reglab/statecodes huggingface dataset:
2023 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 843.321. Availability of Coding Guidelines

Sec. 843.321.  AVAILABILITY OF CODING GUIDELINES.  (a)  A contract between a health maintenance organization and a physician or provider must provide that:
(1)  the physician or provider may request a description and copy of the coding guidelines, including any underlying bundling, recoding, or other payment process and fee schedules applicable to specific procedures that the physician or provider will receive under the contract;
(2)  the health maintenance organization or the health maintenance organization's agent will provide the coding guidelines and fee schedules not later than the 30th day after the date the health maintenance organization receives the request;
(3)  the health maintenance organization or the health maintenance organization's agent will provide notice of changes to the coding guidelines and fee schedules that will result in a change of payment to the physician or provider not later than the 90th day before the date the changes take effect and will not make retroactive revisions to the coding guidelines and fee schedules;  and
(4)  the contract may be terminated by the physician or provider on or before the 30th day after the date the physician or provider receives information requested under this subsection without penalty or discrimination in participation in other health care products or plans.
(b)  A physician or provider who receives information under Subsection (a) may only:
(1)  use or disclose the information for the purpose of practice management, billing activities, and other business operations;  and
(2)  disclose the information to a governmental agency involved in the regulation of health care or insurance.
(c)  The health maintenance organization shall, on request of the physician or provider, provide the name, edition, and model version of the software that the health maintenance organization uses to determine bundling and unbundling of claims.
(d)  The provisions of this section may not be waived, voided, or nullified by contract.
Added by Acts 2003, 78th Leg., ch. 214, Sec. 5, eff. June 17, 2003.
Renumbered from Insurance Code, Section 843.319 by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 23.001(60), eff. September 1, 2005.
2023 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 843.323. Contract Provisions Prohibiting Rejection of Batched Claims

Sec. 843.323.  CONTRACT PROVISIONS PROHIBITING REJECTION OF BATCHED CLAIMS.  (a)  If requested by a participating physician or provider, a health maintenance organization shall include a provision in the physician's or provider's contract providing that the health maintenance organization or the health maintenance organization's clearinghouse may not refuse to process or pay an electronically submitted clean claim, as defined by Subchapter J, because the claim is submitted together with or in a batch submission with a claim that is not a clean claim.
(b)  In accordance with Chapters 82 and 84, the commissioner may issue a cease and desist order against or impose sanctions on a health maintenance organization that violates this section or a contract provision adopted under this section.
Added by Acts 2005, 79th Leg., Ch. 668 (S.B. 50), Sec. 1, eff. September 1, 2005.
2023 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 J. Payment of Claims to Physicians and Providers › Section 843.336. Definition

Sec. 843.336.  DEFINITION.  (a)  In this subchapter, "clean claim" means a claim that complies with this section.
(b)  A nonelectronic claim by a physician or provider, other than an institutional provider, is a clean claim if the claim is submitted using the Centers for Medicare and Medicaid Services Form 1500 or, if adopted by the commissioner by rule, a successor to that form developed by the National Uniform Claim Committee or its successor.  An electronic claim by a physician or provider, other than an institutional provider, is a clean claim if the claim is submitted using the Professional 837 (ASC X12N 837) format or, if adopted by the commissioner by rule, a successor to that format adopted by the Centers for Medicare and Medicaid Services or its successor.
(c)  A nonelectronic claim by an institutional provider is a clean claim if the claim is submitted using the Centers for Medicare and Medicaid Services Form UB-92 or, if adopted by the commissioner by rule, a successor to that form developed by the National Uniform Billing Committee or its successor.  An electronic claim by an institutional provider is a clean claim if the claim is submitted using the Institutional 837 (ASC X12N 837) format or, if adopted by the commissioner by rule, a successor to that format adopted by the Centers for Medicare and Medicaid Services or its successor.
(d)  The commissioner may adopt rules that specify the information that must be entered into the appropriate fields on the applicable claim form for a claim to be a clean claim.
(e)  The commissioner may not require any data element for an electronic claim that is not required in an electronic transaction set needed to comply with federal law.
(f)  A health maintenance organization and a physician or provider may agree by contract to use fewer data elements than are required in an electronic transaction set needed to comply with federal law.
(g)  An otherwise clean claim submitted by a physician or provider that includes additional fields, data elements, attachments, or other information not required under this section is considered to be a clean claim for the purposes of this section.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 214, Sec. 6, eff. June 17, 2003.
2023 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 J. Payment of Claims to Physicians and Providers › Section 843.338. Deadline for Action on Clean Claims

Sec. 843.338.  DEADLINE FOR ACTION ON CLEAN CLAIMS.  Except as provided by Sections 843.3385 and 843.339, not later than the 45th day after the date on which a health maintenance organization receives a clean claim from a participating physician or provider in a nonelectronic format or the 30th day after the date the health maintenance organization receives a clean claim from a participating physician or provider that is electronically submitted, the health maintenance organization shall make a determination of whether the claim is payable and:
(1)  if the health maintenance organization determines the entire claim is payable, pay the total amount of the claim  in accordance with the contract between the physician or provider and the health maintenance organization;
(2)  if the health maintenance organization determines a portion of the claim is payable, pay the portion of the claim that is not in dispute and notify the physician or provider in writing why the remaining portion of the claim will not be paid; or
(3)  if the health maintenance organization determines that the claim is not payable, notify the physician or provider in writing why the claim will not be paid.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 214, Sec. 8, eff. June 17, 2003.
Amended by:
Acts 2011, 82nd Leg., R.S., Ch. 798 (H.B. 2292), Sec. 2, eff. September 1, 2011.
2023 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 J. Payment of Claims to Physicians and Providers › Section 843.3385. Additional Information

Sec. 843.3385.  ADDITIONAL INFORMATION.  (a)  If a health maintenance organization needs additional information from a treating participating physician or provider to determine payment, the health maintenance organization, not later than the 30th calendar day after the date the health maintenance organization receives a clean claim, shall request in writing that the physician or provider provide an attachment to the claim that is relevant and necessary for clarification of the claim.
(b)  The request must describe with specificity the clinical information requested and relate only to information the health maintenance organization can demonstrate is specific to the claim or the claim's related episode of care.  The participating physician or provider is not required to provide an attachment that is not contained in, or is not in the process of being incorporated into, the patient's medical or billing record maintained by a participating physician or provider.
(c)  A health maintenance organization that requests an attachment under this section shall determine whether the claim is payable on or before the later of the 15th day after the date the health maintenance organization receives the requested attachment or the latest date for determining whether the claim is payable under Section 843.338 or 843.339.
(d)  A health maintenance organization may not make more than one request under this section in connection with a claim.  Sections 843.337(e) and (f) apply to a request for and submission of an attachment under Subsection (a).
(e)  If a health maintenance organization requests an attachment or other information from a person other than the participating physician or provider who submitted the claim, the health maintenance organization shall provide notice containing the name of the physician or provider from whom the health maintenance organization is requesting information to the physician or provider who submitted the claim.  The health maintenance organization may not withhold payment pending receipt of an attachment or information requested under this subsection.  If on receiving an attachment or information requested under this subsection the health maintenance organization determines that there was an error in payment of the claim, the health maintenance organization may recover any overpayment under Section 843.350.
(f)  The commissioner shall adopt rules under which a health maintenance organization can easily identify an attachment or other information submitted by a physician or provider under this section.
Added by Acts 2003, 78th Leg., ch. 214, Sec. 9, eff. June 17, 2003.
2023 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 J. Payment of Claims to Physicians and Providers › Section 843.339. Deadline for Action on Prescription Claims; Payment

Sec. 843.339.  DEADLINE FOR ACTION ON PRESCRIPTION CLAIMS; PAYMENT.  (a)  A health maintenance organization, or a pharmacy benefit manager that administers pharmacy claims for the health maintenance organization, that affirmatively adjudicates a pharmacy claim that is electronically submitted shall pay the total amount of the claim through electronic funds transfer not later than the 18th day after the date on which the claim was affirmatively adjudicated.
(b)  A health maintenance organization, or a pharmacy benefit manager that administers pharmacy claims for the health maintenance organization, that affirmatively adjudicates a pharmacy claim that is not electronically submitted shall pay the total amount of the claim not later than the 21st day after the date on which the claim was affirmatively adjudicated.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 214, Sec. 10, eff. June 17, 2003.
Amended by:
Acts 2011, 82nd Leg., R.S., Ch. 798 (H.B. 2292), Sec. 3, eff. September 1, 2011.
2023 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 J. Payment of Claims to Physicians and Providers › Section 843.3405. Investigation and Determination of Payment

Sec. 843.3405.  INVESTIGATION AND DETERMINATION OF PAYMENT.  The investigation and determination of payment, including any coordination of other payments, does not extend the period for determining whether a claim is payable under Section 843.338 or 843.339 or for auditing a claim under Section 843.340.
Added by Acts 2003, 78th Leg., ch. 214, Sec. 12, eff. June 17, 2003.
2023 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 J. Payment of Claims to Physicians and Providers › Section 843.341. Claims Processing Procedures

Sec. 843.341.  CLAIMS PROCESSING PROCEDURES.  (a)  A health maintenance organization shall provide a participating physician or provider with copies of all applicable utilization review policies and claim processing policies or procedures.
(b)  A health maintenance organization's claims payment processes shall:
(1)  use nationally recognized, generally accepted Current Procedural Terminology codes, notes, and guidelines, including all relevant modifiers;  and
(2)  be consistent with nationally recognized, generally accepted bundling edits and logic.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 214, Sec. 13, eff. June 17, 2003.
2023 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 J. Payment of Claims to Physicians and Providers › Section 843.343. Attorney's Fees

Sec. 843.343.  ATTORNEY'S FEES.  A physician or provider may recover reasonable attorney's fees and court costs in an action to recover payment under this subchapter.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 214, Sec. 15, eff. June 17, 2003.
2023 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 J. Payment of Claims to Physicians and Providers › Section 843.344. Applicability of Subchapter to Entities Contracting With Health Maintenance Organization

Sec. 843.344.  APPLICABILITY OF SUBCHAPTER TO ENTITIES CONTRACTING WITH HEALTH MAINTENANCE ORGANIZATION.  This subchapter applies to a person, including a pharmacy benefit manager, with whom a health maintenance organization contracts to:
(1)  process or pay claims;
(2)  obtain the services of physicians and providers to provide health care services to enrollees; or
(3)  issue verifications or preauthorizations.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 214, Sec. 16, eff. June 17, 2003.
Amended by:
Acts 2011, 82nd Leg., R.S., Ch. 798 (H.B. 2292), Sec. 5, eff. September 1, 2011.
2023 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 J. Payment of Claims to Physicians and Providers › Section 843.345. Exception

Sec. 843.345.  EXCEPTION.  This subchapter does not apply to a capitated payment required to be made to a physician or provider under an agreement to provide health care services.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 214, Sec. 17, eff. June 17, 2003.
2023 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 J. Payment of Claims to Physicians and Providers › Section 843.346. Payment of Claims

Sec. 843.346.  PAYMENT OF CLAIMS.  Except as provided by this subchapter, a health maintenance organization shall pay a physician or provider for health care services and benefits provided to an enrollee not later than:
(1)  the 45th day after the date on which a claim for payment is received with the documentation reasonably necessary to process the claim;  or
(2)  if applicable, within the number of calendar days specified by written agreement between the physician or provider and the health maintenance organization.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 214, Sec. 18, eff. June 17, 2003.
2023 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 J. Payment of Claims to Physicians and Providers › Section 843.3483. Remedy for Noncompliance

Sec. 843.3483.  REMEDY FOR NONCOMPLIANCE.  In addition to any other penalty or remedy provided by law, a health maintenance organization that uses a preauthorization process for health care services that violates this subchapter with respect to a required publication, notice, or response regarding its preauthorization requirements, including by failing to comply with any applicable deadline for the publication, notice, or response, must provide an expedited appeal under Section 4201.357 for any health care service affected by the violation.
Added by Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 2.02, eff. September 1, 2019.
2023 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 J. Payment of Claims to Physicians and Providers › Section 843.349. Coordination of Payment

Sec. 843.349.  COORDINATION OF PAYMENT.  (a)  A health maintenance organization may require a physician or provider to retain in the physician's or provider's records updated information concerning other health benefit plan coverage and to provide the information to the health maintenance organization on the applicable form described by Section 843.336.  Except as provided by this section, a health maintenance organization may not require a physician or provider to investigate coordination of other health benefit plan coverage.
(b)  Coordination of other payment under this section does not extend the period for determining whether a service is eligible for payment under Section 843.338 or 843.339 or for auditing a claim under Section 843.340.
(c)  A participating physician or provider who submits a claim for particular health care services to more than one health maintenance organization or insurer shall provide written notice on the claim submitted to each health maintenance organization or insurer of the identity of each other health maintenance organization or insurer with which the same claim is being filed.
(d)  On receipt of notice under Subsection (c), a health maintenance organization shall coordinate and determine the appropriate payment for each health maintenance organization or insurer to make to the physician or provider.
(e)  Except as provided by Subsection (f), if a health maintenance organization is a secondary payor and pays a portion of a claim that should have been paid by the health maintenance organization or insurer that is the primary payor, the overpayment may only be recovered from the health maintenance organization or insurer that is primarily responsible for that amount.
(f)  If the portion of the claim overpaid by the secondary health maintenance organization was also paid by the primary health maintenance organization or insurer, the secondary health maintenance organization may recover the amount of the overpayment under Section 843.350 from the physician or provider who received the payment.  A health maintenance organization processing an electronic claim as a secondary payor shall rely on the primary payor information submitted on the claim by the physician or provider.  Primary payor information may be submitted electronically by the primary payor to the secondary payor.
(g)  A health maintenance organization may share information with another health maintenance organization or an insurer to the extent necessary to coordinate appropriate payment obligations on a specific claim.
Added by Acts 2003, 78th Leg., ch. 214, Sec. 19, eff. June 17, 2003.
2023 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 J. Payment of Claims to Physicians and Providers › Section 843.350. Overpayment

Sec. 843.350.  OVERPAYMENT.  (a)  A health maintenance organization may recover an overpayment to a physician or provider if:
(1)  not later than the 180th day after the date the physician or provider receives the payment, the health maintenance organization provides written notice of the overpayment to the physician or provider that includes the basis and specific reasons for the request for recovery of funds;  and
(2)  the physician or provider does not make arrangements for repayment of the requested funds on or before the 45th day after the date the physician or provider receives the notice.
(b)  If a physician or provider disagrees with a request for recovery of an overpayment, the health maintenance organization shall provide the physician or provider with an opportunity to appeal, and the health maintenance organization may not recover the overpayment until all appeal rights are exhausted.
Added by Acts 2003, 78th Leg., ch. 214, Sec. 19, eff. June 17, 2003.
2023 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 J. Payment of Claims to Physicians and Providers › Section 843.351. Services Provided by Certain Physicians and Providers

Sec. 843.351.  SERVICES PROVIDED BY CERTAIN PHYSICIANS AND PROVIDERS.  The provisions of this subchapter relating to prompt payment by a health maintenance organization of a physician or provider and to verification of health care services apply to a physician or provider who:
(1)  is not included in the health maintenance organization delivery network;  and
(2)  provides to an enrollee:
(A)  care related to an emergency or its attendant episode of care as required by state or federal law;  or
(B)  specialty or other health care services at the request of the health maintenance organization or a physician or provider who is included in the health maintenance organization delivery network because the services are not reasonably available within the network.
Added by Acts 2003, 78th Leg., ch. 214, Sec. 19, eff. June 17, 2003.
2023 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 J. Payment of Claims to Physicians and Providers › Section 843.352. Conflict With Other Law

Sec. 843.352.  CONFLICT WITH OTHER LAW.  To the extent of any conflict between this subchapter and Subchapter C, Chapter 1204, this subchapter controls.
Added by Acts 2003, 78th Leg., ch. 214, Sec. 19, eff. June 17, 2003.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2E.050, eff. April 1, 2009.
2023 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 J. Payment of Claims to Physicians and Providers › Section 843.353. Waiver Prohibited

Sec. 843.353.  WAIVER PROHIBITED.  Except as provided by Sections 843.336(f) and 843.337(c), the provisions of this subchapter may not be waived, voided, or nullified by contract.
Added by Acts 2003, 78th Leg., ch. 214, Sec. 19, eff. June 17, 2003.
2023 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 J. Payment of Claims to Physicians and Providers › Section 843.354. Legislative Declaration

Sec. 843.354.  LEGISLATIVE DECLARATION.  It is the intent of the legislature that the requirements contained in this subchapter regarding payment of claims to providers who are pharmacists or pharmacies apply to all health maintenance organizations and pharmacy benefit managers unless otherwise prohibited by federal law.
Added by Acts 2011, 82nd Leg., R.S., Ch. 798 (H.B. 2292), Sec. 6, eff. September 1, 2011.
2023 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 K. Relations Between Enrollee and Physician or Provider › Section 843.361. Enrollees Held Harmless

Sec. 843.361.  ENROLLEES HELD HARMLESS.  A contract or other agreement between a health maintenance organization and a physician or provider must specify that the physician or provider will hold an enrollee harmless for payment of the cost of covered health care services if the health maintenance organization does not pay the physician or provider for those services.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 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 K. Relations Between Enrollee and Physician or Provider › Section 843.362. Continuity of Care; Obligation of Health Maintenance Organization

Sec. 843.362.  CONTINUITY OF CARE;  OBLIGATION OF HEALTH MAINTENANCE ORGANIZATION.  (a)  In this section, "special circumstance" means a condition regarding which a treating physician or provider reasonably believes that discontinuing care by that physician or provider could cause harm to an enrollee who is a patient.  Examples of an enrollee who has a special circumstance include an enrollee with a disability, acute condition, life-threatening illness, or who is past the 24th week of pregnancy.
(b)  Each contract between a health maintenance organization and a physician and provider must provide that termination of the contract, except for reason of medical competence or professional behavior, does not release the health maintenance organization from the obligation of continuing to reimburse a physician or provider providing medically necessary treatment at the time of termination to an enrollee who has a special circumstance in accordance with the dictates of medical prudence.  Subject to Subsections (d) and (e), the health maintenance organization must provide continued reimbursement at not less than the contract rate in exchange for the enrollee's continued receipt of ongoing treatment from the physician or provider.
(c)  The treating physician or provider shall identify a special circumstance.  The treating physician or provider must:
(1)  request that an enrollee be permitted to continue treatment under the physician's or provider's care;  and
(2)  agree not to seek payment from the enrollee of any amount for which the enrollee would not be responsible if the physician or provider continued to be included in the health maintenance organization delivery network.
(d)  Except as provided by Subsection (e), this section does not extend the obligation of a health maintenance organization to reimburse a terminated physician or provider for ongoing treatment of an enrollee after:
(1)  the 90th day after the effective date of the termination;  or
(2)  if the enrollee has been diagnosed with a terminal illness at the time of termination, the expiration of the nine-month period after the effective date of the termination.
(e)  If an enrollee is past the 24th week of pregnancy at the time of termination, a health maintenance organization's obligation to reimburse a terminated physician or provider or, if applicable, an enrollee extends through delivery of the child and applies to immediate postpartum care and a follow-up checkup within the six-week period after delivery.
(f)  A contract between a health maintenance organization and a physician or provider must provide procedures for resolving disputes regarding the necessity for continued treatment by a physician or provider.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 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 K. Relations Between Enrollee and Physician or Provider › Section 843.363. Protected Physician or Provider Communications With Patients

Sec. 843.363.  PROTECTED PHYSICIAN OR PROVIDER COMMUNICATIONS WITH PATIENTS.  (a)  A health maintenance organization may not, as a condition of a contract with a physician, dentist, or provider, or in any other manner, prohibit, attempt to prohibit, or discourage a physician, dentist, or provider from discussing with or communicating in good faith with a current, prospective, or former patient, or a person designated by a patient, with respect to:
(1)  information or opinions regarding the patient's health care, including the patient's medical condition or treatment options;
(2)  information or opinions regarding the terms, requirements, or services of the health care plan as they relate to the medical needs of the patient;
(3)  the termination of the physician's, dentist's, or provider's contract with the health care plan or the fact that the physician, dentist, or provider will otherwise no longer be providing medical care, dental care, or health care services under the health care plan; or
(4)  information regarding the availability of facilities, both in-network and out-of-network, for the treatment of the patient's medical condition.
(a-1)  A health maintenance organization may not, as a condition of payment with a physician, dentist, or provider, or in any other manner, require a physician, dentist, or provider to provide a notification form stating that the physician, dentist, or provider is an out-of-network provider to a current, prospective, or former patient, or a person designated by the patient, if the form contains additional information that is intended, or is otherwise required to be presented in a manner that is intended, to intimidate the patient.
(b)  A health maintenance organization may not in any manner penalize, terminate, or refuse to compensate for covered services a physician, dentist, or provider for communicating in a manner protected by this section with a current, prospective, or former patient, or a person designated by a patient.
(c)  A contract provision that violates this section is void.
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. 3, eff. September 1, 2015.
2023 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 L. Financial Regulation of Health Maintenance Organizations › Section 843.401. Fiduciary Responsibility

Sec. 843.401.  FIDUCIARY RESPONSIBILITY.  A director, officer, member, employee, or partner of a health maintenance organization who receives, collects, disburses, or invests funds in connection with the activities of the health maintenance organization is responsible for the funds in a fiduciary relationship to the enrollees.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 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 L. Financial Regulation of Health Maintenance Organizations › Section 843.402. Officers' and Employees' Bond

Sec. 843.402.  OFFICERS' AND EMPLOYEES' BOND.  (a)  A health maintenance organization shall maintain in force in its own name a fidelity bond on its officers and employees in an amount of at least $100,000 or another amount prescribed by the commissioner.
(b)  The fidelity bond must be issued by an insurer that holds a certificate of authority in this state.  If, after notice and hearing, the commissioner determines that a fidelity bond is not available from an insurer that holds a certificate of authority in this state, the health maintenance organization may obtain a fidelity bond procured by a surplus lines agent resident in this state in compliance with Chapter 981.
(c)  The fidelity bond must obligate the surety to pay any loss of money or other property the health maintenance organization sustains because of an act of fraud or dishonesty by an employee or officer of the health maintenance organization, acting alone or in concert with others, while employed or serving as an officer of the health maintenance organization.
(d)  Instead of a fidelity bond, a health maintenance organization may deposit cash with the comptroller.  The deposit must be maintained in the amount and is subject to the same conditions required for a fidelity bond under this section.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 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 L. Financial Regulation of Health Maintenance Organizations › Section 843.403. Minimum Net Worth

Sec. 843.403.  MINIMUM NET WORTH.  (a)  A health maintenance organization authorized to provide basic health care services shall maintain a minimum net worth of $1.5 million.
(b)  A health maintenance organization authorized to provide limited health care services shall maintain a minimum net worth of $1 million.
(c)  A health maintenance organization authorized to offer only a single health care service plan shall maintain a minimum net worth of $500,000.
(d)  The minimum net worth required by this section may consist only of:
(1)  money of the United States;
(2)  bonds of this state;
(3)  bonds or other evidences of indebtedness of the United States that are guaranteed as to principal and interest by the United States;  or
(4)  bonds or other interest-bearing evidences of indebtedness of a county or municipality of this state.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 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 L. Financial Regulation of Health Maintenance Organizations › Section 843.404. Additional Net Worth Requirements

Sec. 843.404.  ADDITIONAL NET WORTH REQUIREMENTS.  (a)  The commissioner may adopt rules or by rule establish guidelines requiring a health maintenance organization to maintain a specified net worth based on:
(1)  the nature and kind of risks the health maintenance organization underwrites or reinsures;
(2)  the premium volume of risks the health maintenance organization underwrites or reinsures;
(3)  the composition, quality, duration, or liquidity of the health maintenance organization's investment portfolio;
(4)  fluctuations in the market value of securities the health maintenance organization holds;
(5)  the adequacy of the health maintenance organization's reserves;
(6)  the number of individuals enrolled by the health maintenance organization;  or
(7)  other business risks.
(b)  Rules adopted or guidelines established under this section must be designed to ensure the financial solvency of health maintenance organizations for the protection of enrollees.  The rules or guidelines may provide for a health maintenance organization to comply with a risk-based net worth requirement established under this section in stages over a two-year period.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 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 L. Financial Regulation of Health Maintenance Organizations › Section 843.406. Hazardous Financial Condition

Sec. 843.406.  HAZARDOUS FINANCIAL CONDITION.  (a)  If the financial condition of a health maintenance organization indicates that the continued operation of the health maintenance organization could be hazardous to its enrollees or creditors or the public, the commissioner may, after notice and opportunity for hearing:
(1)  suspend or revoke the health maintenance organization's certificate of authority;  or
(2)  order the health maintenance organization to take action reasonably necessary to correct the condition, including by:
(A)  reducing by reinsurance the total amount of present and potential liability for benefits;
(B)  reducing the volume of new business being accepted;
(C)  reducing expenses by specified methods;
(D)  suspending or limiting for a period the writing of new business;  or
(E)  increasing the health maintenance organization's capital and surplus by contribution.
(b)  In a manner consistent with the purposes of this section, the commissioner by rule may establish:
(1)  uniform standards and criteria for early warning that the continued operation of a health maintenance organization could be hazardous to the health maintenance organization's enrollees or creditors or the public;  and
(2)  standards for evaluating the financial condition of a health maintenance organization.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 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 L. Financial Regulation of Health Maintenance Organizations › Section 843.407. Receivership and Delinquency Proceedings

Sec. 843.407.  RECEIVERSHIP AND DELINQUENCY PROCEEDINGS.  (a)  In addition to all other remedies available by law, if the commissioner believes that a health maintenance organization or another person is insolvent or does not maintain the net worth required under Sections 843.403, 843.4031, and 843.404, the commissioner may bring an action in a Travis County district court to be named receiver in accordance with Section 843.157 and Chapter 443.
(b)  The court may:
(1)  find that a receiver should take charge of the assets of the health maintenance organization; and
(2)  name the commissioner as the receiver of the health maintenance organization in accordance with Section 843.157 and Chapter 443.
(c)  The operations and business of a health maintenance organization represent the business of insurance for purposes of Section 843.157 and Chapters 441 and 443.
(d)  Exclusive venue of receivership and delinquency proceedings for a health maintenance organization is in Travis County.
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.051, eff. April 1, 2009.
2023 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 L. Financial Regulation of Health Maintenance Organizations › Section 843.408. Insolvency and Allocation to Other Health Maintenance Organizations

Sec. 843.408.  INSOLVENCY AND ALLOCATION TO OTHER HEALTH MAINTENANCE ORGANIZATIONS.  (a)  If a health maintenance organization becomes insolvent, the commissioner shall equitably allocate the insolvent health maintenance organization's group contracts and nongroup enrollees among all health maintenance organizations that operate within a portion of the insolvent health maintenance organization's service area.  The commissioner shall allocate the group contracts by order.  In making allocations, the commissioner shall consider the resources of each health maintenance organization.
(b)  A successor health maintenance organization to which one or more groups are allocated shall offer each group the successor health maintenance organization's coverage at rates determined in accordance with the successor health maintenance organization's existing methodology or in accordance with that methodology as adjusted by the commissioner.
(c)  A successor health maintenance organization to which nongroup enrollees are allocated shall offer each nongroup enrollee the successor health maintenance organization's existing coverage for individual or conversion coverage, as determined by the nongroup enrollee's type of coverage from the insolvent health maintenance organization, at rates determined in accordance with the successor health maintenance organization's existing methodology or in accordance with that methodology as adjusted by the commissioner.  A successor health maintenance organization that does not offer direct nongroup enrollment shall provide coverage at rates that reflect the average group rate of the successor health maintenance organization.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
2023 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 L. Financial Regulation of Health Maintenance Organizations › Section 843.409. Examination Expenses

Sec. 843.409.  EXAMINATION EXPENSES.  (a)  A credit against the amount of premium taxes to be paid by a health maintenance organization in a taxable year may not be allowed on:
(1)  an examination fee or expense paid to another state;  or
(2)  an examination expense:
(A)  directly attributable to an examination of the books, records, accounts, or principal offices of a health maintenance organization located outside this state;  or
(B)  paid in a different taxable year.
(b)  The limitations provided by Subsections (a)(1) and (a)(2)(B) apply to foreign health maintenance organizations.
Added by Acts 2003, 78th Leg., ch. 209, Sec. 9A, eff. Jan. 1, 2004;  Acts 2003, 78th Leg., ch. 1276, Sec. 10A.207, eff. Sept. 1, 2003.
2023 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 L. Financial Regulation of Health Maintenance Organizations › Section 843.410. Assessments

Sec. 843.410.  ASSESSMENTS.  (a)  To provide funds for the administrative expenses of the commissioner regarding rehabilitation, liquidation, supervision, conservatorship, or seizure of a health maintenance organization in this state that is placed under supervision or in conservatorship under Chapter 441 or against which a delinquency proceeding is commenced under Chapter 443 and that is found by the commissioner to have insufficient funds to pay the total amount of health care claims and the administrative expenses incurred by the commissioner regarding the rehabilitation, liquidation, supervision, conservatorship, or seizure, the commissioner shall assess each health maintenance organization in the proportion that the gross premiums of the health maintenance organization that were written in this state during the preceding calendar year bear to the aggregate gross premiums that were written in this state by all health maintenance organizations, as found after review of annual statements and other reports the commissioner considers necessary.
(b)  The commissioner may abate or defer an assessment in whole or in part if, in the opinion of the commissioner, payment of the assessment would endanger the ability of a health maintenance organization to fulfill its contractual obligations.  If an assessment is abated or deferred in whole or in part, the amount of the abatement or deferral may be assessed against the remaining health maintenance organizations in a manner consistent with the calculations made by the commissioner under Subsection (a).
(c)  The total of all assessments on a health maintenance organization may not exceed one-fourth of one percent of the health maintenance organization's gross premiums in any one calendar year.
(d)  Notwithstanding any other provision of this subchapter, funds derived from an assessment made under this section may not be used for more than 180 consecutive days for the expenses of administering the affairs of a health maintenance organization the surplus of which is impaired and that is in supervision or conservatorship.  The commissioner may extend the period during which the commissioner makes assessments for the administrative expenses.
Transferred, redesignated and amended from Insurance Code, Section 843.441 by Acts 2011, 82nd Leg., R.S., Ch. 1147 (H.B. 1951), Sec. 2.002, eff. September 1, 2011.
2023 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 N. Enforcement › Section 843.462. Operations During Suspension or After Revocation of Certificate of Authority

Sec. 843.462.  OPERATIONS DURING SUSPENSION OR AFTER REVOCATION OF CERTIFICATE OF AUTHORITY.  (a)  During the period a certificate of authority of a health maintenance organization is suspended, the health maintenance organization may not:
(1)  enroll additional enrollees except newborn children or other newly acquired dependents of existing enrollees;  or
(2)  advertise or solicit in any way.
(b)  After a certificate of authority of a health maintenance organization is revoked, the health maintenance organization:
(1)  shall proceed, immediately following the effective date of the order of revocation, to conclude its affairs;
(2)  may not conduct further business except as essential to the orderly conclusion of its affairs;  and
(3)  may not advertise or solicit in any way.
(c)  Notwithstanding Subsection (b), the commissioner may, by written order, permit the further operation of the health maintenance organization to the extent that the commissioner finds necessary to serve the best interest of enrollees and to provide enrollees with the greatest practical opportunity to obtain continuing health care coverage.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.