HWCN Division Home Page from the Texas Department of Insurance

HWCN Division Home

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The HMO Division, which is responsible for the regulation of HMOs, has become the Health & Workers' Compensation Networks (HWCN) Certification and Quality Assurance Division. Along with that title change, we assumed the responsibilities for the regulation of certified workers' compensation networks.

The HWCN division is made up of knowledgeable staff members who provide assistance to complainants, injured employees, enrollees, certify and regulate HMO Carriers, certified WC Networks, Utilization Review Agents (URAs), Independent Review Organizations (IROs), industry representatives and other members of the public.

Health Maintenance Organization (HMO)

On the HMO homepage, you will be able to find a variety of important information, including a listing of HMOs, HMO licensing information, a link to HMO forms and other HMO-related information.

Workers' Compensation Networks (WCN)

The HWCN division regulates Texas Workers' Compensation Networks which provide health care services to injured employees through certified health care networks. The division is responsible for the certification and regulation of the health care networks. In Texas, an employer may elect to use, but is not required to use, a certified workers’ compensation network.

The Division of Workers' Compensation (DWC) oversees the 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.

Independent Review Organization (IRO)

Independent Review Organizations (IRO) are independent third parties certified by the Texas Department of Insurance to review the medical necessity and appropriateness of health care services provided or proposed to patients. If a health benefit plan or workers' compensation carrier refuses to pay for a treatment because it does not consider the treatment medically necessary or appropriate, you may be able to have an IRO review the decision.

Utilization Review Agent (URA)

Utilization Review Agents (URA) are registered or licensed entities that review requests for health care services being provided (concurrent), proposed to be provided (prospective) or in the case of workers’ compensation, already provided (retrospective) to determine medical necessity and the appropriateness of care. The HWCN division processes applications for entities seeking registration, licensure or licensure renewal as a URA within the state of Texas. Once a URA has been approved to operate, it may perform concurrent, prospective, or retrospective medical necessity reviews for all health care carriers and workers’ compensation carriers.

Third Party Administrator (TPA)

On the Third Party Administrator (TPA) homepage, you will be able to find a variety of information, including a listing of TPAs, TPA licensing information, a link to TPA forms and other TPA-related information.

Highlights

HMOs & TPAs - HMO homepage | Third Party Administrators (TPAs) homepage | HWCN division also regulates Texas Workers' Compensation Networks.

Independent Review Organizations (IRO) - Independent third parties certified by the Texas Department of Insurance to review the medical necessity and appropriateness of health care services provided or proposed to patients.

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Texas Department of Insurance