A State of Texas Certified Workers' Compensation Health Care

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					Aetna Workers’ Comp Access

A State of Texas
Certified Workers’ Compensation Health Care Network




                                    Enrollment Kit



  AWCA 010507
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[Date]



To Our Valued Employee,

As your employer, [CLIENT NAME] is committed to providing you with a safe place to work.
However, if you are injured on the job, we are pleased to advise you that we have chosen Aetna
Workers’ Comp Access® as our State of Texas certified workers’ compensation health care
network (WCHCN) to manage any and all of your health care needs should you have a
compensable work related injury.

Enclosed you will find the information you will need concerning the Aetna Workers’ Compensation
Health Care Network. This kit informs you on what you need to know and do prior to and at the
time of an injury, if one should occur. Please read this information carefully, and complete and
submit all required forms that are enclosed.

If you have any questions, please contact [CLIENT] [REPRESENTATIVE NAME] at [PHONE
NUMBER].

Sincerely,



[NAME, TITLE]

Cc: Employment file




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                                                        TABLE OF CONTENTS


1. WHAT YOU NEED TO DO                                                                                                         4
2. IF YOU ARE INJURED AT WORK                                                                                                  4
3. EMERGENCY AND AFTER-HOUR MEDICAL CARE                                                                                       4
4. WHAT YOU NEED TO KNOW                                                                                                       5
5. AWCA NETWORK SERVICE AREA                                                                                                   5
6. TERMS AND CONDITIONS OF NETWORK                                                                                             6
7. TREATING DOCTOR SELECTION                                                                                                   6
8. PAYMENTS TO PROVIDERS                                                                                                       7
9. CHANGING YOUR TREATING DOCTOR                                                                                               7
10. REFERRALS FOR SPECIALTY CARE                                                                                               7
11. IF YOUR DOCTOR LEAVES THE AWCA NETWORK                                                                                     8
12. OUT OF NETWORK TREATMENT                                                                                                   8
13. CARE REQUIRING PRIOR OR CONCURRENT CERTIFICATION                                                                           8
14. MEDICAL CASE MANAGEMENT                                                                                                    9
15. HOW TO FILE AN APPEAL                                                                                                      9
16. HOW TO FILE A COMPLAINT                                                                                                    10
17. EMPLOYEE RIGHTS                                                                                                            11


Enclosures:
Workers’ Compensation Network Acknowledgement Form
Map of Service Area
Provider Directory




Aetna arranges for the provision of health services. However, Aetna itself is not a provider of those services and therefore cannot guarantee any
results or outcomes. All participating providers are independent contractors and are neither employees nor agents of Aetna or its affiliates. The
availability of any particular provider cannot be guaranteed.




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1. WHAT YOU NEED TO DO:

The Aetna Workers’ Comp Access Health Care Network (AWCA Network) is supporting your
workers’ compensation carrier [CARRIER NAME] with your enrollment. All of the information
contained here is also available in several languages. Contact your [CLIENT] [REPRESENTATIVE
NAME] if there are more materials needed and for questions.

If you live in the service area described by this information, follow these three easy steps:

    •   Step 1: Client/Policy Holder Enrollment form to be filled out and sent to:

        [CLIENT REPRESENTATIVE]
        [ADDRESS and FAX number]

    •   Step 2: Complete the enclosed Workers’ Compensation Network Acknowledgement form
        describing how to get health care under workers’ compensation insurance and submit to:

        [CLIENT REPRESENATIVE NAME]
        [ADDRESS and FAX number]

    •   Step 3: Choose a TREATING DOCTOR from the list of doctors in the network provided in
        this kit or from the list of Treating Doctors your employer has posted, or go to
        awca.aetna.com to find a doctor that is in the AWCA Network. Physicians or providers that
        can be considered Treating Doctors are: General Practice, Internal Medicine, Family
        Practice and Occupation Medicine or Clinics.


2. IF YOU ARE INJURED AT WORK:

Tell your supervisor that you were injured at work as soon as possible. If it is not an emergency,
seek treatment from a doctor in the AWCA Network. You can get a list of network doctors by
asking your supervisor or visiting awca.aetna.com


3. EMERGENCY AND AFTER-HOUR MEDICAL CARE:

Call 911 or go to the nearest emergency room or urgent care center for emergencies. For after-
hours non-emergency medical care, get a list of hospitals and urgent care centers at
awca.aetna.com and tell your employer as soon as possible that you had an injury at work.




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4. WHAT YOU NEED TO KNOW:

The following outlines the terms and conditions for obtaining health care services within
Aetna Workers’ Comp Access Workers’ Compensation Health Care Network (“AWCA” and
“WCHCN”).

If you are hurt on the job and live in the service area described within this information, you must:

    1. Choose a Treating Doctor from the list of doctors in the AWCA Network within your service
       area. Please note that only physicians or providers from the following types can be
       considered Treating Doctors: General Practice, Internal Medicine, Family Practice and
       Occupational Medicine or Clinics.

    2. Or, you may ask your HMO primary care physician to agree to serve as your Treating
       Doctor. See conditions in section 6.

    3. If you already have a workers’ compensation injury, you need to choose a Treating Doctor
       within 14 days of receiving this notice. If you do not make a choice within 14 days, AWCA
       has the right to choose a Treating Doctor for you. All future care must be with your newly
       chosen Treating Doctor within the AWCA Network.

    4. If you seek health care from providers that are not in the AWCA Network without AWCA’s
       approval, other than in cases of emergency, your insurance carrier may not be responsible
       for paying the provider and you may have to pay for that health care.


5. AWCA NETWORK SERVICE AREA:

The AWCA Network has Treating Doctors, specialists, hospitals and other health care services
throughout the state of Texas, including within your service area. A complete directory of all the
providers available within your service area is enclosed in this kit for your review and to assist you
in selecting a Treating Doctor. You can also review a complete directory of all providers in the
AWCA Network throughout Texas by accessing our website at: awca.aetna.com and search “Find
a doctor” on DocFind® or by contacting your insurance carrier. All providers will be noted by
specialty type, including if they can be considered Treating Doctors. Additional information is also
provided regarding each network provider, including but not limited to: if the provider is accepting
new patients and/or if the provider is trained in maximum medical improvement and impairment
ratings. Our website is updated at least three times a week, so we encourage you to access
DocFind® routinely to see additional providers and hospitals that have become available within the
AWCA Network.

A map of the service area is enclosed for your use. This map illustrates the counties in which
AWCA is certified by the Texas Department of Insurance. For additional information, please
contact your insurance carrier.

If you do not live in the service area, your insurance carrier will make a determination within 7 days
as to whether or not they will approve treatment outside of the service area. In the interim, you can
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get treatment from a non-AWCA Network doctor until your insurance carrier makes a decision. If
you get medical care outside of the network, you might have to pay for those services if it is
determined that you live in the service area.


6. TERMS AND CONDITIONS OF NETWORK:

Your AWCA Treating Doctor will: 1) provide care for your workers’ compensation injury or illness;
2) refer you to other doctors in the network for specialty care; 3) cooperate with and participate in
case management activities; and 4) agree to provide medical services under the terms of
participation in the AWCA Network.

If you ask your HMO primary care doctor to agree to serve as your Treating Doctor; your HMO
primary care doctor must agree to: 1) provide you health care for your workers’ compensation
injury or illness; 2) refer you to other doctors in the AWCA Network for specialty care; 3) cooperate
with and participate in case management activities; and 4) agree to provide medical services under
the terms of participation within the AWCA Network.


7. TREATING DOCTOR SELECTION:

If you need help choosing a Treating Doctor or want additional information about the network or
about network providers, please contact the AWCA Network at 1-866-417-8017, or write to:

        Aetna Workers’ Comp Access
        Attention: Client/Provider Relations Liaison
        151 Farmington Ave. RC 61
        Hartford, CT 06156
        Fax Number: 860-273-1954
        Email: AWCATXHCNProviderMailbox@aetna.com

You may call the toll-free number above 24 hours a day, seven days a week. A contact person is
available during normal business hours. After normal business hours, weekends, and holidays,
you may leave a message and someone will call you on the next business day.

All AWCA Network providers have agreed to seek payment for their services only from your
insurance carrier.

If you obtain approval from AWCA to seek treatment with a non-AWCA Network provider, AWCA
will arrange with the non-network provider for services to be provided in a timely manner and within
timeframes appropriate to your circumstances and condition.

In cases of true and legitimate emergencies, call 911 and seek care with the nearest emergency
room or urgent care center in your area regardless of their participation status in the AWCA
Network. All emergency services will be paid by your insurance carrier for any emergency care
needed to treat your work related injury or condition.

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Please note: Except in cases of emergency, your insurance carrier may not be liable, you may
have to pay for services and treatment that you seek out of network if not approved in advance by
AWCA.


8. PAYMENTS TO PROVIDERS:

You do not have to pay for your medical care if you get treatment for your work related injury from
an AWCA Network Treating Doctor or a network specialist that you were referred to by your
Treating Doctor. Also, you do not have to pay for your medical care provided to you from your
HMO primary care doctor for a work related injury, as long as your HMO primary care doctor has
agreed to the terms of the Aetna WCHCN. Those medical bills will be paid by the insurance
carrier.

If you decide to get medical care from an out of network provider, you may have to pay for those
services, except for emergency care.


9. CHANGING YOUR TREATING DOCTOR:

You can change your Treating Doctor at least once during the course of treatment without the need
of obtaining approval from AWCA.

Additionally, you do not need to obtain approval from AWCA if you change your Treating Doctor for
one of the following reasons:

    •   for a second opinion
    •   if your Treating Doctor dies
    •   if your Treating Doctor retires
    •   if your Treating Doctor leaves the AWCA Network
    •   you move outside of the service areas outlined on the enclosed map

Simply choose another Treating Doctor from the AWCA Network listing of Treating Doctors.

If you change your Treating Doctor more than once, the change must be approved by AWCA.


10. REFERRALS FOR SPECIALTY CARE:

Only your Treating Doctor can determine and provide you with a referral to seek treatment with a
specialist. You are only able to seek care by a specialist through a referral from your Treating
Doctor. The specialist must be participating in the AWCA Network.

If your Treating Doctor determines that the specialist you need is not available in the AWCA
Network, your Treating Doctor may call AWCA for approval to have a specialist outside the AWCA
Network treat you.

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In cases of emergency, you do not need a referral for Specialty Care. Seek treatment at the
nearest emergency room, or call 911. Please refer to section 3 “Emergency and after-hour medical
care.”


11. IF YOUR DOCTOR LEAVES THE AWCA NETWORK:

If your doctor leaves the AWCA Network, your employer will tell you the options for continued
medical care. If your condition is acute or life threatening and might be harmed by a change of
doctor, you will be allowed to continue treatment with the doctor for 90 days. If the doctor leaves
the network because of medical disciplinary reasons, you will not be allowed to continue treatment
with the doctor. You will need to find an alternate doctor. Contact your employer or case manager
for advice on your options. Also, please refer to section 9 “Changing your Treating Doctor.”


12. OUT OF NETWORK TREATMENT:

You may treat with an out of network doctor without pre-approval if you need emergency care. All
other out of network treatment must be pre-approved by the AWCA Network.

You may be allowed to get out of network treatment if:
   • you do not live in the network service area
   • you need medical care that is not available in the network service area
   • you are an injured employee who temporarily lives outside of the network service area
      during recovery
   • you did not receive the AWCA Network employee information

Call your workers’ compensation representative to receive approval for out of network care.


13. CARE REQUIRING PRIOR OR CONCURRENT CERTIFICATION:

Medical treatment that may require PRE CERTIFICATION AND/OR CONCURRENT
CERTIFICATION review includes any of the following:

    •   Hospital Admissions
    •   Surgery including injections
    •   Physical, Occupational and Chiropractic treatment or rehabilitation programs include
        Chronic Pain Management, Work Hardening, Work Conditioning, or similar programs or
        services
    •   Psychological testing and therapy
    •   Durable medical equipment, including implanted devices
    •   Diagnostic tests
    •   Experimental or investigational service, device, treatment or drug
    •   Home health services


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    •   In-patient or clinic services, treatments, or programs include weight loss, nursing home,
        chemical dependency, addictions
    •   Narcotic, anti-psychotic, or other drug prescriptions outside of adjuster authorization
    •   Specialist Referrals outside of adjuster authorization

When initial treatment is approved but continued treatment may be necessary, the
TREATING DOCTOR will need to call for concurrent or ongoing review for any service listed
above.


14. MEDICAL CASE MANAGEMENT:

If you are injured on the job, you may work with a Medical Case Manager. This case manager is a
nurse who will help you with your medical treatment, finding the right doctor, and getting back to
work. Your case manager can also answer any questions you have about the AWCA Network.


15. HOW TO FILE AN APPEAL:

Appeals process for DENIED PRE CERTIFICATION AND/OR CONCURRENT
CERTIFICATION:

AWCA and/or our designee will review your doctor’s request to approve treatment and give you
and your doctor a written determination. If the request is not certified, you may request an appeal.

To request an appeal, you can call or write AWCA at:

                Aetna Workers’ Comp Access Network
                Attention: Client/ Provider Relations Liaison
                151 Farmington Ave. RC 61
                Hartford, CT 06156
                1-866-417-8017
                Fax number 1-860-273-1954
                Email: AWCATXHCNProviderMailbox@aetna.com

You may call the toll-free number above 24 hours a day. A contact person is available during
normal business hours. After normal business hours, on weekends and holidays, you may leave a
message and someone will call you during the next business day.

The written appeal must contain:

    •   Your name, address, and phone number
    •   Your employer’s name, address and phone number
    •   The names, addresses, and phone numbers of all providers relevant to the appeal
    •   The nature of your appeal and date it occurred
    •   Any action you believe would remedy the situation

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The appeal must be received within 30 days of the receipt of written decision.

If you don’t agree with the appeal decision, you can file an appeal to the Texas Department of
Insurance. See section 16 “How to file a complaint” for more information.

If you receive a notice that upholds the denial of certifications of services, you will also receive
instructions on how to request review with an independent review organization (IRO). IRO
requests must be sent within 45 days after the date of notification. If an IRO is requested, the
Department of Insurance will assign the IRO. The insurance carrier will pay for the IRO and is
responsible for health care while the IRO is completing its review. If the IRO makes its decision,
and you or your doctor do not seek judicial review, the insurance carrier and the WCHCN will
comply with the IRO’s decision. The Division of Workers’ Compensation and the Department of
Insurance are not considered parties to the medical dispute.


16. HOW TO FILE A COMPLAINT:

You can file a complaint about any aspect of the AWCA Network operations and/or an AWCA
network provider. If you file a complaint, AWCA cannot retaliate against you, your doctor, or any
person filing a complaint for you.

    •   The complaint must be filed within 90 days after the event by calling or writing to:

                 Aetna Workers’ Comp Access
                 Attention: Client/ Provider Relations Liaison
                 151 Farmington Ave. RC 61
                 Hartford, CT 06156
                 1-866-417-8017
                 Fax number 1-860-273-1954
                 Email AWCATXHCNProviderMailbox@aetna.com

You may call the toll-free number above 24 hours a day. A contact person is available during
normal business hours. After normal business hours, on weekends and holidays, you may leave a
message and someone will call you during the next business day.

    •   Within 7 days of receiving the complaint, the AWCA Network will send you an
        acknowledgement letter

    •   Within 30 days of receiving the complaint, the AWCA will review and resolve the complaint

If you don’t agree with the resolution of your complaint, you may also file a complaint with the
Texas Department of Insurance.




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You may file a complaint with the Texas Department of Insurance at:

                HMO Division
                Mail Code 103-6A
                Texas Department of Insurance
                P.O. Box 149104
                Austin, Texas 78714-9104

To speed up the processing of your request, please include the following information:
    • Your name
    • Current physical address
    • Telephone number
    • Copy of the Insurance Carrier/Employer or WCHCN decision
    • Any information that was provided to make the decision



17. EMPLOYEE RIGHTS:

Texas law does not permit AWCA to retaliate against you if you file a complaint against the
network. AWCA also cannot retaliate if you appeal the decision of the network. The law does not
permit AWCA to retaliate against your Treating Doctor if he or she files a complaint against the
network or appeals the decision of the network on your behalf. You have the right to file a
complaint with the Texas Department of Insurance. The Texas Department of Insurance complaint
form is available on the department’s web site at www.tdi.state.tx.us or you may request a form by
writing to:

                HMO Division, Mail Code 103-6A
                Texas Department of Insurance
                P. O. Box 149104
                Austin, Texas 78714-9104




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                       Workers’ Compensation Network
                             Acknowledgement


I have received information that tells me how to get health care under workers’
compensation insurance.
If I am hurt on the job and live in the service area described in this information, I
understand that:

    1. I must choose a treating doctor from the list of doctors in the network. Or, I may
       ask my HMO primary care physician to agree to serve as my treating doctor.
    2. I must go to my treating doctor for all health care for my injury. If I need a
       specialist, my treating doctor will refer me. If I need emergency care, I may go
       anywhere.
    3. The insurance carrier will pay the treating doctor and other network providers.
    4. I might have to pay the bill if I get health care from someone other than a network
       doctor without network approval.


__________________________________                ___________________
(Signature)                                      (Date)

__________________________________
(Printed Name)

I live at              ________________________________________
                       (Street Address)
                       ____________________________________________________________


                       ________________________________________
                       (City)            (State)     (Zip Code)


Name of Employer______________________________________

Name of Network_______________________________________




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                            工傷賠償網路確認書

        我已經收到有關如何獲得工傷保險範圍內的醫療護理的通知。
     如果我在工作中受傷,並且居住在該通知中規定的承保範圍之內,我知道:

       1. 我必須在該網路內所列的醫生名單中選擇一位主治醫生。或者,要
                    求我的HMO 家庭醫生做為我的主治醫師。
       2. 所受傷患的全部治療和護理必須通過我的主治醫生。如有需要,我
         的主治醫生會介紹我到專科醫生進行治療。如需緊急護理,我可以
                              到任何地方就診。
        3. 保險承保人會負擔主治醫生和其他網路內的醫療護理提供者的費
                                    用。
       4. 如果本人在未得到網路批准的情況下,使用網路外的醫療護理, 費
                              用可能需要自付。
         ______________________________________ ___________________
                                (簽名) (日期)
                   ______________________________________
                                 姓名(印刷體)
             本人住在 ________________________________________
                                  (街道地址)
                       ____________________________________________________________

                ________________________________________
                         (城市) (州) (郵政編碼)
              雇主名稱 ______________________________________
              網路名稱 _______________________________________




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                             Recibo de información sobre
                        la Red de Compensación al Trabajador

    He recibido información sobre cómo obtener atención de salud bajo el seguro de
                              compensación al trabajador.
     Si me lesionara en el empleo y vivo dentro del área de servicio descrita en este
                               documento entiendo que:

  1.- Tengo que escoger al doctor que me va a tratar de la lista de doctores en la red. O,
           puedo preguntarle a mi médico principal del HMO si acepta tratarme.
  2.- Tengo que ir al doctor que me da el tratamiento para toda la atención que necesito
para la lesión. Si necesito un especialista el doctor que me está atendiendo tendrá que dar
 una recomendación. Si necesito atención de emergencia puedo obtenerla donde quiera.
3.- La aseguradora pagará directamente al doctor y a los otros proveedores de la red que
                                     me den tratamiento.
 4.- Es posible que yo tenga que pagar las cuentas si voy a un doctor o proveedor que no
                       está en la red y no tengo aprobación de la red.
 ___________________________________________ __________________________
                                         Firma Fecha
     Nombre en letra de imprenta:_________________________________________
     Mi domicilio: _____________________________________________________
                                         Dirección
              _____________________________________________________
              _____________________________________________________
                                 Ciudad Estado Código postal
 Nombre del empleador:__________________________________________________
 Nombre de la red _______________________________________________________




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                  Mạng Lưới Bồi Thường Tai Nạn Lao Động
                              Bản Xác Nhận

 Tôi đã nhận được thông tin trình bày về cách thức có được dịch vụ chăm sóc sức khỏe
               theo chương trình bảo hiểm bồi thường tai nạn lao động.
 Nếu tôi bị thương tích trong công việc và cư ngụ trong khu vực phục vụ được trình bày
                             trong tài liệu này, tôi hiểu rằng:

   1. Tôi phải chọn một bác sĩ điều trị từ danh sách các bác sĩ trong mạng lưới. Hoặc,
   tôi có thể yêu cầu bác sĩ chăm sóc chính của tôi trong chương trình HMO làm bác
                                      sĩ điều trị cho tôi.
   2. Tôi phải tới bác sĩ điều trị của tôi để nhận toàn bộ các dịch vụ chăm sóc chữa trị
    cho thương tích của tôi. Nếu tôi cần bác sĩ chuyên khoa, bác sĩ điều trị của tôi sẽ
     giới thiệu cho tôi. Nếu tôi cần chăm sóc khẩn cấp, tôi có thể tới bất kỳ nơi nào.
  3. Hãng bảo hiểm sẽ trả thù lao cho bác sĩ điều trị và các nhà cung cấp dịch vụ khác
                                       trong mạng lưới.
  4. Tôi có thể phải trả chi phí nếu nhận dịch vụ chăm sóc sức khỏe từ một người khác
     không phải là bác sĩ tham gia mạng lưới khi không có sự chấp thuận của mạng
                                             lưới.
         ______________________________________ ___________________
                                      (Chữ Ký) (Ngày)
                      ______________________________________
                                   (Tên Viết Bằng Chữ In)
             Tôi cư ngụ tại ________________________________________
                                    (Địa Chỉ Đường Phố)
                     ____________________________________________________________
                      ________________________________________
                          (Thành Phố) (Tiểu Bang) (Số Zip Code)
               Tên của Hãng Sở______________________________________
              Tên của Mạng Lưới_______________________________________




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