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Zenith Health Care NetworkEmployee Notice of Network RequirementsYour employer has picked a network ofDoctors and hospitals to give you health c arefor work injuries. The network is ZenithHealth Care Network (ZHCN). This n etworkis a certified workers’ compensation healthcare network.If you think you do not live in a Service Ar eayou may contact Zenith Insurance Company(Zenith). You have to request a review inwriting. If you request a revie w, you have toprovide proof to show that you do not live inthe Service Area. Call 1-800-8 41-3987 withquestions.If you are injured at work you m ust check tosee if you live in a ZHCN Service Area. Ifyou do liv e in a ZHCN Servic e Area, youmust receive all health care for your injurythrough ZHCN.Your request for review shou ld be s ent to:The information in this notice will explain theService Area and will help you get medic alcare through ZHCN. If you have anyquestions, you can ask your employer, or call1-800-841-3987.Access to Health Care ServicesWhen requested, ZHCN must arrange formedical services in a timely manner. Thisincludes referrals to specia lists. Servicesmust be arranged in an appropriate time,taking into considerati on your circumstancesand medical condition. In any c ircumstance,services must be arranged no later than 21days after the date of the request.ZHCN Service AreaA map of the Service Area is att ached. It isalso available at www. TheZenith.com or bycalling 1-800-841-3987.If you liv e in a Servic e Area, you must pic kyour Treating Doctor from the ZHCN ProviderDirectory. Your Treating Doctor will treat you.Your Treating Doctor may refer you toanother health care provider.1Zenith Insurance CompanyAttention: ZHCNP.O. Box 1558Sarasota, FL 34230-1558Email: txnetwork@thezenith.comZenith will review y our request and withinseven (7) days of receipt of your request willmake a decision and give you written notice.If you do not agree withZenith’s decision,you may file a compla int. Complaints shou ldbe filed with the Department of Insurance(SeeComplaints section for moreinformation).While your request is under review, you m ayseek all medical care within the network. Todo this, you should s elect a ZHCN Treatin gDoctor. All health care for your work injurywill be set up with your Treating Doctor.If ZHCN decides that you do live in a ServiceArea, you may have to pay for health care if itis from a provider that is not in the ZHCN.How to Get Health Care through ZHCNTell your supervisor or manager immediatelyif you are injured at work.You should pick y our Treating Doctor fromthe ZHCN Provider Dire ctory. You may nee dZenith Health Care Network (ZHCN)NONR (rev 0915)
a referral to a specialist or other health car eprovider. Your ZHCN Treating Doctor mustmake all referrals. If you need emergencycare, you do not have to go through yourZHCN Treating Doctor.ZHCN Providers have agreed to only billZenith for services related to a compensablework injury. You may want to get health carefrom providers who are not in the ZHCN. Todo this, you must first get approval fromZenith. If you do not get approval to useproviders who are not in the Network, youmay have to pay for those services yourself.The exceptions to this rule are: Emergency Care If you do not live within the ZHCN Servic eArea Out-of-network care that Zenith preauthorized Your PPO Primary T reating Physician isyour Treating DoctorEmergency CareIf you are injured at any time - and you thinkit is a medical or mental health emergency call 911 or go to the nearest medical facilityoffering emergency care services.You may be injured while y ou are outside ofthe Service Area. If this happens and y outhink it is a medical or mental healthemergency, go to the nearest medical fac ilityoffering emergency care services or call 911.You should contact Zenith as soon aspossible at 1-800-440-5020 to report yourinjury.Texas Law definesthe term “medicalemergency” as an acut e medical conditionthat occurs suddenly. Symptoms are severeand include severe pain . A patient’s health,bodily function or function of any organ orbody part could be in serious jeopardywithout immediate m edical care. The TexasLaw also defines the term “mental healthemergency”. It is a condition that couldreasonably be expected to present danger tothe person experienc ing the mental healt hcondition or another person.2Non- Emergency CareIf you are hurt at work, and it is notanemergency, pick a Treating Doc tor from theProvider Directory.The Provider Directory is available: Online at www.TheZenith.com From your employer By calling Zenith at 1-800-841-3988You should call your Treating Doctor to setup an appointment. You may also call Zenithfor help picking a Treating Doc tor. Zenithcan help you set up an appointment.You may be injured while y ou are outside theService Area. If this happens and you neednon-emergency health care please callZenith at 1-800-440-5020. Zenith will helpyou locate a medical provider.After-Hours CareYou may need after-hours medical c are. Ifthis happens, call ZHCN at 1-800-440-5020.Zenith will help you find a provider or facility.You may also vis it www.TheZenith.com toselect a provider. You should c ontact youremployer to report your injury as soon aspossible.If you have a medical emergency, call 911 o rgo to the nearest emergency room. After youget treated for your em ergency, all fo llow-upand non-emergency care must be set upthrough your Treating Doctor.Selecting a Treating DoctorYou must pick a Treating Doctor from theProvider Directory. Y our Treating Doctormust be located in y our Service Area. T heProvider Directory will show which provider sare taking new patients. If you would like helppicking a T reating Doctor, please call Zenithat 1-800-841-3988.If you are a member of a PPO you may pick yourPrimary Care Physician as your TreatingDoctor. You must have chosen this doctor asyour primary care physician through yourPPO before your work related injuryoccurred and your PPO Primary CareZenith Health Care Network (ZHCN)NONR (rev 0915)
Physician has to agree to treat your workerscompensation injury. To do this, complete theattached “Physician pre-designation form”.Return the completed fo rm to your employer.If you would lik e your PPO Primary CarePhysician to treat you for a work injury,please contact Zenith at 1-800-841-3987.Zenith will review your request and notify y ouof their decision withi n 72 hours. Your PPOPrimary Care Ph ysician will not beconsidered as an initial choic e of a TreatingDoctor unless this process is followed.Doctor. To do this, pick a new TreatingDoctor from the Provider Directory. If y ouwould like help with this, call Zenith at 1-800841-3988.The following als o will not be c onsidered aninitial choice of Treating Doctor: A Doctor who works for your employer; A Doctor providing emergency care; or Any doctor who provided care before theemployee was enrolled in theZHCN,unless it was your PPO Primary CarePhysician which you pre-designated usingthe process set forth above.If one of these conditions applies to you, yourTreating Doctor has to contact Zenith andrequest a review. Zeni th will review t heTreating Doctor’s request then give you a ndyour Doctor written noti ce of their decision. Ifyou or your Doctor di sagrees with Zenith’sdecision, you may file a complaint (SeeComplaints section for more information).You may not be happy with the first TreatingDoctor you picked. If this happens, you canpick an alternate Treating Doctor. ContactZenith for help pick ing an alternate TreatingDoctor. When you pic k an alternate TreatingDoctor, you must provide the name of theDoctor to Zenith:Zenith Insurance CompanyAttention: ZHCNP.O. Box 1558Sarasota, FL 34230-15581-800-841-3987If you are not happywith the alternateTreating Doctor, you must contact Zenith t osubmit a request for additional changes.Contact Zenith at 1-800-841-3987 to submityour request. Zenith wil l review your requestand give you written notice of their decis ionwithin seven (7) days.Continuing your treatment if your TreatingDoctor is terminated from the NetworkIf your Treating Doct or leaves the Networ k,Zenith will notify you in writing. If thishappens, and y ou need to continuetreatment, you must pick anot her Treating3You may continue treatment with youroriginal Treating Doctor under certaincircumstances: If you have a life-threatening medicalcondition Your medical condition is acute and adisruption in care could harm youServices Requiring Pre-AuthorizationAll health care must be set up t hrough yourTreating Doctor. Your Treating Doctor willtreat you. Your Treating Doctor may refer youfor treatment for yo ur work injury. Certainservices must be approved by Zenith inadvance.Those services are: All Hospitalizations All outpatient surgeries including: epiduralsteroid injections, facet injections, triggerpoint injections, sacroiliac joint injections,prolotherapy injections, radiologicalcryotherapy, and manipulations underanesthesia, and including the specific siteor facility where the service will beperformed; All Surgeries Psychological or Psychiatric Testing, andevaluations All Bone Growth stimulators All chemonucleolysis, vertebral axialdecompressions (Vax-D), radio frequencythermocoagulation of facet joints (RFTC),and IDET procedures;Zenith Health Care Network (ZHCN)NONR (rev 0915)
All myelograms, discograms, venograms,surface electromyograms, EMGs, andnerve conduction studies;Repeat diagnostic studiesWork Hardening and Work conditioningRehabilitation programsAll Durable Medical EquipmentAll nursing home, convalescent,residential, and all home health careservices and treatments;Chemical dependence, weight lossprograms, and gym memberships;Any investigational or experimentalservice or deviceAll physical therapy, occupational therapy,chiropractic therapy, and chiropracticmanipulationsDrugs not included on the TexasDepartment of Insurance, Division ofWorkers’ Compensation (DWC)Pharmacy Closed Formulary including butnot limited to: drugs identified with a status of "N"in the current edition of the ODGTreatment in Workers' Comp(ODG) / Appendix A, ODGWorkers' Compensation DrugFormulary, and any updates; any compound that contains a drugidentified with a status of "N" in thecurrent edition of the ODGTreatment in Workers' Comp(ODG) / Appendix A, ODGWorkers' Compensation DrugFormulary, and any updates; and any investigational or experimentaldrug for which there is early,developing scientific or clinicalevidence demonstrating thepotential efficacy of the treatment,but which is not yet broadlyaccepted as the prevailingstandard of care as defined inLabor Code §413.014(a). Intrathecal drug delivery systemsTo have any of these servic es approved,yourDoctor must follow ZHCNpreauthorization requirements. Zenith will4give you written notice of the decision. Youhave a right to request a reconsideration ofan adverse determination (an adver sedetermination is when the proposed medic alcare is determined not medically necessary).You will receive information with the adversedetermination notice about how to submit areconsideration. You also have a right torequest a review by an Independent ReviewOrganization if the reconsideration decisionon an adverse determination is upheld.Zenith will give you information about theserights as well. The review will be randomlyassigned to an Independent ReviewOrganization by the Texas De partment ofInsurance. An employee with a lifethreatening condition is allowe d animmediate review by an independent revieworganization and is not required to complywith the procedures f or a reconsideration ofan adverse determination.ComplaintsIf you are unhappy with ZHCN, you may file acomplaint. You may complain ab out any partof the ZHCN op eration. Verbal complaintsand written complaints are accepted.You have 90 days to submit a complaint. The90 day period starts on the date when theproblem or issue first came up. When yourcomplaint has been received,Zenith willreview it. Zenith will send you a writtennotice explaining the review a nd decision.The notice will be s ent within 30 calendardays from the date your complaint isreceived.Complaints should be directed to:Zenith Insurance CompanyATTN: Provider Group21255 Califa StreetWoodland Hills, CA 91367Phone: 1-800-841-3988Email: txnetwork@thezenith.comYou may not be satisfied with how yourcomplaint was handled. If this happens, y ouhave a right to complain . There is a form toZenith Health Care Network (ZHCN)NONR (rev 0915)
use for your complaint. Your completed formshould be sent to the Texas Department ofInsurance’s Health & Workers’ CompensationNetwork (HWCN) Division.The Department’s complaint form can beobtained from www.tdi.texas.gov or:The HMO DivisionMail 103-6ATexas Department of InsuranceP.O. Box 1491045Austin, TX 78714-9104It is not legal for a network to retaliate againstan employee, employer, or medical provide rfor filing a complaint. It is not legal for anetwork to retaliate against an employee ormedical provider who ap peals a decision ofthe network.Zenith Health Care Network (ZHCN)NONR (rev 0915)
6Zenith Health Care Network (ZHCN)NONR (rev 0915)
The Network’s service area consists of 231 counties. The counties in bold and with the * belowwere originally effective February 16, 2010. Please also refer to the accompanying rmstrongHemphillMartinSan Augustine *Young*DallasDawsonHendersonMason*Atascosa*San JacintoDeaf SmithMatagordaSan Patricio*Austin*HidalgoBaileyDeltaHillMcCullochSan nsonMitchellStarr*El ie*Montgomery rson*TarrantBrooksFisherJim HoggNacogdoches TaylorBrownFloydJim WellsTerry*NavarroBurlesonNewtonThrockmorton*Fort eKarnesTom o mbleUvalde*ParkerCastroGoliadKlebergParmerVan llin*Liberty*WhartonHallLimestoneRed er*ComalComancheHansfordLive son7Zenith Health Care Network (ZHCN)NONR (rev 0915)
Doctor to Zenith: Zenith Insurance Company Attention: ZHCN P.O. Box 1558 Sarasota, FL 34230-1558 1-800-841-3987 If you are not happy with the alternate Treating Doctor, you must contact Zenith t o submit a request for additional changes. Contact Zenith at 1-800-841-3987 to submit your request. Zenith will review your request
