reglab/housing_qa huggingface dataset:
TX Ins Code § 843.319 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter I. Relations With Physicians and Providers|Section 843.319. Certain Required Contracts

Sec. 843.319.  CERTAIN REQUIRED CONTRACTS.  Notwithstanding Section 843.304, a health maintenance organization may not deny a contract to a podiatrist licensed by the Texas Department of Licensing and Regulation who joins the professional practice of a contracted physician or provider, satisfies the application procedures of the health maintenance organization, and meets the qualification and credentialing requirements for contracting with the health maintenance organization.|Added by Acts 2003, 78th Leg., ch. 237, Sec. 4, eff. Sept. 1, 2003.Amended by: Acts 2019, 86th Leg., R.S., Ch. 467 (H.B. 4170), Sec. 19.012, eff. September 1, 2019.|
TX Ins Code § 843.320 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter I. Relations With Physicians and Providers|Section 843.320. Use of Hospitalist

Sec. 843.320.  USE OF HOSPITALIST.  (a)  In this section, "hospitalist" means a physician who:(1)  serves as physician of record at a hospital for a hospitalized patient of another physician; and(2)  returns the care of the patient to that other physician at the end of the patient's hospitalization.(b)  A contract between a health maintenance organization and a physician may not require the physician to use a hospitalist for a hospitalized patient.|Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.211(a), eff. Sept. 1, 2003.|
TX Ins Code § 843.321 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter I. Relations With Physicians and Providers|Section 843.321. Availability of Coding Guidelines

Sec. 843.321.  AVAILABILITY OF CODING GUIDELINES.  (a)  A contract between a health maintenance organization and a physician or provider must provide that:(1)  the physician or provider may request a description and copy of the coding guidelines, including any underlying bundling, recoding, or other payment process and fee schedules applicable to specific procedures that the physician or provider will receive under the contract;(2)  the health maintenance organization or the health maintenance organization's agent will provide the coding guidelines and fee schedules not later than the 30th day after the date the health maintenance organization receives the request;(3)  the health maintenance organization or the health maintenance organization's agent will provide notice of changes to the coding guidelines and fee schedules that will result in a change of payment to the physician or provider not later than the 90th day before the date the changes take effect and will not make retroactive revisions to the coding guidelines and fee schedules;  and(4)  the contract may be terminated by the physician or provider on or before the 30th day after the date the physician or provider receives information requested under this subsection without penalty or discrimination in participation in other health care products or plans.(b)  A physician or provider who receives information under Subsection (a) may only:(1)  use or disclose the information for the purpose of practice management, billing activities, and other business operations;  and(2)  disclose the information to a governmental agency involved in the regulation of health care or insurance.(c)  The health maintenance organization shall, on request of the physician or provider, provide the name, edition, and model version of the software that the health maintenance organization uses to determine bundling and unbundling of claims.(d)  The provisions of this section may not be waived, voided, or nullified by contract.|Added by Acts 2003, 78th Leg., ch. 214, Sec. 5, eff. June 17, 2003.Renumbered from Insurance Code, Section 843.319 by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 23.001(60), eff. September 1, 2005.|
TX Ins Code § 843.323 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter I. Relations With Physicians and Providers|Section 843.323. Contract Provisions Prohibiting Rejection of Batched Claims

Sec. 843.323.  CONTRACT PROVISIONS PROHIBITING REJECTION OF BATCHED CLAIMS.  (a)  If requested by a participating physician or provider, a health maintenance organization shall include a provision in the physician's or provider's contract providing that the health maintenance organization or the health maintenance organization's clearinghouse may not refuse to process or pay an electronically submitted clean claim, as defined by Subchapter J, because the claim is submitted together with or in a batch submission with a claim that is not a clean claim.(b)  In accordance with Chapters 82 and 84, the commissioner may issue a cease and desist order against or impose sanctions on a health maintenance organization that violates this section or a contract provision adopted under this section.|Added by Acts 2005, 79th Leg., Ch. 668 (S.B. 50), Sec. 1, eff. September 1, 2005.|
TX Ins Code § 843.336 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter J. Payment of Claims to Physicians and Providers|Section 843.336. Definition

Sec. 843.336.  DEFINITION.  (a)  In this subchapter, "clean claim" means a claim that complies with this section.(b)  A nonelectronic claim by a physician or provider, other than an institutional provider, is a clean claim if the claim is submitted using the Centers for Medicare and Medicaid Services Form 1500 or, if adopted by the commissioner by rule, a successor to that form developed by the National Uniform Claim Committee or its successor.  An electronic claim by a physician or provider, other than an institutional provider, is a clean claim if the claim is submitted using the Professional 837 (ASC X12N 837) format or, if adopted by the commissioner by rule, a successor to that format adopted by the Centers for Medicare and Medicaid Services or its successor.(c)  A nonelectronic claim by an institutional provider is a clean claim if the claim is submitted using the Centers for Medicare and Medicaid Services Form UB-92 or, if adopted by the commissioner by rule, a successor to that form developed by the National Uniform Billing Committee or its successor.  An electronic claim by an institutional provider is a clean claim if the claim is submitted using the Institutional 837 (ASC X12N 837) format or, if adopted by the commissioner by rule, a successor to that format adopted by the Centers for Medicare and Medicaid Services or its successor.(d)  The commissioner may adopt rules that specify the information that must be entered into the appropriate fields on the applicable claim form for a claim to be a clean claim.(e)  The commissioner may not require any data element for an electronic claim that is not required in an electronic transaction set needed to comply with federal law.(f)  A health maintenance organization and a physician or provider may agree by contract to use fewer data elements than are required in an electronic transaction set needed to comply with federal law.(g)  An otherwise clean claim submitted by a physician or provider that includes additional fields, data elements, attachments, or other information not required under this section is considered to be a clean claim for the purposes of this section.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 214, Sec. 6, eff. June 17, 2003.|
TX Ins Code § 843.338 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter J. Payment of Claims to Physicians and Providers|Section 843.338. Deadline for Action on Clean Claims

Sec. 843.338.  DEADLINE FOR ACTION ON CLEAN CLAIMS.  Except as provided by Sections 843.3385 and 843.339, not later than the 45th day after the date on which a health maintenance organization receives a clean claim from a participating physician or provider in a nonelectronic format or the 30th day after the date the health maintenance organization receives a clean claim from a participating physician or provider that is electronically submitted, the health maintenance organization shall make a determination of whether the claim is payable and:(1)  if the health maintenance organization determines the entire claim is payable, pay the total amount of the claim  in accordance with the contract between the physician or provider and the health maintenance organization;(2)  if the health maintenance organization determines a portion of the claim is payable, pay the portion of the claim that is not in dispute and notify the physician or provider in writing why the remaining portion of the claim will not be paid; or(3)  if the health maintenance organization determines that the claim is not payable, notify the physician or provider in writing why the claim will not be paid.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 214, Sec. 8, eff. June 17, 2003.Amended by: Acts 2011, 82nd Leg., R.S., Ch. 798 (H.B. 2292), Sec. 2, eff. September 1, 2011.|
TX Ins Code § 843.3385 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter J. Payment of Claims to Physicians and Providers|Section 843.3385. Additional Information

Sec. 843.3385.  ADDITIONAL INFORMATION.  (a)  If a health maintenance organization needs additional information from a treating participating physician or provider to determine payment, the health maintenance organization, not later than the 30th calendar day after the date the health maintenance organization receives a clean claim, shall request in writing that the physician or provider provide an attachment to the claim that is relevant and necessary for clarification of the claim.(b)  The request must describe with specificity the clinical information requested and relate only to information the health maintenance organization can demonstrate is specific to the claim or the claim's related episode of care.  The participating physician or provider is not required to provide an attachment that is not contained in, or is not in the process of being incorporated into, the patient's medical or billing record maintained by a participating physician or provider.(c)  A health maintenance organization that requests an attachment under this section shall determine whether the claim is payable on or before the later of the 15th day after the date the health maintenance organization receives the requested attachment or the latest date for determining whether the claim is payable under Section 843.338 or 843.339.(d)  A health maintenance organization may not make more than one request under this section in connection with a claim.  Sections 843.337(e) and (f) apply to a request for and submission of an attachment under Subsection (a).(e)  If a health maintenance organization requests an attachment or other information from a person other than the participating physician or provider who submitted the claim, the health maintenance organization shall provide notice containing the name of the physician or provider from whom the health maintenance organization is requesting information to the physician or provider who submitted the claim.  The health maintenance organization may not withhold payment pending receipt of an attachment or information requested under this subsection.  If on receiving an attachment or information requested under this subsection the health maintenance organization determines that there was an error in payment of the claim, the health maintenance organization may recover any overpayment under Section 843.350.(f)  The commissioner shall adopt rules under which a health maintenance organization can easily identify an attachment or other information submitted by a physician or provider under this section.|Added by Acts 2003, 78th Leg., ch. 214, Sec. 9, eff. June 17, 2003.|
TX Ins Code § 843.339 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter J. Payment of Claims to Physicians and Providers|Section 843.339. Deadline for Action on Prescription Claims; Payment

Sec. 843.339.  DEADLINE FOR ACTION ON PRESCRIPTION CLAIMS; PAYMENT.  (a)  A health maintenance organization, or a pharmacy benefit manager that administers pharmacy claims for the health maintenance organization, that affirmatively adjudicates a pharmacy claim that is electronically submitted shall pay the total amount of the claim through electronic funds transfer not later than the 18th day after the date on which the claim was affirmatively adjudicated.(b)  A health maintenance organization, or a pharmacy benefit manager that administers pharmacy claims for the health maintenance organization, that affirmatively adjudicates a pharmacy claim that is not electronically submitted shall pay the total amount of the claim not later than the 21st day after the date on which the claim was affirmatively adjudicated.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 214, Sec. 10, eff. June 17, 2003.Amended by: Acts 2011, 82nd Leg., R.S., Ch. 798 (H.B. 2292), Sec. 3, eff. September 1, 2011.|
TX Ins Code § 843.3405 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter J. Payment of Claims to Physicians and Providers|Section 843.3405. Investigation and Determination of Payment

Sec. 843.3405.  INVESTIGATION AND DETERMINATION OF PAYMENT.  The investigation and determination of payment, including any coordination of other payments, does not extend the period for determining whether a claim is payable under Section 843.338 or 843.339 or for auditing a claim under Section 843.340.|Added by Acts 2003, 78th Leg., ch. 214, Sec. 12, eff. June 17, 2003.|
TX Ins Code § 843.341 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter J. Payment of Claims to Physicians and Providers|Section 843.341. Claims Processing Procedures

Sec. 843.341.  CLAIMS PROCESSING PROCEDURES.  (a)  A health maintenance organization shall provide a participating physician or provider with copies of all applicable utilization review policies and claim processing policies or procedures.(b)  A health maintenance organization's claims payment processes shall:(1)  use nationally recognized, generally accepted Current Procedural Terminology codes, notes, and guidelines, including all relevant modifiers;  and(2)  be consistent with nationally recognized, generally accepted bundling edits and logic.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 214, Sec. 13, eff. June 17, 2003.|
TX Ins Code § 843.343 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter J. Payment of Claims to Physicians and Providers|Section 843.343. Attorney's Fees

Sec. 843.343.  ATTORNEY'S FEES.  A physician or provider may recover reasonable attorney's fees and court costs in an action to recover payment under this subchapter.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 214, Sec. 15, eff. June 17, 2003.|
TX Ins Code § 843.344 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter J. Payment of Claims to Physicians and Providers|Section 843.344. Applicability of Subchapter to Entities Contracting With Health Maintenance Organization

Sec. 843.344.  APPLICABILITY OF SUBCHAPTER TO ENTITIES CONTRACTING WITH HEALTH MAINTENANCE ORGANIZATION.  This subchapter applies to a person, including a pharmacy benefit manager, with whom a health maintenance organization contracts to:(1)  process or pay claims;(2)  obtain the services of physicians and providers to provide health care services to enrollees; or(3)  issue verifications or preauthorizations.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 214, Sec. 16, eff. June 17, 2003.Amended by: Acts 2011, 82nd Leg., R.S., Ch. 798 (H.B. 2292), Sec. 5, eff. September 1, 2011.|
TX Ins Code § 843.345 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter J. Payment of Claims to Physicians and Providers|Section 843.345. Exception

Sec. 843.345.  EXCEPTION.  This subchapter does not apply to a capitated payment required to be made to a physician or provider under an agreement to provide health care services.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 214, Sec. 17, eff. June 17, 2003.|
TX Ins Code § 843.346 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter J. Payment of Claims to Physicians and Providers|Section 843.346. Payment of Claims

Sec. 843.346.  PAYMENT OF CLAIMS.  Except as provided by this subchapter, a health maintenance organization shall pay a physician or provider for health care services and benefits provided to an enrollee not later than:(1)  the 45th day after the date on which a claim for payment is received with the documentation reasonably necessary to process the claim;  or(2)  if applicable, within the number of calendar days specified by written agreement between the physician or provider and the health maintenance organization.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 214, Sec. 18, eff. June 17, 2003.|
TX Ins Code § 843.3483 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter J. Payment of Claims to Physicians and Providers|Section 843.3483. Remedy for Noncompliance

Sec. 843.3483.  REMEDY FOR NONCOMPLIANCE.  In addition to any other penalty or remedy provided by law, a health maintenance organization that uses a preauthorization process for health care services that violates this subchapter with respect to a required publication, notice, or response regarding its preauthorization requirements, including by failing to comply with any applicable deadline for the publication, notice, or response, must provide an expedited appeal under Section 4201.357 for any health care service affected by the violation.|Added by Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 2.02, eff. September 1, 2019.|
TX Ins Code § 843.349 (2021)
2021 Texas Statutes|Insurance Code|Title 6 - Organization of Insurers and Related Entities|Subtitle C - Life, Health, and Accident Insurers and Related Entities|Chapter 843 - Health Maintenance Organizations|Subchapter J. Payment of Claims to Physicians and Providers|Section 843.349. Coordination of Payment

Sec. 843.349.  COORDINATION OF PAYMENT.  (a)  A health maintenance organization may require a physician or provider to retain in the physician's or provider's records updated information concerning other health benefit plan coverage and to provide the information to the health maintenance organization on the applicable form described by Section 843.336.  Except as provided by this section, a health maintenance organization may not require a physician or provider to investigate coordination of other health benefit plan coverage.(b)  Coordination of other payment under this section does not extend the period for determining whether a service is eligible for payment under Section 843.338 or 843.339 or for auditing a claim under Section 843.340.(c)  A participating physician or provider who submits a claim for particular health care services to more than one health maintenance organization or insurer shall provide written notice on the claim submitted to each health maintenance organization or insurer of the identity of each other health maintenance organization or insurer with which the same claim is being filed.(d)  On receipt of notice under Subsection (c), a health maintenance organization shall coordinate and determine the appropriate payment for each health maintenance organization or insurer to make to the physician or provider.(e)  Except as provided by Subsection (f), if a health maintenance organization is a secondary payor and pays a portion of a claim that should have been paid by the health maintenance organization or insurer that is the primary payor, the overpayment may only be recovered from the health maintenance organization or insurer that is primarily responsible for that amount.(f)  If the portion of the claim overpaid by the secondary health maintenance organization was also paid by the primary health maintenance organization or insurer, the secondary health maintenance organization may recover the amount of the overpayment under Section 843.350 from the physician or provider who received the payment.  A health maintenance organization processing an electronic claim as a secondary payor shall rely on the primary payor information submitted on the claim by the physician or provider.  Primary payor information may be submitted electronically by the primary payor to the secondary payor.(g)  A health maintenance organization may share information with another health maintenance organization or an insurer to the extent necessary to coordinate appropriate payment obligations on a specific claim.|Added by Acts 2003, 78th Leg., ch. 214, Sec. 19, eff. June 17, 2003.|