Physicians Cooperative of Texas (PCT) is a certified Workers’ Compensation Network focused on the improvement of clinical outcomes to Texas injured workers. 

Our Mission is to provide personable, comprehensive, superior health care, customer service and Managed Care services developed by the cooperative efforts and input from Members, Preferred Providers, Employers, Payors and Community Leaders.

How to Reach Us

 For additional information about PCT or PCT Participating Providers please see below.

Office Hours:

Monday through Friday       8:00 am to 5:00 pm Central Standard Time

 

Phone Numbers:

Toll Free                                (866) 469-7289

 Address:                                 Physicians Cooperative of Texas

                                                3755 Capital of Texas Highway

                                                Suite 160B

                                                Austin, TX 78704

 

Email Address:                      pctexas@pctexas.org

 

Website:                                 www.pctexas.org

                                                PCT policies are located here and require a password to access.

PCT Service Areas

Regional Service Area Description

Physicians Cooperative of Texas (PCT) is certified to provide services in the following geographic service areas:

Region 1 (D/FW area) Counties: Collin, Dallas, Denton, Hunt, Rockwall, Tarrant

·        Region 3 (Austin/San Antonio area)  Counties: Bastrop, Bexar, Caldwell, Comal, Guadalupe, Hays, Lee, Medina, Travis, Williamson

·        Region 4 (El Paso area) Counties: El Paso

·         

A map of the service area is provided with the PCT Provider and Treating Doctor Listings attached.

If you live within the counties identified as the PCT service area, you must obtain medical treatment for any covered work-related injuries only by a PCT Participating Provider, except as provided by PCT Out Of Network Services policies.

You are considered to “live” within the PCT service area if you:

1.      Live permanently in the PCT service area. (your physical address reported to your Employer ).

2.      Temporarily live in the PCT service area as required by your Employer.

3.      Temporarily live in the PCT service area for the purpose of receiving necessary assistance with routine daily activities because of a compensable injury (Routine daily activities include activities a person normally does in daily living, including sleeping, eating, bathing, dressing, grooming and homemaking).

 

Live Outside the Service Area

If you do NOT live within the PCT service area, you must notify your Employer or Payor immediately.  Members living outside the service area may use the PCT Participating Providers while the Employer and/or Payor review the options for the Member.

 

Treating Doctors

All health care services and referrals must be provided by the PCT Treating Doctor if you live inside the PCT service area (except for Emergency Services).

 

Billing / Payment for Services

 

PCT Participating Providers Billing

PCT Participating Providers are required to bill the Payor for all health care services provided to you. PCT Participating Providers will not bill you for any services related to an eligible and compensable injury.

 

Out of Network Providers Billing

If you receive treatment from an out of network Provider without prior approval by PCT, you may be responsible for the full payment of services received by the out of network Provider.

 

The Member is not responsible for payment of treatment received by an out of network  Provider if:

1.  you receive a PCT approved referral from a PCT Treating Doctor, or
2. due to Emergency Care, or
3.  if you live outside the PCT service area.  (If after review the Payor finds the Member does live within the service area, the Member will be responsible for payment of services received by an out of network Provider.) 

 

PCT Network Services

If you live inside the PCT network service area, you must receive all medical treatment from a PCT Participating Provider unless indicated below in Out of Network Services.

 

Out of Network Services

 

Out of Network

You are allowed to receive medical treatment out of network if:

1. you do not live within the service area,
2. you require emergency care, or
3. your Treating Doctor refers you to an out of network Provider and that referral has been approved by PCT.

Live Outside the Service Area

If you do not live within the PCT service area, you must notify your Employer or Payor immediately.  If you live outside the PCT service area, you are not required to access the PCT Participating Providers, but may do so while the Employer and/or Payor review the options for you.

 

Emergency Care

An emergency is a serious injury or the sudden onset of an illness that may endanger your life or cause permanent impairment. 

 

In the case of a true emergency, you should call 911 or go to the nearest PCT network facility for emergency care.  If going to the nearest PCT network facility is not feasible due to time, urgency, or distance, you should go to the closest Acute Care Facility for emergency care.

 

PCT requires you or a family member to contact us when medically able (within 24 hours) to arrange follow-up care and confirm coverage.  Consult PCT for details

 

Emergent or Emergency care is defined as health care services provided after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity, including but not limited to severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that his or her condition, sickness, or injury is of a nature that failure to get immediate care could result in:

1.      Placing your health in serious jeopardy;

2.      Serious impairment to bodily functions;

3.      Serious dysfunction to any bodily organ or part;

4.      Serious disfigurement; or

5.      In the case of a pregnant woman, serious jeopardy to the health of the fetus.

 

After Hours and Urgent Care

For non-emergency urgent healthcare or after hours, please go to the nearest PCT urgent care facility or call PCT immediately for assistance.  PCT Urgent Care (24 Hours) facilities

are available to provide advice and treatment of urgent health problems 24 hours a day, 7 days a week, 365 days a year.  Urgent health problems (physical or emotional) include sudden, serious and unexpected illnesses, injuries, or conditions which require immediate attention.

 

Nights, Weekends, and Holidays, call PCT after Hours Urgent Care at {member specific telephone number} if you think you need urgent care (physical or emotional) when other health services are closed. After Hours Urgent Care is staffed by a team of physicians, nurse practitioners, nurses and medical assistants/administrative staff, ready to meet your needs for urgent care.  Please understand that patients with more serious conditions may be seen before others.

 

If you have a very serious condition that cannot be fully evaluated or treated at a PCT urgent care facility, we will arrange to transfer you to a hospital emergency room. In the event that you are transferred, be sure to contact PCT.

 

 

Referral to Out of network Provider

A Treating Doctor will request referrals to out-of-network Providers if medically necessary services are not available within the network.  Referrals to out-of-network providers must be approved by PCT.

 

 

Pre-Authorization

 

Pre-authorization determines whether medical services are medically necessary and provided in the appropriate setting or at the appropriate level of care.  Pre-authorization is not a verification and does not guarantee payment.  Pre-authorization requirements are a responsibility of the PCT provider, not the Member.

 

Out of network services always require pre-authorization. If no pre-authorization or referral is obtained for the out of network services, no benefits are available and out of network claims will be denied. See Out of Network Services for exceptions to this requirement.

 

The following services require pre-authorization by PCT:

1. Out of network services
2. Facility Admissions: includes Hospital, Rehabilitation and Psychiatric
3. Outpatient surgical or Ambulatory Surgical Center services
4. Hospice
5. Spinal Surgery
6. Mental Health, psychological testing, psychotherapy, repeat interviews, biofeedback (unless the service is included in a pre-authorized service or exempt rehabilitation program)
7. External and implantable bone growth stimulators
8. Chemonucleolysis
9. Myelograms, discograms, or surface electromyograms
10. Unless otherwise specified, repeat individual diagnostic study, with a fee established in the current Medical Fee Guideline of greater than $350 or documentation of procedure (DOP)
11. Work hardening and work conditioning programs provided in a facility that has not been approved for exemption by the Commission (see “Who is exempt from preauthorization and concurrent review?”)
12. Rehabilitation programs to include
    1. outpatient medical rehabilitation and
    2. chronic pain management / interdisciplinary pain rehabilitation
13. Durable medical equipment (DME) in excess of $500 per item (either purchase or expected cumulative rental) and all transcutaneous electrical nerve stimulator (TENS) units
14. Nursing home, convalescent, residential, skilled nursing facility and all home health care services and treatments
15. Chemical dependency or weight loss programs
16. 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 nor included in the PCT treatment protocols
17. Physical, speech and occupational therapy services, if not included in another preauthorized service such as surgery.  Preauthorization is not required for the first two visits following an examination when the treatments are rendered within the first two weeks following the date of injury.
18. Dental procedures
19. Obstetrical care
20. High-tech outpatient diagnostic radiology procedures not included in another preauthorized service or the PCT treatment protocol

 

 

 

Continuity of Care

 

PCT provides for the continuity in the care if your health could be jeopardized if medically necessary covered services are disrupted or interrupted for any reason.  PCT assists you with the coordination of any transition of care from an out of network Provider to a PCT Participating Provider, or from a PCT Participating Provider who terminates with the network to an active PCT Participating Provider. 

 

PCT will contact you and provide education if the need for transition occurs, assisting in locating a PCT Participating Provider and gathering medical records and clinical information needed to transfer you to the PCT Participating Provider.

If you are being treated by an out of network Provider, you may not be required to select a PCT Treating Doctor if PCT determines that changing physicians would be medically harmful to you.  You may be transferred to a PCT Participating Provider when you become medically stationary or it would no longer be medically harmful to change providers.

 

 

Complaint and Appeal Procedures

 

For general complaints, disputes or appeals, you should contact PCT either by letter, email or by telephone.  All complaints and disputes must be submitted within 90 days of the date of the disputed action.

 

The complaint should be mailed to:

 

Physicians Cooperative of Texas

Member Complaint Department

6937 N IH-35, Suite 500

Austin, Texas 78752

 

Telephone:                  512-421-4868

Toll Free Telephone:   866-311-6233

Email:                          pctexas@pctexas.org

 

PCT will acknowledge receipt of the complaint by letter within five (5) business days and send to you an acknowledgment letter that will include a description of the compliant procedures, time frames, and a one-page complaint form for the enrollee to complete if the complaint is received verbally.   We are always available to discuss any of these items with you if you so wish.

 

Adverse Determinations (Denials)

Adverse determination means a determination, made through PCT utilization review or retrospective review, that the health care services furnished or proposed to be furnished to you are not medically necessary or appropriate.

 

PCT Utilization Management (UM) nurses do not make adverse determinations of referral or pre-authorization requests; the PCT Physician Advisor and/or Medical Director makes the determination.  The UM Nurse Reviewers, Physician Advisors and Medical Directors have no direct financial incentive to deny coverage for any service.  The PCT Participating Provider who ordered the services shall be afforded a reasonable opportunity to discuss the plan of treatment for you and the clinical basis for the decision with a PCT Physician Advisor prior to issuance of an adverse determination.

 

If the denial is based on medical necessity, you and the PCT Participating Provider of record are provided with the independent review notification and the form prescribed by the Texas Department of Insurance.

 

Appeals of Adverse Determinations (Denials)

To ensure timely response to an appeal, please include the following information and submit to:

Physicians Cooperative of Texas

Member Complaints Department

6937 N IH-35, Suite 500

Austin, Texas 78752

 

Please include the following information in the appeal:

1.         Your full name

2.         Your social security number

3.         If appealing party is not you, include the full name and relationship to you.

4.         Dates of service during which the appeal took place, if applicable.

5.         Place where service(s) took place, i.e., hospital, doctor office, radiology, home health visit at home, etc. if applicable.

6.         If appeal is for Emergency Care, please send a copy of the ER records.

7.         Provide a brief description of the incident, including names, dates and times that will support resolution of the appeal.

 

Coordination of Timely Care

PCT Participating Providers and employees are required to coordinate care, provide services and be accessible to you on a timely basis.  This includes initial evaluation, ongoing treatment, referrals to specialists, responsiveness to inquiries or complaints, medical management, utilization review and case management.  

 

Except for emergencies, PCT will arrange for covered healthcare services, including referrals to specialists, to be accessible to you on a timely basis upon request and within the time appropriate to the circumstances and condition, but not later than 21 days after the date of the request.

  

 

Complaints to the Texas Department of Insurance

 

Anyone may submit a complaint to the Texas Department of Insurance.  Send complaint to:

Texas Department of Insurance

WHCN Division, Mail Code 103-6A

P.O. Box 149104

Austin, TX 78714-9104

 

Or Fax the complaint to: (512) 490-1012

You may use the online complaint form at www.tdi.state.tx.us

 

Send email complaints to: HmoNewComplaints@tdi.state.tx.us or ConsumerProtection@tdi.state.us