reglab/housing_qa huggingface dataset:
TX Ins Code § 843.303 (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 843.303. Denial of Initial Contract to Physician or Provider

Sec. 843.303.  DENIAL OF INITIAL CONTRACT TO PHYSICIAN OR PROVIDER.  (a)  A health maintenance organization that denies a contract to a physician or provider who initially applies to contract with the health maintenance organization to provide health care services on behalf of the health maintenance organization shall provide to the applicant written notice of the reasons the initial application was denied.(b)  Unless otherwise limited by Article 21.52B, this section does not prohibit a health maintenance organization from rejecting an initial application from a physician or provider based on the determination that the plan has sufficient qualified physicians or providers.(c)  A health maintenance organization may not deny a contract to a podiatrist described by Section 843.319.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 237, Sec. 3, eff. Sept. 1, 2003.|
TX Ins Code § 843.304 (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 843.304. Exclusion of Provider Based on Type of License Prohibited

Sec. 843.304.  EXCLUSION OF PROVIDER BASED ON TYPE OF LICENSE PROHIBITED.  (a)  A provider licensed or otherwise authorized to practice in this state may not be denied the opportunity to participate in providing health care services that are delivered by a health maintenance organization and that are within the scope of the provider's license or authorization solely because of the type of license or authorization held by the provider.(b)  If a hospital, facility, agency, or supplier is certified by the Medicare program, Title XVIII of the Social Security Act (42 U.S.C. Section 1395 et seq.), or accredited by the Joint Commission on Accreditation of Healthcare Organizations or another national accrediting body, a health maintenance organization shall accept that certification or accreditation.(c)  This section does not require that a health maintenance organization:(1)  use a particular type of provider in its operation;(2)  accept each provider of a category or type, except as provided by Article 21.52B;  or(3)  contract directly with providers of a particular category or type.(d)  This section does not limit a health maintenance organization's authority to establish the terms under which health care services are provided by providers.(e)  A provider must comply with the terms established by the health maintenance organization for the provision of health services and for designation as a provider by the health maintenance organization.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.3041 (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 843.3041. Acupuncturist Services

Sec. 843.3041.  ACUPUNCTURIST SERVICES.  (a)  A health maintenance organization that includes acupuncture in the services covered by the organization's health care plan may not refuse to provide reimbursement for the performance of a covered acupuncture service solely because the service is performed by an acupuncturist.(b)  This section does not require a health maintenance organization to offer acupuncture as a covered service.|Added by Acts 2005, 79th Leg., Ch. 622 (H.B. 2371), Sec. 1, eff. September 1, 2005.|
TX Ins Code § 843.3042 (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 843.3042. Chiropractic Services

Sec. 843.3042.  CHIROPRACTIC SERVICES.  (a)  A health maintenance organization offering a health care plan that covers a service that is within the scope of a chiropractor's license may not refuse to provide reimbursement to an in-network chiropractor for the performance of the covered service solely because the service is provided by a chiropractor.(b)  This section does not require a health maintenance organization to cover a particular health care service.(c)  This section does not affect the right of a health maintenance organization to determine whether a health care service is medically necessary.(d)  A health maintenance organization that violates this section is subject to an administrative penalty as provided by Chapter 84 of not more than $1,000 for each claim that remains unpaid in violation of this section.  Each day the violation continues constitutes a separate violation.|Added by Acts 2019, 86th Leg., R.S., Ch. 116 (S.B. 1739), Sec. 1, eff. September 1, 2019.|
TX Ins Code § 843.3045 (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 843.3045. Nurse First Assistant

Sec. 843.3045.  NURSE FIRST ASSISTANT.  A health maintenance organization may not refuse to contract with a nurse first assistant, as defined by Section 301.1525, Occupations Code, to be included in the provider's network or refuse to reimburse the nurse first assistant for a covered service that a physician has requested the nurse first assistant to perform.|Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.210(a), eff. Sept. 1, 2003.|
TX Ins Code § 843.305 (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 843.305. Annual Application Period for Physicians and Providers to Contract

Sec. 843.305.  ANNUAL APPLICATION PERIOD FOR PHYSICIANS AND PROVIDERS TO CONTRACT.  (a)  This section applies only to a health maintenance organization that provides coverage for health care services through:(1)  one or more physicians or providers who are not partners or employees of the health maintenance organization;  or(2)  one or more physicians or providers who are not owned or operated by the health maintenance organization.(b)  A health maintenance organization shall provide a period of 20 calendar days each calendar year during which any physician or provider in a service area may, under the terms established by the health maintenance organization for the provision of services and the designation of physicians and providers, apply to participate in providing health care services.(c)  A health maintenance organization that denies the application of a physician or provider shall notify the physician or provider in writing of the reason for the denial.(d)  This section does not require that a health maintenance organization:(1)  use a particular type of physician or provider in its operation;(2)  accept a physician or provider of a category or type that does not meet the practice standards and qualifications established by the health maintenance organization;  or(3)  contract directly with physicians or providers of a particular category or type.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.306 (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 843.306. Termination of Participation; Advisory Review Panel

Sec. 843.306.  TERMINATION OF PARTICIPATION;  ADVISORY REVIEW PANEL.  (a)  Before terminating a contract with a physician or provider, a health maintenance organization shall provide to the physician or provider a written explanation of the reasons for termination.(b)  On request, before the effective date of the termination and within a period not to exceed 60 days, a physician or provider is entitled to a review by an advisory review panel of the health maintenance organization's proposed termination, except in a case involving:(1)  imminent harm to patient health;(2)  an action by a state medical or dental board, another medical or dental licensing board, or another licensing board or government agency that effectively impairs the physician's or provider's ability to practice medicine, dentistry, or another profession;  or(3)  fraud or malfeasance.(c)  An advisory review panel must:(1)  be composed of physicians and providers who are appointed to serve on the standing quality assurance committee or utilization review committee of the health maintenance organization;  and(2)  include, if available, at least one representative of the physician's or provider's specialty or a similar specialty.(d)  The health maintenance organization must consider, but is not bound by, the recommendation of the advisory review panel.(e)  The health maintenance organization on request shall provide to the affected physician or provider a copy of the recommendation of the advisory review panel and the health maintenance organization's determination.(f)  A health maintenance organization may not terminate participation of a physician or provider solely because the physician or provider informs an enrollee of the full range of physicians and providers available to the enrollee, including out-of-network providers.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.Amended by: Acts 2015, 84th Leg., R.S., Ch. 275 (H.B. 574), Sec. 2, eff. September 1, 2015.|
TX Ins Code § 843.307 (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 843.307. Expedited Review Process on Termination or Deselection

Sec. 843.307.  EXPEDITED REVIEW PROCESS ON TERMINATION OR DESELECTION.  On request by the physician or provider, a physician or provider whose participation in a health care plan is being terminated or who is deselected is entitled to an expedited review process by the health maintenance organization.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.308 (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 843.308. Notification of Patients of Deselected Physician or Provider

Sec. 843.308.  NOTIFICATION OF PATIENTS OF DESELECTED PHYSICIAN OR PROVIDER.  (a)  Except as provided by Subsection (b), if a physician or provider is deselected for a reason other than the request of the physician or provider, a health maintenance organization may not notify patients of the deselection until the effective date of the deselection or the advisory review panel makes a formal recommendation.(b)  If the contract of a physician or provider is deselected for a reason related to imminent harm, a health maintenance organization may notify patients immediately.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.309 (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 843.309. Contracts With Physicians or Providers: Notice to Certain Enrollees of Termination of Physician or Provider Participation in Plan

Sec. 843.309.  CONTRACTS WITH PHYSICIANS OR PROVIDERS:  NOTICE TO CERTAIN ENROLLEES OF TERMINATION OF PHYSICIAN OR PROVIDER PARTICIPATION IN PLAN.  A contract between a health maintenance organization and a physician or provider must provide that reasonable advance notice shall be given to an enrollee of the impending termination from the plan of a physician or provider who is currently treating the enrollee.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.310 (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 843.310. Contracts With Physicians or Providers: Certain Indemnity Clauses Prohibited

Sec. 843.310.  CONTRACTS WITH PHYSICIANS OR PROVIDERS:  CERTAIN INDEMNITY CLAUSES PROHIBITED.  A contract between a health maintenance organization and a physician or provider may not contain a clause purporting to indemnify the health maintenance organization for any liability in tort resulting from an act or omission of the health maintenance organization.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.311 (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 843.311. Contracts With Podiatrists

Sec. 843.311.  CONTRACTS WITH PODIATRISTS.  A contract between a health maintenance organization and a podiatrist licensed by the Texas Department of Licensing and Regulation must provide that:(1)  the podiatrist may request, and the health maintenance organization shall provide not later than the 30th day after the date of the 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 health maintenance organization may not unilaterally make material retroactive revisions to the coding guidelines and payment schedules; and(3)  the podiatrist may, while practicing within the scope of the law regulating podiatry, provide x-rays and nonprefabricated orthotics covered by the evidence of coverage.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.Amended by: Acts 2019, 86th Leg., R.S., Ch. 467 (H.B. 4170), Sec. 19.011, eff. September 1, 2019.|
TX Ins Code § 843.3115 (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 843.3115. Contracts With Dentists

Sec. 843.3115.  CONTRACTS WITH DENTISTS.  (a)  In this section, "covered service" means a dental care service for which reimbursement is available under an enrollee's health care plan contract, or for which reimbursement is available subject to a contractual limitation, including:(1)  a deductible;(2)  a copayment;(3)  coinsurance;(4)  a waiting period;(5)  an annual or lifetime maximum limit;(6)  a frequency limitation; or(7)  an alternative benefit payment.(b)  A contract between a health maintenance organization and a dentist may not limit the fee the dentist may charge for a service that is not a covered service.|Added by Acts 2011, 82nd Leg., R.S., Ch. 1061 (S.B. 554), Sec. 1, eff. September 1, 2011.|
TX Ins Code § 843.312 (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 843.312. Physician Assistants and Advanced Practice Nurses

Sec. 843.312.  PHYSICIAN ASSISTANTS AND ADVANCED PRACTICE NURSES.  (a)  A health maintenance organization may not refuse a request by a physician participating in the health maintenance organization delivery network and a physician assistant or advanced practice nurse who is authorized by the physician to provide care under Subchapter B, Chapter 157, Occupations Code, to identify a physician assistant or advanced practice nurse as a provider in the network.(b)  A health maintenance organization may refuse a request under Subsection (a) if the physician assistant or advanced practice nurse does not meet the quality of care standards previously established by the health maintenance organization for participation in the network by physician assistants and advanced practice nurses.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.313 (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 843.313. Economic Profiling

Sec. 843.313.  ECONOMIC PROFILING.  (a)  A health maintenance organization that conducts or uses economic profiling of physicians or providers participating in the health maintenance organization delivery network shall make available to a network physician or provider on request that physician's or provider's economic profile, including the standards by which the physician or provider is measured.(b)  The use of an economic profile must recognize the characteristics of a physician's or provider's practice that may account for variations from expected costs.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.314 (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 843.314. Inducement to Limit Medically Necessary Services Prohibited

Sec. 843.314.  INDUCEMENT TO LIMIT MEDICALLY NECESSARY SERVICES PROHIBITED.  (a)  A health maintenance organization may not use a financial incentive or make a payment to a physician or provider if the incentive or payment 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 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.316 (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 843.316. Alternative Capitation System

Sec. 843.316.  ALTERNATIVE CAPITATION SYSTEM.  As an alternative to the procedures prescribed by Section 843.315, a health maintenance organization may request approval from the department of a capitation payment system that ensures:(1)  immediate availability and accessibility of a primary care physician or primary care provider;  and(2)  payment to a primary care physician or primary care provider of a capitated amount certified by a qualified actuary to be actuarially sufficient to compensate the primary care physician or primary care provider for the risk assumed.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.317 (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 843.317. Exclusion of Physician or Provider Based on Affiliation With Health Maintenance Organization Prohibited

Sec. 843.317.  EXCLUSION OF PHYSICIAN OR PROVIDER BASED ON AFFILIATION WITH HEALTH MAINTENANCE ORGANIZATION PROHIBITED.  A physician, health care provider, group of physicians or health care providers, or health care facility or institution may not exclude a physician or provider from staff privileges or a facility or institution solely because the physician or provider is associated with a health maintenance organization that holds a certificate of authority under this chapter.|Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.|
TX Ins Code § 843.318 (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 843.318. Certain Contracts of Participating Physician or Provider Not Prohibited

Sec. 843.318.  CERTAIN CONTRACTS OF PARTICIPATING PHYSICIAN OR PROVIDER NOT PROHIBITED.  (a)  This chapter and this code do not prohibit a physician or provider who is participating in a health maintenance organization delivery network, whether by contracting with a health maintenance organization under Section 843.101 or by subcontracting with a physician or provider in the health maintenance organization delivery network, from entering into a contractual arrangement within a health maintenance organization delivery network described by Subsections (b)-(e).(b)  A physician may contract to provide medical care or arrange to provide medical care through subcontracts with other physicians.  A physician may contract to provide through another provider any service that is ancillary to the practice of medicine, other than hospital or other institutional or inpatient provider services.(c)  A provider may contract to provide, or arrange to provide through a subcontract with a similarly licensed provider, any health care service that the providers are licensed to provide, other than medical care.(d)  A provider may contract to provide, or arrange to provide through a subcontract with another provider, a health care service that the provider is not licensed to provide, other than medical care, if the contracted or subcontracted services constitute less than 15 percent of the total amount of services the provider is to provide or arrange to provide.(e)  A contract or subcontract authorized under this section may provide for compensation under:(1)  a fee-for-service arrangement;(2)  a risk-sharing arrangement;  or(3)  a capitation arrangement under which a fixed predetermined payment is made in exchange for the provision of, or for the arrangement to provide and the guaranty of the provision of, a defined set of covered services to covered persons for a specified period without regard to the quantity of services actually provided.|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. 3B.025, eff. September 1, 2007.Acts 2007, 80th Leg., R.S., Ch. 921 (H.B. 3167), Sec. 9.025, eff. September 1, 2007.|