reglab/housing_qa huggingface dataset:
TX Ins Code § 843.211 (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 F. Relations With Enrollees and Group Contract Holders|Section 843.211. Applicability of Subchapter to Entities Contracting With Health Maintenance Organization

Sec. 843.211.  APPLICABILITY OF SUBCHAPTER TO ENTITIES CONTRACTING WITH HEALTH MAINTENANCE ORGANIZATION.  This subchapter applies to a person to whom a health maintenance organization contracts to:(1)  process or pay claims;(2)  obtain the services of physicians or other providers to provide health care services to enrollees; or(3)  issue verifications or preauthorizations.|Added by Acts 2007, 80th Leg., R.S., Ch. 997 (S.B. 1731), Sec. 13, eff. September 1, 2007.|
TX Ins Code § 843.251 (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 G. Dispute Resolution|Section 843.251. Complaint System Required; Commissioner Rules and Examination

Sec. 843.251.  COMPLAINT SYSTEM REQUIRED;  COMMISSIONER RULES AND EXAMINATION.  (a)  A health maintenance organization shall implement and maintain a complaint system that provides reasonable procedures to resolve an oral or written complaint initiated by a complainant concerning health care services.  The complaint system must include a process for the notice and appeal of a complaint.(b)  The commissioner may adopt reasonable rules as necessary or proper to implement the provisions of this subchapter relating to the complaint system and administer matters relating to the complaint system.(c)  The commissioner may examine a complaint system for compliance with this subchapter and may require the health maintenance organization to make corrections as the commissioner considers necessary.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.252 (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 G. Dispute Resolution|Section 843.252. Complaint Initiation and Initial Response; Deadlines for Response and Resolution

Sec. 843.252.  COMPLAINT INITIATION AND INITIAL RESPONSE;  DEADLINES FOR RESPONSE AND RESOLUTION.  (a)  If a complainant notifies a health maintenance organization of a complaint, the health maintenance organization, not later than the fifth business day after the date of receiving the complaint, shall send to the complainant a letter acknowledging the date of receipt of the complaint.(b)  The letter required under Subsection (a) must:(1)  include a description of the health maintenance organization's complaint procedures and time frames;  and(2)  if the complaint is made orally, be accompanied by a one-page complaint form that prominently and clearly states that the form must be returned to the health maintenance organization for prompt resolution of the complaint.(c)  A health maintenance organization shall acknowledge, investigate, and resolve a complaint not later than the 30th calendar day after the date the health maintenance organization receives the written complaint or one-page complaint form from the complainant.(d)  Subsections (a)-(c) do not apply to a complaint concerning an emergency or a denial of continued hospitalization.  A health maintenance organization shall investigate and resolve a complaint concerning an emergency or a denial of continued hospitalization:(1)  in accordance with the medical or dental immediacy of the case;  and(2)  not later than one business day after the health maintenance organization receives the complaint.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.253 (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 G. Dispute Resolution|Section 843.253. Complaint Investigation and Resolution

Sec. 843.253.  COMPLAINT INVESTIGATION AND RESOLUTION.  (a)  A health maintenance organization shall investigate each complaint received in accordance with the health maintenance organization's policies and in compliance with this chapter.(b)  After a health maintenance organization has investigated a complaint, the health maintenance organization shall issue a response letter to the complainant within the time prescribed by Section 843.252(c) that:(1)  explains the health maintenance organization's resolution of the complaint;(2)  states the specific medical and contractual reasons for the resolution;(3)  states the specialization of any physician or other provider consulted;  and(4)  contains a complete description of the process for appeal, including the deadlines for the appeals process and the deadlines for the final decision on the appeal.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.254 (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 G. Dispute Resolution|Section 843.254. Appeal to Complaint Appeal Panel; Deadlines

Sec. 843.254.  APPEAL TO COMPLAINT APPEAL PANEL;  DEADLINES.  (a)  A health maintenance organization shall provide an appeals process for a complainant who is not satisfied with the resolution of the complaint.  The appeals process must include the right of the complainant to:(1)  appear in person before a complaint appeal panel at the site at which the enrollee normally receives health care services or at another site agreed to by the complainant;  or(2)  address a written appeal to the complaint appeal panel.(b)  The health maintenance organization shall send an acknowledgment letter to the complainant not later than the fifth business day after the date the written request for appeal is received.(c)  The health maintenance organization shall complete the appeals process not later than the 30th calendar day after the date the written request for appeal is received.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.255 (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 G. Dispute Resolution|Section 843.255. Composition of Complaint Appeal Panel

Sec. 843.255.  COMPOSITION OF COMPLAINT APPEAL PANEL.  (a)  A health maintenance organization shall appoint members to a complaint appeal panel to advise the health maintenance organization on the resolution of a disputed decision appealed by a complainant.(b)  A complaint appeal panel shall be composed of an equal number of health maintenance organization staff members, physicians or other providers, and enrollees.  A member of a complaint appeal panel may not have been previously involved in the disputed decision.(c)  The physicians or other providers on a complaint appeal panel must have experience in the area of care that is in dispute and must be independent of any physician or provider who made any previous determination.  If specialty care is in dispute, the complaint appeal panel must include a person who is a specialist in the field of care to which the appeal relates.(d)  The enrollee members of a complaint appeal panel may not be employees of the health maintenance organization.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.256 (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 G. Dispute Resolution|Section 843.256. Information Provided to Complainant Relating to Complaint Appeal Panel

Sec. 843.256.  INFORMATION PROVIDED TO COMPLAINANT RELATING TO COMPLAINT APPEAL PANEL.  Not later than the fifth business day before the date a complaint appeal panel is scheduled to meet, unless the complainant agrees otherwise, the health maintenance organization shall provide to the complainant or the complainant's designated representative:(1)  any documentation to be presented to the complaint appeal panel by the health maintenance organization staff;(2)  the specialization of any physicians or providers consulted during the investigation;  and(3)  the name and affiliation of each health maintenance organization representative on the complaint appeal panel.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.257 (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 G. Dispute Resolution|Section 843.257. Rights of Complainant at Complaint Appeal Panel Meeting

Sec. 843.257.  RIGHTS OF COMPLAINANT AT COMPLAINT APPEAL PANEL MEETING.  A complainant, or a designated representative if the enrollee is a minor or is disabled, is entitled to:(1)  appear in person before the complaint appeal panel;(2)  present alternative expert testimony;  and(3)  request the presence of and question any person responsible for making the disputed decision that resulted in the appeal.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.258 (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 G. Dispute Resolution|Section 843.258. Appeal Involving Ongoing Emergency or Continued Hospitalization

Sec. 843.258.  APPEAL INVOLVING ONGOING EMERGENCY OR CONTINUED HOSPITALIZATION.  (a)  The investigation and resolution of an appeal of a complaint relating to an ongoing emergency or denial of continued hospitalization shall be concluded:(1)  in accordance with the medical or dental immediacy of the case;  and(2)  not later than one business day after the complainant's request for appeal is received.(b)  Because of the ongoing emergency or continued hospitalization and at the request of the complainant, the health maintenance organization shall provide, instead of a complaint appeal panel, a review by a physician or provider who:(1)  has not previously reviewed the case;  and(2)  is of the same or a similar specialty as the physician or provider who would typically manage the medical condition, procedure, or treatment under consideration for review in the appeal.(c)  The physician or provider reviewing the appeal may interview the patient or the patient's designated representative and shall decide the appeal.(d)  The physician or provider may deliver initial notice of the decision on the appeal orally if the physician or provider subsequently provides written notice of the decision not later than the third day after the date of the decision.(e)  The investigation and resolution of an appeal after emergency care has been provided shall be conducted in accordance with the procedures otherwise established under this subchapter, including the right to review by a complaint appeal panel.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.259 (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 G. Dispute Resolution|Section 843.259. Notice of Decision on Appeal

Sec. 843.259.  NOTICE OF DECISION ON APPEAL.  (a)  A health maintenance organization shall include in a notice of the final decision on an appeal a statement of the specific medical determination, clinical basis, and contractual criteria used to reach the final decision.(b)  The notice must include the toll-free telephone number and address of the department.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.260 (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 G. Dispute Resolution|Section 843.260. Record of Complaints

Sec. 843.260.  RECORD OF COMPLAINTS.  (a)  A health maintenance organization shall maintain a complaint and appeal log regarding each complaint.  The log must identify those complaints relating to limited provider networks and delegated entities.(b)  A health maintenance organization shall maintain a record of and documentation on each complaint, complaint proceeding, and action taken on each complaint, including a complaint relating to a limited provider network or delegated entity, until the third anniversary of the date the complaint was received.(c)  A complainant is entitled to a copy of the record of the complainant's complaint and any proceeding relating to that complaint.(d)  The department, during any investigation of a health maintenance organization, may review documentation maintained under Subsection (b), including original documentation, regarding a complaint and action taken on the complaint.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.209(a), eff. Sept. 1, 2003.|
TX Ins Code § 843.261 (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 G. Dispute Resolution|Section 843.261. Special Provisions for Appeals of Adverse Determinations

Sec. 843.261.  SPECIAL PROVISIONS FOR APPEALS OF ADVERSE DETERMINATIONS.  (a)  A health maintenance organization shall implement and maintain an internal appeal system that:(1)  provides reasonable procedures for the resolution of an oral or written appeal concerning dissatisfaction or disagreement with an adverse determination; and(2)  includes procedures for notification, review, and appeal of an adverse determination in accordance with Chapter 4201.(b)  An appeal must be initiated by an enrollee, a person acting on behalf of an enrollee, or an enrollee's provider of record.(c)  When an enrollee, a person acting on behalf of an enrollee, or an enrollee's provider of record expresses orally or in writing any dissatisfaction or disagreement with an adverse determination, the health maintenance organization or utilization review agent shall:(1)  consider the expression of dissatisfaction or disagreement as an appeal of the adverse determination; and(2)  review and resolve the appeal in accordance with Chapter 4201.(d)  A health maintenance organization may integrate its appeal procedures related to adverse determinations with the complaint and appeal procedures established by the health maintenance organization under Section 843.251 and otherwise governed by this subchapter only if the procedures related to adverse determinations comply with this section and Chapter 4201.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.Amended by: Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2E.046, eff. April 1, 2009.|
TX Ins Code § 843.262 (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 G. Dispute Resolution|Section 843.262. Certain Decisions Binding

Sec. 843.262.  CERTAIN DECISIONS BINDING.  (a)  If an enrollee, a person acting on behalf of an enrollee, or an enrollee's provider of record appeals an adverse determination as provided under Section 843.261 and the health maintenance organization or utilization review agent, as applicable, resolves the claim in favor of the enrollee, the decision is binding on the health maintenance organization.(b)  After a binding decision in favor of an enrollee relating to a proposed health care service, the health maintenance organization shall provide or arrange for the health care service within a time frame that is appropriate for the treatment of the medical condition that was the subject of the appeal.(c)  After a binding decision in favor of an enrollee relating to a health care service already provided, the health maintenance organization shall pay the cost of the service, if not already paid by the health maintenance organization, not later than the 45th day after the date the health maintenance organization receives notice of the binding decision.  A health maintenance organization that fails to pay the cost of service as required by this subsection is subject to penalties provided under Section 843.342.(d)  This section applies only to a health care plan of a political subdivision that is exempt from application of the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.).|Added by Acts 2003, 78th Leg., ch. 348, Sec. 1, eff. Sept. 1, 2003.|
TX Ins Code § 843.281 (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 H. General Provisions Regarding Complaints|Section 843.281. Retaliatory Action Prohibited

Sec. 843.281.  RETALIATORY ACTION PROHIBITED.  (a)  A health maintenance organization may not engage in retaliatory action, including refusal to renew or cancellation of coverage, against a group contract holder or enrollee because the group or enrollee or a person acting on behalf of the group or enrollee has filed a complaint against the health maintenance organization or appealed a decision of the health maintenance organization.(b)  A health maintenance organization may not engage in retaliatory action, including refusal to renew or termination of a contract, against a physician or provider because the physician or provider has, on behalf of an enrollee, reasonably filed a complaint against the health maintenance organization or appealed a decision of the health maintenance organization.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.282 (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 H. General Provisions Regarding Complaints|Section 843.282. Submitting Complaints to Department

Sec. 843.282.  SUBMITTING COMPLAINTS TO DEPARTMENT.  (a)  Any person, including a person who has attempted to resolve a complaint through a health maintenance organization's complaint system process and is dissatisfied with the resolution, may submit a complaint to the department alleging a violation of:(1)  this chapter;(2)  Section 1367.053;(3)  Subchapter A, Chapter 1452;(4)  Subchapter B, Chapter 1507;(5)  Chapters 222, 251, and 258, as applicable to a  health maintenance organization; or(6)  Chapter 1271 or 1272.(b)  The commissioner shall complete an investigation of a complaint against a health maintenance organization to determine whether a violation has occurred not later than the 60th day after the date the department receives the complaint and all information necessary for the commissioner to make a determination.(c)  The commissioner may extend the time necessary to complete an investigation if:(1)  additional information is needed;(2)  an on-site review is necessary;(3)  the health maintenance organization, the physician or provider, or the complainant does not provide all documentation necessary to complete the investigation;  or(4)  other circumstances beyond the control of the department occur.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.Amended by: Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2E.047, eff. April 1, 2009.|
TX Ins Code § 843.283 (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 H. General Provisions Regarding Complaints|Section 843.283. Posting of Information on Complaint Process Required

Sec. 843.283.  POSTING OF INFORMATION ON COMPLAINT PROCESS REQUIRED.  A contract between a health maintenance organization and a physician or provider must require the physician or provider to post, in the office of the physician or provider, a notice to enrollees on the process for resolving complaints with the health maintenance organization.  The notice must include the department's toll-free telephone number for filing a complaint.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.301 (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 843.301. Practice of Medicine Not Affected

Sec. 843.301.  PRACTICE OF MEDICINE NOT AFFECTED.  This chapter, Section 1367.053, Subchapter A, Chapter 1452, Subchapter B, Chapter 1507, Chapters 222, 251, and 258, as applicable to a health maintenance organization, and Chapters 1271 and 1272 do not:(1)  authorize any person, other than a licensed physician or practitioner of the healing arts, acting within the scope of the person's license, to engage directly or indirectly in the practice of medicine or a healing art; or(2)  authorize any person to regulate, interfere with, or intervene in any manner in the practice of medicine or a healing art.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.Amended by: Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2E.048, eff. April 1, 2009.|
TX Ins Code § 843.302 (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 843.302. Disclosure of Application Procedures and Qualification Requirements to Physician or Provider

Sec. 843.302.  DISCLOSURE OF APPLICATION PROCEDURES AND QUALIFICATION REQUIREMENTS TO PHYSICIAN OR PROVIDER.  A health maintenance organization shall, on request, make available and disclose to a physician or provider written application procedures and qualification requirements for contracting with the health maintenance organization.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|