Out of Network Authorization
Workers' compensation health care networks contract with doctors and hospitals to treat injured employees. If your employer participates in a workers’ compensation network, you must use doctors, hospitals, and other health care providers in the network to get care for a work-related injury. The only exception is for emergencies or if the network approves a referral to an out-of-network provider. (Reference)
If you would like to request an out of network provider, please complete the following information for review.
Please attach all medical documentation including Statement of Medical Necessity, medical notes and any additional information needed to provide our Texas HCN of the necessity of the services requested.
Contact Prime Health Services, Inc. for further assistance at 1 (866) 348-3887.
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Prime Health Services, Inc.
331 Mallory Station Rd
Franklin, TN 37067