Sedgwick Claims Management Services, Inc. dba

Sedgwick Preferred Network

**** ********** *******, ***** ***

San Antonio, Texas 78216

Phone: 210-***-**** ● Toll-free: 1-800-***-**** ● Fax: 210-***-**** Notice of Network Requirements

Employee Information

Your employer has chosen the Sedgwick Preferred Network (SPN) to care for its injured workers. SPN is a certified workers’ compensation health care network with a wide array of treating doctors, specialists, and hospitals that are available and accessible to you 24 hours a day, seven days a week within the network’s service areas. The distance from any location in the network’s service areas to a treating doctor or general hospital is no greater than 30 miles. The distance from any location in the networks service area to a specialist or specialty hospital is no greater than 75 miles. You can locate a list of Sedgwick Preferred Network providers at the following link: www.sedgwickproviders.com/txspn. The provider website is updated at least quarterly, to include the names and addresses of network providers grouped by specialty and identifies providers who are accepting new patients. Treating doctors may be Family Practice, General Practice, Internal Medicine, Occupational Medicine, Family Nurse Practitioners, and Family Practice Physician Assistants. Providers who are authorized to assess maximum medical improvement and render impairment ratings are identified in the directory. There are no limitations of accessibility and referrals to specialists. All providers in the network have agreed to accept workers’ compensation patients.

If you live in one of these service areas you must obtain all health care and specialist referrals for a work-related injury through a treating doctor selected from the network list for the service area in which you live, except for emergencies.

Emergency Medical Care

Emergency medical services are available 24 hours a day, seven days a week. There are no restrictions regarding where emergency services may be obtained; however, emergency medical care after normal business hours is usually more readily available from a hospital emergency room or urgent care clinic. If you are injured and it is an emergency, you should seek treatment at the nearest emergency facility as soon as possible. This also applies if you are injured outside the service area or if you are injured after normal business hours. Emergency care does not need to be approved in advance. “Medical emergency” and “mental health emergencies” are defined in Texas laws. They are a medical condition that comes up suddenly. There are 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. A

“mental health emergency” means a condition could reasonably be expected to present danger to you or another person.

Except for emergency services, you are required to obtain all health care and specialist referrals through your treating doctor. The network will arrange for non-emergency services upon your request, including referrals to specialists that are accessible to you. Referrals will be made on a timely basis and within the time appropriate to your circumstances and condition, but in no event will this take longer than 21 days after the date of your request.

Accessibility and Availability

The network ensures that the network's provider panel includes an adequate number of treating doctors and specialists who are available and accessible 24 hours a day, seven days a week within the network's service area. The network includes sufficient numbers and types of health care providers to ensure you have choice, access, and quality of care.

An adequate number of treating doctors and specialists have admitting privileges at one or more network hospitals located within the network's service area to ensure that any necessary hospital admissions can be made. Hospital services are available and accessible 24 hours a day, seven days a week, within the network's service area.

The SPN network provides for the necessary hospital services by contracting with general, special, and psychiatric hospitals. Physical and occupational therapy services and chiropractic services are available and accessible within the network's service area.

Payment for Medical Care

Network health care providers will be paid by your Employer/Carrier. You will not be billed for medical care to treat a compensable injury. The network, its contracted health care providers, management contractors, or third parties to which the network has delegated a function, are prohibited from billing or attempting to collect any amounts from you for health care services under any circumstances, including the insolvency of your employer or the network. However, Texas Insurance Code Section §1305.451 (b) (6) states “if the injured employee seeks health care from a non-network provider without network approval, the Employer/Carrier may not be liable and the employee may be liable for payment of that health care except for emergency services.” Employer/Carrier Liability for Out-of-Network Health Care An Employer/Carrier that contracts with the Network is liable for out-of-network care in the following cases:

(1) emergency care;

(2) health care provided to an injured employee who does not live in the network service area;

(3) health care provided by an out-of-network provider pursuant to a referral from the injured employee’s treating doctor that has been approved by the network as follows:

(a) if an injured employee’s treating doctor requests a referral to an out-of- network provider for medically necessary health care services that are not available from network providers, the network will approve or deny a referral to an out-of-network provider within the time appropriate under the circumstances but under no circumstance longer than seven days after the date the referral is requested

(b) if the network denies the referral request because the requested service is available from network providers, the employee may file a complaint in accordance with the networks’ complaint process (see below Complaint Review Procedures)

(c) if the network denies the referral request because the specialist referral is not medically necessary, the employee may file a request for independent review.

Employees Who Do Not Live in the Service Area

If you do not live within the network’s service area you may choose to participate in the network established by your Employer/Carrier, or with which your Employer/Carrier has a contract upon mutual agreement between you and your Employer/Carrier.

It is assumed you live at the street address you gave your employer. If you no longer work for this employer, you are assumed to live at the address on file with them.

If you are no longer at the address on file with your employer or you are unsure if you live in the service area, you may ask for a review by calling 210-***-**** or 1-800-***-**** for toll-free calls (www.sedgwickproviders.com/txspn). You will be notified in writing of the network’s decision within 7 days. The notice will include a copy of the decision, a short summary of the evidence reviewed, and information about how to file a complaint with Texas Department of Insurance (TDI).

A copy of the decision will also be sent to your employer. If you do not live in the service area you may choose to receive all health care from the network while your request is reviewed.

An employee who is found to have falsely claimed to live outside the service area or misrepresented where they live and receives health care from a non-network provider, may have to pay for that treatment.

Choosing or Changing Treating Doctors

If you live within the service area you are entitled to an initial choice of a treating doctor from the list provided by the network of all treating doctors under contract

(in accordance with Texas Insurance Code Section §1305.104(a)). The network list of contracted treating providers may be obtained by calling 210- 332-1608 or 1-800-***-**** for toll-free calls (www.sedgwickproviders.com/txspn). Please note that the following do not count as an initial choice of treating doctor:

1. A doctor on your employer’s payroll.

2. A doctor providing emergency care.

3. Any doctor who provided care before you were enrolled in the network, unless the doctor was your HMO primary care doctor prior to the injury and you choose him to be your treating doctor.

Changing to an Alternate Treating Doctor

If you are unhappy with your first choice of treating doctor, you may choose another treating doctor by calling 210-***-**** or 1-800-***-**** for toll-free calls (www.sedgwickproviders.com/txspn). The network may not deny a second choice of treating doctor.

The following does not count as a second choice of treating doctor: 1. A referral by your treating doctor.

2. The selection of a new treating doctor because the previous treating doctor

a. Dies

b. Retires

c. Leaves the network

3. A change of treating doctor is needed due to a move outside the network service area.

Additional Changes of Treating Doctor

If you want to change your treating doctor a third or more times you must get an approval by filling out the “Treating Doctor Selection Form” which is available by calling 210-***-**** or 1-800-***-****, for toll-free calls

(www.sedgwickproviders.com/txspn).

For Employees Injured Prior to Their Employer’s Network Selection If you live in the service area and are being treated by a non-network provider, you must pick a new treating doctor from the network list. Exceptions to this are as follows:

1. Your current treating doctor is on the network. 2. If you are a member of an HMO at the time of the injury, you may ask your HMO primary care doctor to be your treating doctor. If your HMO primary care doctor agrees to the network’s terms and to obey applicable sections of the Texas Insurance Code, then your request will be approved. 3. An injured employee with a claim that arose on or after September 1, 2005 and before the date the employer elects the network may not be transferred into the network.

Specialists as the Treating Doctor

If you have chronic life-threatening injuries or chronic pain you may ask to use a specialist as your treating doctor. Approval may be requested by filling out the

“Treating Doctor Selection Form” available by calling 210-***-**** or 1-800- 800-3795, for toll-free calls (www.sedgwickproviders.com/txspn). If a Doctor is Terminated from the Network

In case of imminent harm to patient health, suspension or loss of license to practice or fraud, the network may terminate a provider immediately and will notify you immediately of the termination. If the provider terminates the contract, the network will provide you with notification of the termination if you are receiving care from the terminating provider. The network will give such notice immediately upon receipt of the provider’s termination request or as soon as reasonably possible before the effective date of termination. At the time you are notified of the termination, you will be entitled to choose a new treating doctor from the list of contracted providers in the network. If your doctor leaves the network and you have a life threatening or acute condition for which a disruption of care would be harmful to you, your doctor may request that you continue to treat with him or her for an extra 90 days. The network may also approve you to continue to treat with your physician for continuity of care. Adverse Decisions

An adverse decision is a determination by a Utilization Review Agent that health care services provided or proposed to be provided to a patient are not medically necessary. Adverse decisions will be sent with information on how to ask for reconsideration. Requests for reconsideration must be filed no later than 30 days after the adverse decision.

To ask for reconsideration, call 210-***-**** or 1-800-***-**** for toll-free calls. Written requests may be faxed to 210-***-**** or mailed to Sedgwick at 9601 McAllister Freeway, Ste. 500, San Antonio, TX 78216. An independent doctor will review requests for reconsideration. The network will acknowledge requests for reconsideration within 5 days. The acknowledgement may also include a list of records that need to be provided. The network will issue a written decision about the request for reconsideration within 30 days. The decision will be sent to you and your requesting provider and will include the medical reasons for the decision and the specialty and state of licensure of the reviewer.

Independent Review of Adverse Determinations

If a request for reconsideration upholds a denial, the requestor may timely file a request for independent review (IRO). For a request regarding preauthorization or concurrent review, the request should be filed no later than the 45 th

day after

the date of denial of the reconsideration. For a request regarding retrospective medical necessity review, the request should be filed no later than the 45 th

day

after the denial of reconsideration.

The Health and Workers’ Compensation Network & Quality Assurance Division of the Texas Department of Insurance will assign the review request to an Independent Review Organization. At a minimum, the decision of the independent review organization includes the elements listed and the certification required under Texas Labor Code Section §413.032.

After an independent review organization’s review and decision under this section, a party to a medical dispute that disputes the decision may seek judicial review of the decision. The division of workers' compensation and the department are not considered to be parties to the medical dispute. A decision of an independent review organization related to a request for preauthorization or concurrent review is binding. The carrier is liable for health care during the pendency of any appeal, and the carrier and network shall comply with the decision. If judicial review is not sought under this section, the carrier and network shall comply with the independent review organization's decision. Judicial review under this section is conducted in the manner provided for judicial review of contested cases under Subchapter G, Chapter 2001, of the Texas Government Code.

Expedited Reconsideration Procedures

The medical status of some injuries requires reconsiderations be processed quickly. Reconsideration of denials for post-stabilization care, treatment of life threatening conditions, medical interlocutory orders, and ongoing hospitalization will be completed within 1 day or less. Employees with a life-threatening illness are entitled to an immediate IRO review. These cases are not required to complete the reconsideration process and may go straight to an IRO for life- threatening conditions.

Complaint Review Procedures

If you are unhappy with anything about the network, you may file a complaint within 90 days of the date of the event that is the reason for the complaint. A complaint may be filed by calling 210-***-**** or to 1-800-***-**** for toll-free calls.

Written complaints may be sent to 9601 McAllister Freeway, Suite 500, and San Antonio, TX 78216 or be emailed to the

adu9oi@r.postjobfree.com.

Complaints will be reviewed by the network complaint coordinator. A complaint form will be filled out which will list the date, name and affiliation of the person making the complaint. The form will also include a description of the incident, category of the complaint, and any other important details. The person filing the complaint will receive an acknowledgement within 7 days. This letter will show the date the complaint was received, describe the complaint and list the time frame for the network’s response. A copy of the network’s complaint procedures will also be sent.

Any person who files a complaint will receive a written resolution within 30 days. The response will explain the network’s decision, give the reasons for the decision and list the specialty of any doctor consulted. Persons unhappy with the decision or the complaint process may file a complaint with the Texas Department of Insurance (TDI). TDI’s complaint form is available on their website at www.tdi.state.tx.us or from the HMO Division, TDI Mail Code 103-6A, P.O. Box 149104, Austin, Texas 78714-9104.

The network is not allowed to retaliate against anyone who files a complaint or appeals a decision of the network. The network is also not allowed to retaliate against a health care provider filing a reasonable complaint or appealing a decision of the network.

Telephone Access

Sedgwick Preferred Network has personnel reasonably available through a toll- free telephone service at least 40 hours per week during normal business hours in Texas to discuss your care and to respond to requests for information regarding adverse determinations.

The network has a telephone system which is capable for accepting or recording or providing instructions to incoming calls during other than normal business hours. The network will respond to those calls within two business days after the date the call was received or within two business days of when the details necessary to respond were received by the network from the caller. Preauthorization Requirements

For Treatments and Services

Non-emergency health care requiring preauthorization includes: 1. inpatient hospital admissions including the principal scheduled procedure(s) and the length of stay;

2. outpatient surgical or ambulatory surgical services as defined in subsection (A);

3. spinal surgery;

4. all non-exempted work hardening or non-exempted work conditioning programs;

5. physical and occupation therapy services, which includes those services listed in the Healthcare Common Procedure Coding System (HCPCS) at the following levels:

(A) Level I code range for Physical Medicine & Rehabilitation, but limited to:

(i) Modalities, both supervised and constant attendance;

(ii) Therapeutic procedures, excluding work hardening and work conditioning;

(iii) Orthotics/Prosthetics Management;

(iv) Other procedures, limited to the unlisted physical medicine and rehabilitation procedure code;

(B) Level II temporary code(s) for physical and occupational therapy services provided in a home setting;

(C) Except for the first six visits of physical or occupational therapy following the evaluation when such treatment is rendered within the first two weeks immediate following;

(i) The date of injury, or

(ii) A surgical intervention previously preauthorized by the carrier.

6. any investigational or experimental service or device for which there is early, developing scientific or clinical evidence demonstrating the potential efficacy of the treatment, service, or device but that is not yet broadly accepted as the prevailing standard of care;

7. all psychological testing and psychotherapy, repeat interviews, and biofeedback, except when any service is part of a preauthorized or Division exempted return-to-work rehabilitation program; 8. unless otherwise specified in this subsection, a repeat individual diagnostic study;

(A) with a reimbursement rate of greater than $350 as established in the current Medical Fee Guideline or;

(B) without a reimbursement rate established in the current Medical Fee Guideline;

9. all durable medical equipment (DME) in excess of $500 billed charges per item (either purchase or expected cumulative rental); 10. chronic pain management/interdisciplinary pain rehabilitation; 11. drugs in included in the Division’s formulary; 12. treatments and services that exceed or are not addressed by the Commissioner’s adopted treatment guidelines or protocols and are not contained in a treatment plan preauthorized by the carrier; 13. any treatment for an injury or diagnosis outside the ODG guidelines; 14. Chiropractic treatment.

Sedgwick Preferred Network

Employee Acknowledgement Form

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 Employer/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 Dallas

GXO Warehouse Company, Inc.

Willie Oliver

TX

4323 Bonnieview Rd

75216

Sedgwick Preferred Network Service Area Map

Aransas Atascosa Austin Bandera

Bastrop Bee Bell Bexar

Blanco Brazoria Brazos Burleson

Caldwell Calhoun Callahan Cameron

Coke Collin Colorado Comal

Crane Crosby Dallas Denton

DeWitt Ector Ellis El Paso

Falls Fayette Fisher Floyd

Fort Bend Galveston Garza Glasscock

Goliad Gonzales Grimes Guadalupe

Hale Harris Hays Hidalgo

Hockley Irion Jackson Jim Wells

Johnson Jones Karnes Kaufman

Kendall Kleberg Lamb Lavaca

Lee Liberty Live Oak Lubbock

Lynn McLennan Matagorda Medina

Midland Milam Montgomery Nolan

Nueces Parker Potter Randall

Reagan Refugio Robertson Rockwall

Runnels San Patricio Shackelford Sterling

Tarrant Taylor Terry Tom Green

Travis Upton Victoria Walker

Waller Washington Wharton Wichita

Williamson Wilson Wise

SEDGWICK PREFERRED NETWORK

TDI APPROVED SERVICE AREA

Sedgwick CMS dba

Sedgwick Preferred Network

9601 McAllister Freeway, Suite 500

San Antonio, Texas 78216

Teléfono: 210-***-**** ● Teléfono Grátis: 1-800-***-**** ● Fax: 210-***-****

Información Acerca de los Requisitos de la Red de Servicios Médicos

Información Para el Empleado

Su empleador ha escogido a la red de servicios médicos llamada Sedgwick Preferred Network (sigla en inglés SPN) para ofrecer tratamiento médico a sus trabajadores lesionados. SPN es una red de servicios médicos certificada en compensación para trabajadores. Si usted vive en el área donde ofrecemos servicios, todos los tratamientos médicos y remisiones deben ser ordenadas por su médico tratante. Usted debe escoger a su médico tratante dentro de la red de servicios médicos. La red tiene una amplia gama de tratar doctores, especialistas, y los hospitales que son disponibles y accesibles a los empleados 24 horas al día, siete días a la semana, dentro de las áreas de servicio de red. La distancia, de cualquier localización en las áreas de servicio de red, a un doctor que trata o a un hospital general, es no mayor de 30 millas. La distancia, de cualquier localización en el área de servicio de red, a un hospital del especialista o de la especialidad, es no mayor de 75 millas. Una lista de abastecedoras de tratamientos médicos se puede encontrar en el siguiente sitio web: www.sedgwickproviders.com/txspn

El Web site del abastecedor de red se pone al día por lo menos trimestralmente, con nombres y direcciones de los abastecedores de red agrupados por especialidad y que los abastecedores están aceptando a nuevos pacientes. Tratando los doctores en la red son práctica de la familia, medicina general, medicina ocupacional, médico de la enfermera, ayudantes del médico dentro de esas especialidades. El directorio incluye a abastecedores que se autorizan a determinar la mejora médica máxima, y a rendir grados de la debilitación Los empleados que viven en una de estas áreas de servicio deben obtener todo el cuidado médico y remisiones del especialista, para lesión trabajar-relacionada, a través de un doctor que trata, que será seleccionado de la lista de la red, para el área de servicio en la cual viven a excepción de emergencias. Tratamiento Médico de Emergencia

Los servicios médicos de la emergencia están disponibles 24 horas al día, siete días a la semana. No hay restricciones con respecto donde los servicios de emergencia pueden ser obtenidos.

Si usted se lesiona y es una emergencia, deberá obtener tratamiento en el centro de emergencia más cercano tan pronto como sea posible. Esto también aplica si se lesiona fuera del área de servicio. También aplica si se lesiona fuera del horario de trabajo.

La atención de emergencia no necesita de aprobación anticipada. "Emergencia médica" y "emergencias de salud mental" areis definidos en las leyes de Texas. Lo son es una dolencia que aparece de repente.

Es una afección médica de aparecimiento súbito. Hay síntomas agudos que son lo suficientemente graves que una persona razonable considerará que necesita atención inmediata o usted sufriría daños. Dicho daño podría incluir su salud o poner en peligro sus funciones orgánicas o la pérdida de la función de cualquier órgano o parte. "Salud mental emergencia" significa que una condición podría razonablemente suponer peligro para usted u otra persona. Excepción de servicios de emergencia, el empleado obtendrá todo el cuidado médico y remisiones del especialista a través del doctor que trata del empleado. La asistencia médica de la emergencia, después de horas de oficina normales, está generalmente más fácilmente disponible de un cuarto de emergencia del hospital o de una clínica urgente el cuidado.

A excepción de emergencias, una red arreglará para los servicios, incluyendo remisiones a los especialistas, ser accesible a los empleados sobre una base oportuna a petición, pero no más no adelante que el día pasado de la tercera semana después de la fecha de la petición, y en el plazo de el tiempo apropiado a las circunstancias y a la condición del empleado dañado, pero no más no adelante que 21 días después de la fecha de la petición. Accesibilidad y Disponibilidad

La red asegurará que el panel del abastecedor de red incluya un número adecuado de tratar a los doctores y a los especialistas, que deben ser disponibles y accesibles a los empleados 24 horas al día, de siete días a la semana, dentro del área de servicio de red. Una red debe incluir suficientes números y tipos de abastecedores del cuidado médico para asegurar la opción, el acceso, y la calidad del cuidado a los empleados dañados. Un número adecuado de los doctores y de los especialistas que tratan debe tener admitir privilegios en unos o más hospitales de la red situados dentro del área de servicio de red para asegurarse de que cualquier admisión de hospital necesaria está hecha. Los servicios del hospital deben ser disponibles y accesibles 24 horas al día, siete días a la semana, dentro del área de servicio de red.

La red preverá los servicios necesarios del hospital contrayendo de los hospitales generales, especiales, y psiquiátricos. Los servicios físicos y ocupacionales de la terapia y los servicios del chiropractic deben ser disponibles y accesibles dentro del área de servicio de red.

Pago por Servicios Médicos

Los abastecedores del cuidado médico de la red serán pagados por el portador de seguro. No mandarán la cuenta a los empleados para la asistencia médica para tratar lesión compensable. Prohíben la red, a sus abastecedores contraídos del cuidado médico, contratistas de la gerencia, o los terceros participante, a los cuales la red ha delegado una función, de la facturación, o de procurar recoger cualquier cantidad de los empleados para los servicios del cuidado médico bajo cualesquiera circunstancias, incluyendo la insolvencia del portador o de la red. Sin embargo, la sección 1305.451 (b) (6) “si los empleados dañados buscan cuidado médico, de un abastecedor fuera de red, sin la aprobación de la red, el portador de seguro pueden no ser obligados, y el empleado puede ser obligado para el pago de ese cuidado médico excepción de servicios de emergencia.”

Responsabilidad de Patrón / Portador de Seguro por Cuidado Médico de la Hacia Fuera-de-Red

Un patrón /portador de seguro que contrae con una red es obligado para el cuidado de la hacia fuera-de-red en los casos siguientes:

(1) cuidado de la emergencia;

(2) el cuidado médico proporcionó a un empleado dañado que no vive en el cuidado médico del área de servicio de red;

(3) proporcionado por un abastecedor de la hacia fuera-de-red conforme a una remisión del doctor que trata del empleado dañado que ha sido aprobado por la red como sigue:

(a) si el doctor que trata de un empleado dañado solicita una remisión a un abastecedor de la hacia fuera-de-red para los servicios médicamente necesarios del cuidado médico que no están disponibles de abastecedores de red, la red aprobará o negará una remisión a un abastecedor de la hacia fuera-de-red dentro del tiempo apropiado bajo las circunstancias pero, bajo cualquier circunstancia, no más no adelante que siete días después de la fecha se solicita la remisión;

(b) si la red niega la petición de la remisión, porque el servicio solicitado está disponible de abastecedores de red, el empleado puede archivar una queja de acuerdo con el proceso de la queja de las redes;

(c) si la red niega la petición de la remisión, porque la remisión del especialista no es médicamente necesaria, el empleado puede pedir una revisión independiente.

Empleados Que no Viven en el área de la Red de Servicios Médicos

Un empleado que no vive dentro de un área de servicio de red puede elegir participar en una red establecida por el Empleador / Aseguradora o con el que el tiene un contrato sobre el acuerdo mutuo entre el empleado y el. Nosotros asumimos que usted vive en la dirección que le ha dado a su empleador. O si usted ya no trabaja para el empleador, entonces damos por hecho que usted vive en la

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