guidelines.
The number your doctor must call to request one of these treatments is 800-482-7276, ext. 6654. If a treatment or service request is denied, we will tell you in writing. This written notice will have information about your right to request a reconsideration or appeal of the denied treatment. It will also tell you about your right to request review by an Independent Review Organization through the Texas Department of Insurance.