reglab/housing_qa huggingface dataset:
TX Ins Code § 1301.057 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter B. Relations With Physicians or Health Care Providers|Section 1301.057. Termination of Participation; Expedited Review Process

Sec. 1301.057.  TERMINATION OF PARTICIPATION;  EXPEDITED REVIEW PROCESS.  (a)  Before terminating a contract with a preferred provider, an insurer shall:(1)  provide written reasons for the termination;  and(2)  if the affected provider is a practitioner, provide, on request, a reasonable review mechanism, except in a case involving:(A)  imminent harm to a patient's health;(B)  an action by a state medical or other physician licensing board or other government agency that effectively impairs the practitioner's ability to practice medicine;  or(C)  fraud or malfeasance.(b)  The review mechanism described by Subsection (a)(2) must incorporate, in an advisory role only, a review panel selected in the manner described by Section 1301.053(b) and must be completed within a period not to exceed 60 days.(c)  The insurer shall provide to the affected practitioner:(1)  the panel's recommendation, if any;  and(2)  on request, a written explanation of the insurer's determination, if that determination is contrary to the panel's recommendation.(d)  On request, an insurer shall provide to a practitioner whose participation in a preferred provider benefit plan is being terminated:(1)  an expedited review conducted in accordance with a process that complies with rules established by the commissioner; and(2)  all information on which the insurer wholly or partly based the termination, including the economic profile of the preferred provider, the standards by which the provider is measured, and the statistics underlying the profile and standards.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2015, 84th Leg., R.S., Ch. 275 (H.B. 574), Sec. 6, eff. September 1, 2015.|
TX Ins Code § 1301.058 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter B. Relations With Physicians or Health Care Providers|Section 1301.058. Economic Profiling

Sec. 1301.058.  ECONOMIC PROFILING.  An insurer that conducts, uses, or relies on economic profiling to admit or terminate the participation of physicians or health care providers in a preferred provider benefit plan shall make available to a physician or health care provider on request the economic profile of that physician or health care provider, including the written criteria by which the physician or health care provider's performance is to be measured.  An economic profile must be adjusted to recognize the characteristics of a physician's or health care provider's practice that may account for variations from expected costs.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1301.059 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter B. Relations With Physicians or Health Care Providers|Section 1301.059. Quality Assessment

Sec. 1301.059.  QUALITY ASSESSMENT.  (a)  In this section, "quality assessment" means a mechanism used by an insurer to evaluate, monitor, or improve the quality and effectiveness of the medical care delivered by physicians or health care providers to persons covered by a health insurance policy to ensure that the care delivered is consistent with the care delivered by an ordinary, reasonable, and prudent physician or health care provider under the same or similar circumstances.(b)  An insurer may not engage in quality assessment except through a panel of at least three physicians selected by the insurer from among a list of physicians contracting with the insurer.  The physicians contracting with the insurer in the applicable service area shall provide the list of physicians to the insurer.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1301.060 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter B. Relations With Physicians or Health Care Providers|Section 1301.060. Compensation on Discounted Fee Basis

Sec. 1301.060.  COMPENSATION ON DISCOUNTED FEE BASIS.  A preferred provider contract must include a provision by which the physician or health care provider agrees that if the preferred provider is compensated on a discounted fee basis, the insured may be billed only on the discounted fee and not the full charge.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1301.061 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter B. Relations With Physicians or Health Care Providers|Section 1301.061. Preferred Provider Networks

Sec. 1301.061.  PREFERRED PROVIDER NETWORKS.  (a)  An insurer may enter into an agreement with a preferred provider organization for the purposes of offering a network of preferred providers.  The agreement may provide that either the insurer or the preferred provider organization on the insurer's behalf will comply with the notice requirements and other requirements imposed on the insurer by this subchapter.(b)  An insurer that enters into an agreement with a preferred provider organization under this section shall meet the requirements of this chapter or ensure that those requirements are met.(c)   Each preferred provider benefit plan offered in this state must comply with this chapter.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 3B.0271(a), eff. September 1, 2007.|
TX Ins Code § 1301.062 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter B. Relations With Physicians or Health Care Providers|Section 1301.062. Preferred Provider Contracts Between Insurers and Podiatrists

Sec. 1301.062.  PREFERRED PROVIDER CONTRACTS BETWEEN INSURERS AND PODIATRISTS.  A preferred provider contract between an insurer and a podiatrist licensed by the Texas Department of Licensing and Regulation must provide that:(1)  the podiatrist may request a copy of the coding guidelines and payment schedules applicable to the compensation that the podiatrist will receive under the contract for services;(2)  the insurer shall provide a copy of the coding guidelines and payment schedules not later than the 30th day after the date of the podiatrist's request;(3)  the insurer may not unilaterally make material retroactive revisions to the coding guidelines and payment schedules; and(4)  the podiatrist may, practicing within the scope of the law regulating podiatry, furnish x-rays and nonprefabricated orthotics covered by the health insurance policy.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2019, 86th Leg., R.S., Ch. 467 (H.B. 4170), Sec. 19.014, eff. September 1, 2019.|
TX Ins Code § 1301.0625 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter B. Relations With Physicians or Health Care Providers|Section 1301.0625. Health Care Collaboratives

Sec. 1301.0625.  HEALTH CARE COLLABORATIVES.  (a)  Subject to the requirements of this chapter, a health care collaborative may be designated as a preferred provider under a preferred provider benefit plan and may offer enhanced benefits for care provided by the health care collaborative.(b)  A preferred provider contract between an insurer and a health care collaborative may use a payment methodology other than a fee-for-service or discounted fee methodology.  A reimbursement methodology used in a contract under this subsection is not subject to Chapter 843.(c)  A contract authorized by Subsection (b) must specify that the health care collaborative and the physicians or providers providing health care services on behalf of the collaborative will hold an insured harmless for payment of the cost of covered health care services if the insurer or the health care collaborative do not pay the physician or health care provider for the services.(d)  An insurer issuing an exclusive provider benefit plan authorized by another law of this state may limit access to only preferred providers participating in a health care collaborative if the limitation is consistent with all requirements applicable to exclusive provider benefit plans.|Added by Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 4.03, eff. September 28, 2011.|
TX Ins Code § 1301.063 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter B. Relations With Physicians or Health Care Providers|Section 1301.063. Contract Provisions Relating to Use of Hospitalist

Sec. 1301.063.  CONTRACT PROVISIONS RELATING TO 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 preferred provider contract between an insurer and a physician may not require the physician to use a hospitalist for a hospitalized patient.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1301.064 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter B. Relations With Physicians or Health Care Providers|Section 1301.064. Contract Provisions Relating to Payment of Claims

Sec. 1301.064.  CONTRACT PROVISIONS RELATING TO PAYMENT OF CLAIMS.  Subject to Subchapter C, a preferred provider contract must provide for payment to a physician or health care provider for health care services and benefits provided to an insured under the contract and to which the insured is entitled under the terms of the contract 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 health care provider and the insurer.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1301.0641 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter B. Relations With Physicians or Health Care Providers|Section 1301.0641. Contract Provisions Prohibiting Rejection of Batched Claims

Sec. 1301.0641.  CONTRACT PROVISIONS PROHIBITING REJECTION OF BATCHED CLAIMS.  (a)  If requested by a preferred provider, an insurer shall include a provision in the preferred provider's contract providing that the insurer or the insurer's clearinghouse may not refuse to process or pay an electronically submitted clean claim, as defined by Subchapter C, 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 an insurer that violates this section or a contract provision adopted under this section.|Added by Acts 2005, 79th Leg., Ch. 668 (S.B. 50), Sec. 2, eff. September 1, 2005.|
TX Ins Code § 1301.065 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter B. Relations With Physicians or Health Care Providers|Section 1301.065. Shifting of Insurer's Tort Liability Prohibited

Sec. 1301.065.  SHIFTING OF INSURER'S TORT LIABILITY PROHIBITED.  A preferred provider contract may not require any physician, health care provider, or physicians' group to execute a hold harmless clause to shift the insurer's tort liability resulting from the insurer's acts or omissions to the preferred provider.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1301.066 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter B. Relations With Physicians or Health Care Providers|Section 1301.066. Retaliation Against Preferred Provider Prohibited

Sec. 1301.066.  RETALIATION AGAINST PREFERRED PROVIDER PROHIBITED.  An insurer may not engage in any retaliatory action against a physician or health care provider, including terminating the physician's or provider's participation in the preferred provider benefit plan or refusing to renew the physician's or provider's contract, because the physician or provider has:(1)  on behalf of an insured, reasonably filed a complaint against the insurer;  or(2)  appealed a decision of the insurer.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1301.067 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter B. Relations With Physicians or Health Care Providers|Section 1301.067. Interference With Relationship Between Patient and Physician or Health Care Provider Prohibited

Sec. 1301.067.  INTERFERENCE WITH RELATIONSHIP BETWEEN PATIENT AND PHYSICIAN OR HEALTH CARE PROVIDER PROHIBITED.  (a)  An insurer may not, as a condition of a preferred provider contract with a physician or health care provider or in any other manner, prohibit, attempt to prohibit, or discourage a physician or provider from discussing with or communicating to a current, prospective, or former patient, or a person designated by a patient, information or an opinion:(1)  regarding the patient's health care, including the patient's medical condition or treatment options;  or(2)  in good faith regarding the provisions, terms, requirements, or services of the health insurance policy as they relate to the patient's medical needs.(a-1)  An insurer may not, as a condition of payment with a physician or health care provider or in any other manner, require a physician or health care provider to provide a notification form stating that the physician or health care provider is an out-of-network provider to a current, prospective, or former patient, or a person designated by the patient, if the form contains additional information that is intended, or is otherwise required to be presented in a manner that is intended, to intimidate the patient.(b)  An insurer may not in any way penalize, terminate the participation of, or refuse to compensate for covered services a physician or health care provider for discussing or communicating with a current, prospective, or former patient, or a person designated by a patient, pursuant to this section.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2015, 84th Leg., R.S., Ch. 275 (H.B. 574), Sec. 7, eff. September 1, 2015.|
TX Ins Code § 1301.068 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter B. Relations With Physicians or Health Care Providers|Section 1301.068. Inducement to Limit Medically Necessary Services Prohibited

Sec. 1301.068.  INDUCEMENT TO LIMIT MEDICALLY NECESSARY SERVICES PROHIBITED.  (a)  An insurer may not use any financial incentive or make payment to a physician or health care provider that acts directly or indirectly as an inducement to limit medically necessary services.(b)  This section does not prohibit the use of capitation as a method of payment.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.|
TX Ins Code § 1301.069 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter B. Relations With Physicians or Health Care Providers|Section 1301.069. Services Provided by Certain Physicians and Health Care Providers

Sec. 1301.069.  SERVICES PROVIDED BY CERTAIN PHYSICIANS AND HEALTH CARE PROVIDERS.  The provisions of this chapter relating to prompt payment by an insurer of a physician or health care provider and to verification of medical care or health care services apply to a physician or provider who:(1)  is not a preferred provider included in the preferred provider network; and(2)  provides to an insured:(A)  care related to an emergency or its attendant episode of care as required by state or federal law; or(B)  specialty or other medical care or health care services at the request of the insurer or a preferred provider because the services are not reasonably available from a preferred provider who is included in the preferred delivery network.|Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(d), eff. September 1, 2005.|
TX Ins Code § 1301.101 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter C. Prompt Payment of Claims|Section 1301.101. Definition

Sec. 1301.101.  DEFINITION.  In this subchapter, "clean claim" means a claim that complies with Section 1301.131.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(a), eff. September 1, 2005.|
TX Ins Code § 1301.102 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter C. Prompt Payment of Claims|Section 1301.102. Submission of Claim

Sec. 1301.102.  SUBMISSION OF CLAIM.  (a)  A physician or health care provider must submit a claim to an insurer not later than the 95th day after the date the physician or provider provides the medical care or health care services for which the claim is made.(b)  Except as provided by Chapter 1213, a physician or health care provider may, as appropriate:(1)  mail a claim by United States mail, first class, or by overnight delivery service;(2)  submit the claim electronically;(3)  fax the claim; or(4)  hand deliver the claim.(c)  An insurer shall accept as proof of timely filing a claim filed in compliance with Subsection (b) or information from another insurer or health maintenance organization showing that the physician or health care provider submitted the claim to the insurer or health maintenance organization in compliance with Subsection (b).(d)  If a physician or health care provider fails to submit a claim in compliance with this section, the physician or provider forfeits the right to payment unless the failure to submit the claim in compliance with this section is a result of a catastrophic event that substantially interferes with the normal business operations of the physician or provider.(e)  The period for submitting a claim under this section may be extended by contract.(f)  A physician or health care provider may not submit a duplicate claim for payment before the 46th day after the date the original claim was submitted.  The commissioner shall adopt rules under which an insurer may determine whether a claim is a duplicate claim.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(a), eff. September 1, 2005.|
TX Ins Code § 1301.1021 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter C. Prompt Payment of Claims|Section 1301.1021. Receipt of Claim

Sec. 1301.1021.  RECEIPT OF CLAIM.  (a)  If a claim for medical care or health care services provided to a patient is mailed, the claim is presumed to have been received by the insurer on the fifth day after the date the claim is mailed or, if the claim is mailed using overnight service or return receipt requested, on the date the delivery receipt is signed.(b)  If the claim is submitted electronically, the claim is presumed to have been received on the date of the electronic verification of receipt by the insurer or the insurer's clearinghouse.  If the insurer or the insurer's clearinghouse does not provide a confirmation within 24 hours of submission by the physician or health care provider, the physician's or provider's clearinghouse shall provide the confirmation.  The physician's or provider's clearinghouse must be able to verify that the filing contained the correct payor identification of the entity to receive the filing.(c)  If the claim is faxed, the claim is presumed to have been received on the date of the transmission acknowledgment.(d)  If the claim is hand delivered, the claim is presumed to have been received on the date the delivery receipt is signed.|Amended by: Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(a), eff. September 1, 2005.|
TX Ins Code § 1301.103 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter C. Prompt Payment of Claims|Section 1301.103. Deadline for Action on Clean Claims

Sec. 1301.103.  DEADLINE FOR ACTION ON CLEAN CLAIMS.  Except as provided by Sections 1301.104 and 1301.1054, not later than the 45th day after the date an insurer receives a clean claim from a preferred provider in a nonelectronic format or the 30th day after the date an insurer receives a clean claim from a preferred provider that is electronically submitted, the insurer shall make a determination of whether the claim is payable and:(1)  if the insurer determines the entire claim is payable, pay the total amount of the claim in accordance with the contract between the preferred provider and the insurer;(2)  if the insurer determines a portion of the claim is payable, pay the portion of the claim that is not in dispute and notify the preferred provider in writing why the remaining portion of the claim will not be paid; or(3)  if the insurer determines that the claim is not payable, notify the preferred provider in writing why the claim will not be paid.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(a), eff. September 1, 2005.Acts 2011, 82nd Leg., R.S., Ch. 798 (H.B. 2292), Sec. 8, eff. September 1, 2011.|