2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle C - Managed Care › Chapter 1271 - Benefits Provided by Health Maintenance Organizations; Evidence of Coverage; Charges › Subchapter D. Certain Benefits Required › Section 1271.157. Non-Network Facility-Based Providers

Sec. 1271.157.  NON-NETWORK FACILITY-BASED PROVIDERS.  (a)  In this section, "facility-based provider" means a physician or provider who provides health care services to patients of a health care facility.
(b)  Except as provided by Subsection (d), a health maintenance organization shall pay for a covered health care service performed for or a covered supply related to that service provided to an enrollee by a non-network physician or provider who is a facility-based provider at the usual and customary rate or at an agreed rate if the provider performed the service at a health care facility that is a network provider.  The health maintenance organization shall make a payment required by this subsection directly to the physician or provider not later than, as applicable:
(1)  the 30th day after the date the health maintenance organization receives an electronic clean claim as defined by Section 843.336 for those services that includes all information necessary for the health maintenance organization to pay the claim; or
(2)  the 45th day after the date the health maintenance organization receives a nonelectronic clean claim as defined by Section 843.336 for those services that includes all information necessary for the health maintenance organization to pay the claim.
(c)  Except as provided by Subsection (d), a non-network facility-based provider or a person asserting a claim as an agent or assignee of the provider may not bill an enrollee receiving a health care service or supply described by Subsection (b) in, and the enrollee does not have financial responsibility for, an amount greater than an applicable copayment, coinsurance, and deductible under the enrollee's health care plan that:
(1)  is based on:
(A)  the amount initially determined payable by the health maintenance organization; or
(B)  if applicable, a modified amount as determined under the health maintenance organization's internal appeal process; and
(2)  is not based on any additional amount determined to be owed to the provider under Chapter 1467.
(d)  This section does not apply to a nonemergency health care or medical service:
(1)  that an enrollee elects to receive in writing in advance of the service with respect to each non-network physician or provider providing the service; and
(2)  for which a non-network physician or provider, before providing the service, provides a complete written disclosure to the enrollee that:
(A)  explains that the physician or provider does not have a contract with the enrollee's health benefit plan;
(B)  discloses projected amounts for which the enrollee may be responsible; and
(C)  discloses the circumstances under which the enrollee would be responsible for those amounts.
(e)  This section may not be construed to require the imposition of a penalty under Section 843.342.
Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 1.04, eff. September 1, 2019.