reglab/statecodes huggingface dataset:
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1451 - Access to Certain Practitioners and Facilities › Subchapter G. Access to Dietitian Services › Section 1451.301. Applicability of General Provisions of Other Law

Sec. 1451.301.  APPLICABILITY OF GENERAL PROVISIONS OF OTHER LAW.  The provisions of Chapter 1201, including provisions relating to the applicability, purpose, and enforcement of that chapter, the construction of policies under that chapter, rulemaking under that chapter, and definitions of terms applicable in that chapter, apply to this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1451 - Access to Certain Practitioners and Facilities › Subchapter G. Access to Dietitian Services › Section 1451.302. Dietitian Services

Sec. 1451.302.  DIETITIAN SERVICES.  An individual or group accident and health insurance policy delivered or issued for delivery in this state may not:
(1)  exclude or deny coverage for services performed by:
(A)  a dietitian;  or
(B)  a provisionally licensed dietitian acting under the supervision of a dietitian;  or
(2)  refuse payment or reimbursement for charges for services described by Subdivision (1) if the services:
(A)  are in the scope of the dietitian's license;
(B)  are related to an injury or illness the policy covers if the services are scheduled in the policy;  and
(C)  are provided under a professional recommendation of a physician whose treatment or examination for the injury or illness would be covered by the policy and would be payable or reimbursable under the policy.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1451 - Access to Certain Practitioners and Facilities › Subchapter H. Disability Certified by Podiatrist › Section 1451.351. Loss of Income Benefits for Disability Treatable by Podiatrist

Sec. 1451.351.  LOSS OF INCOME BENEFITS FOR DISABILITY TREATABLE BY PODIATRIST.  (a)  This section applies only to an insurance policy delivered, issued for delivery, or renewed in this state that provides benefits covering loss of income as a result of an acute temporary disability caused by sickness or injury.
(b)  An insurance policy may not deny payment of benefits described by Subsection (a) solely because the disability is certified or attested to by a podiatrist if the disability is caused by a sickness or injury that may be treated within the scope of the podiatrist's license.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1451 - Access to Certain Practitioners and Facilities › Subchapter I. Use of Osteopathic Hospital › Section 1451.401. Contract With Osteopathic Hospital

Sec. 1451.401.  CONTRACT WITH OSTEOPATHIC HOSPITAL.  A health maintenance organization or preferred provider benefit plan issuer that contracts with a hospital to provide services to covered individuals may not refuse to contract with an osteopathic hospital solely because the hospital is an osteopathic hospital.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1451 - Access to Certain Practitioners and Facilities › Subchapter I. Use of Osteopathic Hospital › Section 1451.402. Services at Osteopathic Hospital

Sec. 1451.402.  SERVICES AT OSTEOPATHIC HOSPITAL.  A health maintenance organization or preferred provider benefit plan issuer that provides benefits for inpatient or outpatient services provided by an allopathic hospital shall seek to provide benefits for similar services provided by an osteopathic hospital if there is an osteopathic hospital within the service area of the health maintenance organization or preferred provider benefit plan issuer that will provide the services at a substantially similar cost.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1451 - Access to Certain Practitioners and Facilities › Subchapter I. Use of Osteopathic Hospital › Section 1451.403. Request for Action of Commissioner

Sec. 1451.403.  REQUEST FOR ACTION OF COMMISSIONER.  An aggrieved party may request that the commissioner conduct an investigation, review, hearing, or other proceeding to determine compliance with this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1451 - Access to Certain Practitioners and Facilities › Subchapter I. Use of Osteopathic Hospital › Section 1451.404. Enforcement

Sec. 1451.404.  ENFORCEMENT.  The commissioner shall take all reasonable actions to ensure compliance with this subchapter, including issuing orders and assessing penalties.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1451 - Access to Certain Practitioners and Facilities › Subchapter J. Reimbursement of Health Care Providers › Section 1451.451. Reimbursement Under Medicaid-Based Fee Schedule

Sec. 1451.451.  REIMBURSEMENT UNDER MEDICAID-BASED FEE SCHEDULE.
Text of subsection effective until April 01, 2025
(a)  An insurance company, health maintenance organization, or preferred provider organization that contracts with a health care provider to provide services in connection with Chapter 533, Government Code, or Chapter 62, Health and Safety Code, may not require the health care provider to provide access to or transfer the provider's name and contracted discounted fee for use with health benefit plans issued to individuals and groups under Chapter 1271 or 1301.
Text of subsection effective on April 01, 2025
(a)  An insurance company, health maintenance organization, or preferred provider organization that contracts with a health care provider to provide services in connection with Chapter 540 or 540A, Government Code, as applicable, or Chapter 62, Health and Safety Code, may not require the health care provider to provide access to or transfer the provider's name and contracted discounted fee for use with health benefit plans issued to individuals and groups under Chapter 1271 or 1301.
(b)  An insurance company, health maintenance organization, or preferred provider organization may provide access to or transfer a provider's name and discounted fee described by Subsection (a) only if:
(1)  the insurance company, health maintenance organization, or preferred provider organization provides written notice to the provider that is printed in conspicuous boldface type near a separate signature line and includes a statement substantially similar to the following:  "By signing on this line, you may be agreeing to apply this company's Medicaid or CHIP fee schedule to services you provide to commercial insurance or HMO enrollees."; and
(2)  the provider authorizes the access or transfer and agrees to accept the contracted discounted fee by signing the notice described in Subdivision (1).
Added by Acts 2013, 83rd Leg., R.S., Ch. 778 (S.B. 1221), Sec. 1, eff. June 14, 2013.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 2.132, eff. April 1, 2025.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1451 - Access to Certain Practitioners and Facilities › Subchapter K. Health Care Provider Directories › Section 1451.501. Definitions

Sec. 1451.501.  DEFINITIONS.  In this subchapter:
(1)  "Facility" has the meaning assigned by Section 324.001, Health and Safety Code.
(1-a)  "Facility-based physician or provider" means a physician or health care provider:
(A)  to whom a facility has granted clinical privileges; and
(B)  who provides services to patients of the facility under those clinical privileges.
(1-b)  "Health care provider" means a practitioner, institutional provider, or other person or organization that furnishes health care services and that is licensed or otherwise authorized to practice in this state.  The term includes a pharmacist, pharmacy, hospital, nursing home, or other medical or health-related service facility that provides care for the sick or injured or other care.  The term does not include a physician.
(2)  "Physician" means an individual licensed to practice medicine in this state.
Added by Acts 2015, 84th Leg., R.S., Ch. 1038 (H.B. 1624), Sec. 2, eff. September 1, 2015.
Amended by:
Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 1.01, eff. September 1, 2019.
Acts 2023, 88th Leg., R.S., Ch. 18 (S.B. 1003), Sec. 1, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1451 - Access to Certain Practitioners and Facilities › Subchapter K. Health Care Provider Directories › Section 1451.502. Applicability of Subchapter

Sec. 1451.502.  APPLICABILITY OF SUBCHAPTER.  This subchapter applies only to a health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or a small or large employer group contract or similar coverage document that is offered by:
(1)  an insurance company;
(2)  a group hospital service corporation operating under Chapter 842;
(3)  a fraternal benefit society operating under Chapter 885;
(4)  a stipulated premium company operating under Chapter 884;
(5)  a reciprocal exchange operating under Chapter 942;
(6)  a health maintenance organization operating under Chapter 843;
(7)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846; or
(8)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844.
Added by Acts 2015, 84th Leg., R.S., Ch. 1038 (H.B. 1624), Sec. 2, eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1451 - Access to Certain Practitioners and Facilities › Subchapter K. Health Care Provider Directories › Section 1451.503. Exception

Text of section effective until April 01, 2025
Sec. 1451.503.  EXCEPTION.  This subchapter does not apply to:
(1)  a health benefit plan that provides coverage:
(A)  only for a specified disease or for another single benefit;
(B)  only for accidental death or dismemberment;
(C)  for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury;
(D)  as a supplement to a liability insurance policy;
(E)  for credit insurance;
(F)  only for dental or vision care;
(G)  only for hospital expenses; or
(H)  only for indemnity for hospital confinement;
(2)  a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss), as amended;
(3)  a workers' compensation insurance policy;
(4)  medical payment insurance coverage provided under a motor vehicle insurance policy;
(5)  a long-term care insurance policy, including a nursing home fixed indemnity policy, unless the commissioner determines that the policy provides benefit coverage so comprehensive that the policy is a health benefit plan as described by Section 1451.502;
(6)  the child health plan program under Chapter 62, Health and Safety Code, or the health benefits plan for children under Chapter 63, Health and Safety Code; or
(7)  a Medicaid managed care program operated under Chapter 533, Government Code, or a Medicaid program operated under Chapter 32, Human Resources Code.
Added by Acts 2015, 84th Leg., R.S., Ch. 1038 (H.B. 1624), Sec. 2, eff. September 1, 2015.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 2.133, eff. April 1, 2025.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1451 - Access to Certain Practitioners and Facilities › Subchapter K. Health Care Provider Directories › Section 1451.503. Exception

Text of section effective on April 01, 2025
Sec. 1451.503.  EXCEPTION.  This subchapter does not apply to:
(1)  a health benefit plan that provides coverage:
(A)  only for a specified disease or for another single benefit;
(B)  only for accidental death or dismemberment;
(C)  for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury;
(D)  as a supplement to a liability insurance policy;
(E)  for credit insurance;
(F)  only for dental or vision care;
(G)  only for hospital expenses; or
(H)  only for indemnity for hospital confinement;
(2)  a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss), as amended;
(3)  a workers' compensation insurance policy;
(4)  medical payment insurance coverage provided under a motor vehicle insurance policy;
(5)  a long-term care insurance policy, including a nursing home fixed indemnity policy, unless the commissioner determines that the policy provides benefit coverage so comprehensive that the policy is a health benefit plan as described by Section 1451.502;
(6)  the child health plan program under Chapter 62, Health and Safety Code, or the health benefits plan for children under Chapter 63, Health and Safety Code; or
(7)  a Medicaid managed care program operated under Chapter 540 or 540A, Government Code, as applicable, or a Medicaid program operated under Chapter 32, Human Resources Code.
Added by Acts 2015, 84th Leg., R.S., Ch. 1038 (H.B. 1624), Sec. 2, eff. September 1, 2015.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 2.133, eff. April 1, 2025.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1451 - Access to Certain Practitioners and Facilities › Subchapter K. Health Care Provider Directories › Section 1451.505. Physician and Health Care Provider Directory on Internet Website

Sec. 1451.505.  PHYSICIAN AND HEALTH CARE PROVIDER DIRECTORY ON INTERNET WEBSITE.  (a) A health benefit plan issuer shall display on a public Internet website maintained by the issuer the directory required by Section 1451.504.  A direct electronic link to the directory must be displayed in a conspicuous manner in the electronic summary of benefits and coverage of each health benefit plan issued by the health benefit plan issuer on the Internet website.
(b)  The health benefit plan issuer shall clearly indicate in the directory each health benefit plan issued by the issuer that may provide coverage for services provided by each physician or health care provider included in the directory.
(c)  The directory must be:
(1)  electronically searchable by physician or health care provider name, specialty, if any, facility, and location; and
(2)  publicly accessible without necessity of providing a password, a user name, or personally identifiable information.
(d)  The health benefit plan issuer shall conduct an ongoing review of the directory and correct or update the information as necessary. Except as provided by Subsection (e), corrections and updates, if any, must be made not less than once each month.
(e)  The health benefit plan issuer shall conspicuously display in the directory required by Section 1451.504 an e-mail address and a toll-free telephone number to which any individual may report any inaccuracy in the directory. If the issuer receives a report from any person that specifically identified directory information may be inaccurate, the issuer shall investigate the report and correct the information, as necessary, not later than the seventh day after the date the report is received.
Added by Acts 2015, 84th Leg., R.S., Ch. 1038 (H.B. 1624), Sec. 2, eff. September 1, 2015.
Amended by:
Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 1.03, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter A. Credentialing of Physicians and Providers by Health Maintenance Organization › Section 1452.001. Applicability of Certain Definitions

Sec. 1452.001.  APPLICABILITY OF CERTAIN DEFINITIONS.  In this subchapter, a term defined by Section 843.002 has the meaning assigned by that section.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter A. Credentialing of Physicians and Providers by Health Maintenance Organization › Section 1452.002. Verification of Physician's License or Certificate

Sec. 1452.002.  VERIFICATION OF PHYSICIAN'S LICENSE OR CERTIFICATE.  The commissioner shall require a health maintenance organization to verify that a physician's license to practice medicine and any other certificate the physician is required to hold, including a certificate issued by the Department of Public Safety or the federal Drug Enforcement Administration or a certificate issued under the Medicare program, is valid as of the date of:
(1)  initial credentialing of the physician;  and
(2)  each recredentialing.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter A. Credentialing of Physicians and Providers by Health Maintenance Organization › Section 1452.003. Site Visit for Initial Credentialing

Sec. 1452.003.  SITE VISIT FOR INITIAL CREDENTIALING.  (a)  The commissioner shall require a health maintenance organization that conducts a site visit for the purpose of initial credentialing of a physician or provider to evaluate during the visit a site's accessibility, appearance, space, medical or dental recordkeeping practices, availability of appointments, and confidentiality procedures.
(b)  The commissioner may not require the health maintenance organization to evaluate the appropriateness of equipment during the site visit.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter A. Credentialing of Physicians and Providers by Health Maintenance Organization › Section 1452.004. Limitation on Commissioner's Authority

Sec. 1452.004.  LIMITATION ON COMMISSIONER'S AUTHORITY.  The commissioner may not require a health maintenance organization to:
(1)  formally recredential a physician or provider more frequently than once in any three-year period;
(2)  verify the validity of a license or certificate held by a physician as of a date other than the date of initial credentialing or recredentialing of the physician;
(3)  use clinical personnel to perform a site visit for initial credentialing of a physician or provider unless clinical review is needed during the site visit;  or
(4)  require a site visit be performed for the purpose of recredentialing of a physician or provider.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter A. Credentialing of Physicians and Providers by Health Maintenance Organization › Section 1452.005. Site Visit for Cause Not Precluded

Sec. 1452.005.  SITE VISIT FOR CAUSE NOT PRECLUDED.  This subchapter does not preclude a health maintenance organization from conducting a site visit of a physician or provider at any time for cause, including a complaint made by a member or another external complaint made to the health maintenance organization.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter A. Credentialing of Physicians and Providers by Health Maintenance Organization › Section 1452.006. Rules Related to Selection of Physicians and Providers by Health Maintenance Organization

Sec. 1452.006.  RULES RELATED TO SELECTION OF PHYSICIANS AND PROVIDERS BY HEALTH MAINTENANCE ORGANIZATION.  A rule adopted by the commissioner under Section 843.102 that relates to implementation and maintenance by a health maintenance organization of a process for selecting and retaining affiliated physicians and providers must comply with:
(1)  this subchapter;  and
(2)  standards adopted by the National Committee for Quality Assurance, to the extent those standards do not conflict with other laws of this state.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter B. Standardized Forms › Section 1452.051. Definitions

Sec. 1452.051.  DEFINITIONS.  In this subchapter:
(1)  "Advanced practice nurse" has the meaning assigned by Section 301.152, Occupations Code.
(2)  "Physician" means an individual licensed to practice medicine in this state.
(3)  "Physician assistant" means an individual who holds a license issued under Chapter 204, Occupations Code.
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. 11.045(a), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter B. Standardized Forms › Section 1452.052. Standardized Form for Verification of Credentials

Sec. 1452.052.  STANDARDIZED FORM FOR VERIFICATION OF CREDENTIALS.  (a)  The commissioner by rule shall:
(1)  prescribe a standardized form for the verification of the credentials of a physician, advanced practice nurse, or physician assistant; and
(2)  require a public or private hospital, a health maintenance organization operating under Chapter 843, or the issuer of a preferred provider benefit plan under Chapter 1301 to use the form for verification of credentials.
(b)  In prescribing a form under this section, the commissioner shall consider any credentialing application form that is widely used in this state or any form currently used by the department.
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. 11.045(a), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter C. Expedited Credentialing Process › Section 1452.101. Definitions

Sec. 1452.101.  DEFINITIONS.  In this subchapter:
(1)  "Applicant physician" means a physician applying for expedited credentialing under this subchapter.
(2)  "Enrollee" means an individual who is eligible to receive health care services under a managed care plan.
(3)  "Health care provider" means:
(A)  an individual who is licensed, certified, or otherwise authorized to provide health care services in this state; or
(B)  a hospital, emergency clinic, outpatient clinic, or other facility providing health care services.
(4)  "Managed care plan" means a health benefit plan under which health care services are provided to enrollees through contracts with health care providers and that requires enrollees to use participating providers or that provides a different level of coverage for enrollees who use participating providers.  The term includes a health benefit plan issued by:
(A)  a health maintenance organization;
(B)  a preferred provider benefit plan issuer; or
(C)  any other entity that issues a health benefit plan, including an insurance company.
(5)  "Medical group" means:
(A)  a single legal entity owned by two or more physicians;
(B)  a professional association composed of licensed physicians;
(C)  any other business entity composed of licensed physicians as permitted under Subchapter B, Chapter 162, Occupations Code; or
(D)  two or more physicians on the medical staff of, or teaching at, a medical school or medical and dental unit, as defined or described by Section 61.003, 61.501, or 74.601, Education Code.
(6)  "Participating provider" means a health care provider who has contracted with a health benefit plan issuer to provide services to enrollees.
Added by Acts 2007, 80th Leg., R.S., Ch. 1203 (H.B. 1594), Sec. 1, eff. September 1, 2007.
Amended by:
Acts 2009, 81st Leg., R.S., Ch. 296 (H.B. 389), Sec. 1, eff. September 1, 2009.
Acts 2011, 82nd Leg., R.S., Ch. 414 (S.B. 822), Sec. 1, eff. September 1, 2011.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter C. Expedited Credentialing Process › Section 1452.102. Applicability

Sec. 1452.102.  APPLICABILITY.  This subchapter applies only to a physician who joins an established medical group that has a current contract in force with a managed care plan.
Added by Acts 2007, 80th Leg., R.S., Ch. 1203 (H.B. 1594), Sec. 1, eff. September 1, 2007.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter C. Expedited Credentialing Process › Section 1452.103. Eligibility Requirements

Sec. 1452.103.  ELIGIBILITY REQUIREMENTS.  To qualify for expedited credentialing under this subchapter and payment under Section 1452.104, an applicant physician must:
(1)  be licensed in this state by, and in good standing with, the Texas Medical Board;
(2)  submit all documentation and other information required by the issuer of the managed care plan as necessary to enable the issuer to begin the credentialing process required by the issuer to include a physician in the issuer's health benefit plan network; and
(3)  agree to comply with the terms of the managed care plan's participating provider contract currently in force with the applicant physician's established medical group.
Added by Acts 2007, 80th Leg., R.S., Ch. 1203 (H.B. 1594), Sec. 1, eff. September 1, 2007.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter C. Expedited Credentialing Process › Section 1452.104. Payment of Applicant Physician During Credentialing Process

Sec. 1452.104.  PAYMENT OF APPLICANT PHYSICIAN DURING CREDENTIALING PROCESS.  On submission by the applicant physician of the information required by the managed care plan issuer under Section 1452.103(2), and for payment purposes only, the issuer shall treat the applicant physician as if the physician were a participating provider in the health benefit plan network when the applicant physician provides services to the managed care plan's enrollees, including:
(1)  authorizing the applicant physician to collect copayments from the enrollees; and
(2)  making payments to the applicant physician.
Added by Acts 2007, 80th Leg., R.S., Ch. 1203 (H.B. 1594), Sec. 1, eff. September 1, 2007.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter C. Expedited Credentialing Process › Section 1452.105. Directory Entries

Sec. 1452.105.  DIRECTORY ENTRIES.  Pending the approval of an application submitted under Section 1452.104, the managed care plan may exclude the applicant physician from the managed care plan's directory of participating physicians, the managed care plan's website listing of participating physicians, or any other listing of participating physicians.
Added by Acts 2007, 80th Leg., R.S., Ch. 1203 (H.B. 1594), Sec. 1, eff. September 1, 2007.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter C. Expedited Credentialing Process › Section 1452.106. Effect of Failure to Meet Credentialing Requirements

Sec. 1452.106.  EFFECT OF FAILURE TO MEET CREDENTIALING REQUIREMENTS.  If, on completion of the credentialing process, the managed care plan issuer determines that the applicant physician does not meet the issuer's credentialing requirements:
(1)  the managed care plan issuer may recover from the applicant physician or the physician's medical group an amount equal to the difference between payments for in-network benefits and out-of-network benefits; and
(2)  the applicant physician or the physician's medical group may retain any copayments collected or in the process of being collected as of the date of the issuer's determination.
Added by Acts 2007, 80th Leg., R.S., Ch. 1203 (H.B. 1594), Sec. 1, eff. September 1, 2007.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter C. Expedited Credentialing Process › Section 1452.107. Enrollee Held Harmless

Sec. 1452.107.  ENROLLEE HELD HARMLESS.  An enrollee in the managed care plan is not responsible and shall be held harmless for the difference between in-network copayments paid by the enrollee to a physician who is determined to be ineligible under Section 1452.106 and the managed care plan's charges for out-of-network services.  The physician and the physician's medical group may not charge the enrollee for any portion of the physician's fee that is not paid or reimbursed by the enrollee's managed care plan.
Added by Acts 2007, 80th Leg., R.S., Ch. 1203 (H.B. 1594), Sec. 1, eff. September 1, 2007.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter C. Expedited Credentialing Process › Section 1452.108. Limitation on Managed Care Issuer Liability

Sec.  1452.108.  LIMITATION ON MANAGED CARE ISSUER LIABILITY.  A managed care plan issuer that complies with this subchapter is not subject to liability for damages arising out of or in connection with, directly or indirectly, the payment by the issuer of an applicant physician as if the physician were a participating provider in the health benefit plan network.
Added by Acts 2007, 80th Leg., R.S., Ch. 1203 (H.B. 1594), Sec. 1, eff. September 1, 2007.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter D. Expedited Credentialing Process › Section 1452.151. Definitions

Sec. 1452.151.  DEFINITIONS.  In this subchapter:
(1)  "Applicant podiatrist" means a podiatrist applying for expedited credentialing under this subchapter.
(2)  "Enrollee" means an individual who is eligible to receive health care services under a managed care plan.
(3)  "Health care provider" means:
(A)  an individual who is licensed, certified, or otherwise authorized to provide health care services in this state; or
(B)  a hospital, emergency clinic, outpatient clinic, or other facility providing health care services.
(4)  "Managed care plan" means a health benefit plan under which health care services are provided to enrollees through contracts with health care providers and that requires enrollees to use participating providers or that provides a different level of coverage for enrollees who use participating providers.  The term includes a health benefit plan issued by:
(A)  a health maintenance organization;
(B)  a preferred provider benefit plan issuer; or
(C)  any other entity that issues a health benefit plan, including an insurance company.
(5)  "Participating provider" means a health care provider who has contracted with a health benefit plan issuer to provide services to enrollees.
(6)  "Professional practice" means a business entity that is owned by one or more podiatrists or physicians.
Added by Acts 2013, 83rd Leg., R.S., Ch. 79 (S.B. 365), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter D. Expedited Credentialing Process › Section 1452.152. Applicability

Sec. 1452.152.  APPLICABILITY.  This subchapter applies only to a podiatrist who joins an established professional practice that has a current contract in force with a managed care plan.
Added by Acts 2013, 83rd Leg., R.S., Ch. 79 (S.B. 365), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter D. Expedited Credentialing Process › Section 1452.153. Eligibility Requirements

Sec. 1452.153.  ELIGIBILITY REQUIREMENTS.  To qualify for expedited credentialing under this subchapter and payment under Section 1452.154, an applicant podiatrist must:
(1)  be licensed as a podiatrist in this state by, and be in good standing with, the Texas Department of Licensing and Regulation;
(2)  submit all documentation and other information required by the issuer of the managed care plan as necessary to enable the issuer to begin the credentialing process required by the issuer to include a podiatrist in the issuer's health benefit plan network; and
(3)  agree to comply with the terms of the managed care plan's participating provider contract currently in force with the applicant podiatrist's established professional practice.
Added by Acts 2013, 83rd Leg., R.S., Ch. 79 (S.B. 365), Sec. 1, eff. September 1, 2013.
Amended by:
Acts 2019, 86th Leg., R.S., Ch. 467 (H.B. 4170), Sec. 19.016, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter D. Expedited Credentialing Process › Section 1452.154. Payment of Applicant Podiatrist During Credentialing Process

Sec. 1452.154.  PAYMENT OF APPLICANT PODIATRIST DURING CREDENTIALING PROCESS.  On submission by the applicant podiatrist of the information required by the managed care plan issuer under Section 1452.153(2), and for payment purposes only, the issuer shall treat the applicant podiatrist as if the podiatrist were a participating provider in the health benefit plan network when the applicant podiatrist provides services to the managed care plan's enrollees, including:
(1)  authorizing the applicant podiatrist to collect copayments from the enrollees; and
(2)  making payments to the applicant podiatrist.
Added by Acts 2013, 83rd Leg., R.S., Ch. 79 (S.B. 365), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter D. Expedited Credentialing Process › Section 1452.155. Directory Entries

Sec. 1452.155.  DIRECTORY ENTRIES.  Pending the approval of an application submitted under Section 1452.154, the managed care plan may exclude the applicant podiatrist from the managed care plan's directory of participating podiatrists, the managed care plan's website listing of participating podiatrists, or any other listing of participating podiatrists.
Added by Acts 2013, 83rd Leg., R.S., Ch. 79 (S.B. 365), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter D. Expedited Credentialing Process › Section 1452.156. Effect of Failure to Meet Credentialing Requirements

Sec. 1452.156.  EFFECT OF FAILURE TO MEET CREDENTIALING REQUIREMENTS.  If, on completion of the credentialing process, the managed care plan issuer determines that the applicant podiatrist does not meet the issuer's credentialing requirements:
(1)  the managed care plan issuer may recover from the applicant podiatrist or the podiatrist's professional practice an amount equal to the difference between payments for in-network benefits and out-of-network benefits; and
(2)  the applicant podiatrist or the podiatrist's professional practice may retain any copayments collected or in the process of being collected as of the date of the issuer's determination.
Added by Acts 2013, 83rd Leg., R.S., Ch. 79 (S.B. 365), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter D. Expedited Credentialing Process › Section 1452.157. Enrollee Held Harmless

Sec. 1452.157.  ENROLLEE HELD HARMLESS.  An enrollee in the managed care plan is not responsible and shall be held harmless for the difference between in-network copayments paid by the enrollee to a podiatrist who is determined to be ineligible under Section 1452.156 and the managed care plan's charges for out-of-network services.  The podiatrist and the podiatrist's professional practice may not charge the enrollee for any portion of the podiatrist's fee that is not paid or reimbursed by the enrollee's managed care plan.
Added by Acts 2013, 83rd Leg., R.S., Ch. 79 (S.B. 365), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter D. Expedited Credentialing Process › Section 1452.158. Limitation on Managed Care Issuer Liability

Sec. 1452.158.  LIMITATION ON MANAGED CARE ISSUER LIABILITY.  A managed care plan issuer that complies with this subchapter is not subject to liability for damages arising out of or in connection with, directly or indirectly, the payment by the issuer of an applicant podiatrist as if the podiatrist were a participating provider in the health benefit plan network.
Added by Acts 2013, 83rd Leg., R.S., Ch. 79 (S.B. 365), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter E. Expedited Credentialing Process › Section 1452.201. Definitions

Sec. 1452.201.  DEFINITIONS.  In this subchapter:
(1)  "Applicant therapeutic optometrist" means a therapeutic optometrist applying for expedited credentialing under this subchapter.
(2)  "Enrollee" means an individual who is eligible to receive health care services under a managed care plan.
(3)  "Health care provider" has the meaning assigned by Section 1452.151.
(4)  "Managed care plan" has the meaning assigned by Section 1452.151.
(5)  "Participating provider" means a health care provider who has contracted with a health benefit plan issuer to provide services to enrollees.
(6)  "Professional practice" means a business entity that is owned by one or more therapeutic optometrists or physicians.
Added by Acts 2013, 83rd Leg., R.S., Ch. 79 (S.B. 365), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter E. Expedited Credentialing Process › Section 1452.202. Applicability

Sec. 1452.202.  APPLICABILITY.  This subchapter applies only to a therapeutic optometrist who joins an established professional practice that has a current contract in force with a managed care plan.
Added by Acts 2013, 83rd Leg., R.S., Ch. 79 (S.B. 365), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter E. Expedited Credentialing Process › Section 1452.203. Eligibility Requirements

Sec. 1452.203.  ELIGIBILITY REQUIREMENTS.  To qualify for expedited credentialing under this subchapter and payment under Section 1452.204, an applicant therapeutic optometrist must:
(1)  be licensed in this state by, and in good standing with, the Texas Optometry Board;
(2)  submit all documentation and other information required by the issuer of the managed care plan as necessary to enable the issuer to begin the credentialing process required by the issuer to include a therapeutic optometrist in the issuer's health benefit plan network; and
(3)  agree to comply with the terms of the managed care plan's participating provider contract currently in force with the applicant therapeutic optometrist's established professional practice.
Added by Acts 2013, 83rd Leg., R.S., Ch. 79 (S.B. 365), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter E. Expedited Credentialing Process › Section 1452.204. Payment of Applicant Therapeutic Optometrist During Credentialing Process

Sec. 1452.204.  PAYMENT OF APPLICANT THERAPEUTIC OPTOMETRIST DURING CREDENTIALING PROCESS.  On submission by the applicant therapeutic optometrist of the information required by the managed care plan issuer under Section 1452.203(2), and for payment purposes only, the issuer shall treat the applicant therapeutic optometrist as if the therapeutic optometrist were a participating provider in the health benefit plan network when the applicant therapeutic optometrist provides services to the managed care plan's enrollees, including:
(1)  authorizing the applicant therapeutic optometrist to collect copayments from the enrollees; and
(2)  making payments to the applicant therapeutic optometrist.
Added by Acts 2013, 83rd Leg., R.S., Ch. 79 (S.B. 365), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter E. Expedited Credentialing Process › Section 1452.205. Directory Entries

Sec. 1452.205.  DIRECTORY ENTRIES.  Pending the approval of an application submitted under Section 1452.204, the managed care plan may exclude the applicant therapeutic optometrist from the managed care plan's directory of participating therapeutic optometrists, the managed care plan's website listing of participating therapeutic optometrists, or any other listing of participating therapeutic optometrists.
Added by Acts 2013, 83rd Leg., R.S., Ch. 79 (S.B. 365), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter E. Expedited Credentialing Process › Section 1452.206. Effect of Failure to Meet Credentialing Requirements

Sec. 1452.206.  EFFECT OF FAILURE TO MEET CREDENTIALING REQUIREMENTS.  If, on completion of the credentialing process, the managed care plan issuer determines that the applicant therapeutic optometrist does not meet the issuer's credentialing requirements:
(1)  the managed care plan issuer may recover from the applicant therapeutic optometrist or the therapeutic optometrist's professional practice an amount equal to the difference between payments for in-network benefits and out-of-network benefits; and
(2)  the applicant therapeutic optometrist or the therapeutic optometrist's professional practice may retain any copayments collected or in the process of being collected as of the date of the issuer's determination.
Added by Acts 2013, 83rd Leg., R.S., Ch. 79 (S.B. 365), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter E. Expedited Credentialing Process › Section 1452.207. Enrollee Held Harmless

Sec. 1452.207.  ENROLLEE HELD HARMLESS.  An enrollee in the managed care plan is not responsible and shall be held harmless for the difference between in-network copayments paid by the enrollee to a therapeutic optometrist who is determined to be ineligible under Section 1452.206 and the managed care plan's charges for out-of-network services.  The therapeutic optometrist and the therapeutic optometrist's professional practice may not charge the enrollee for any portion of the therapeutic optometrist's fee that is not paid or reimbursed by the enrollee's managed care plan.
Added by Acts 2013, 83rd Leg., R.S., Ch. 79 (S.B. 365), Sec. 1, eff. September 1, 2013.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1452 - Physician and Provider Credentials › Subchapter E. Expedited Credentialing Process › Section 1452.208. Limitation on Managed Care Issuer Liability

Sec. 1452.208.  LIMITATION ON MANAGED CARE ISSUER LIABILITY.  A managed care plan issuer that complies with this subchapter is not subject to liability for damages arising out of or in connection with, directly or indirectly, the payment by the issuer of an applicant therapeutic optometrist as if the therapeutic optometrist were a participating provider in the health benefit plan network.
Added by Acts 2013, 83rd Leg., R.S., Ch. 79 (S.B. 365), Sec. 1, eff. September 1, 2013.