reglab/statecodes huggingface dataset:
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter B. Relations With Physicians or Health Care Providers › Section 1301.068. Inducement to Limit Medically Necessary Services Prohibited

Sec. 1301.068.  INDUCEMENT TO LIMIT MEDICALLY NECESSARY SERVICES PROHIBITED.  (a)  An insurer may not use any financial incentive or make payment to a physician or health care provider that acts directly or indirectly as an inducement to limit medically necessary services.
(b)  This section does not prohibit the use of capitation as a method of payment.
Added by Acts 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 D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter B. Relations With Physicians or Health Care Providers › Section 1301.069. Services Provided by Certain Physicians and Health Care Providers

Sec. 1301.069.  SERVICES PROVIDED BY CERTAIN PHYSICIANS AND HEALTH CARE PROVIDERS.  The provisions of this chapter relating to prompt payment by an insurer of a physician or health care provider and to verification of medical care or health care services apply to a physician or provider who:
(1)  is not a preferred provider included in the preferred provider network; and
(2)  provides to an insured:
(A)  care related to an emergency or its attendant episode of care as required by state or federal law; or
(B)  specialty or other medical care or health care services at the request of the insurer or a preferred provider because the services are not reasonably available from a preferred provider who is included in the preferred delivery network.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(d), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter C. Prompt Payment of Claims › Section 1301.101. Definition

Sec. 1301.101.  DEFINITION.  In this subchapter, "clean claim" means a claim that complies with Section 1301.131.
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. 11.037(a), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter C. Prompt Payment of Claims › Section 1301.102. Submission of Claim

Sec. 1301.102.  SUBMISSION OF CLAIM.  (a)  A physician or health care provider must submit a claim to an insurer not later than the 95th day after the date the physician or provider provides the medical care or health care services for which the claim is made.
(b)  Except as provided by Chapter 1213, a physician or health care provider may, as appropriate:
(1)  mail a claim by United States mail, first class, or by overnight delivery service;
(2)  submit the claim electronically;
(3)  fax the claim; or
(4)  hand deliver the claim.
(c)  An insurer shall accept as proof of timely filing a claim filed in compliance with Subsection (b) or information from another insurer or health maintenance organization showing that the physician or health care provider submitted the claim to the insurer or health maintenance organization in compliance with Subsection (b).
(d)  If a physician or health care provider fails to submit a claim in compliance with this section, the physician or provider forfeits the right to payment.
(e)  The period for submitting a claim under this section may be extended by:
(1)  contract;
(2)  notice published by the commissioner allowing an extension of prompt payment deadlines to a later date chosen by the commissioner due to a catastrophic event; or
(3)  the department's approval of a physician's or health care provider's request for an extension due to a catastrophic event that substantially interferes with the normal business operations of the physician or provider.
(e-1)  The commissioner may adopt rules to implement Subsection (e), including rules establishing requirements for a request made under Subsection (e)(3).
(f)  A physician or health care provider may not submit a duplicate claim for payment before the 46th day after the date the original claim was submitted.  The commissioner shall adopt rules under which an insurer may determine whether a claim is a duplicate claim.
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. 11.037(a), eff. September 1, 2005.
Acts 2023, 88th Leg., R.S., Ch. 90 (S.B. 1286), Sec. 3, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter C. Prompt Payment of Claims › Section 1301.1021. Receipt of Claim

Sec. 1301.1021.  RECEIPT OF CLAIM.  (a)  If a claim for medical care or health care services provided to a patient is mailed, the claim is presumed to have been received by the insurer on the fifth day after the date the claim is mailed or, if the claim is mailed using overnight service or return receipt requested, on the date the delivery receipt is signed.
(b)  If the claim is submitted electronically, the claim is presumed to have been received on the date of the electronic verification of receipt by the insurer or the insurer's clearinghouse.  If the insurer or the insurer's clearinghouse does not provide a confirmation within 24 hours of submission by the physician or health care provider, the physician's or provider's clearinghouse shall provide the confirmation.  The physician's or provider's clearinghouse must be able to verify that the filing contained the correct payor identification of the entity to receive the filing.
(c)  If the claim is faxed, the claim is presumed to have been received on the date of the transmission acknowledgment.
(d)  If the claim is hand delivered, the claim is presumed to have been received on the date the delivery receipt is signed.
Amended by:
Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(a), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter C. Prompt Payment of Claims › Section 1301.103. Deadline for Action on Clean Claims

Sec. 1301.103.  DEADLINE FOR ACTION ON CLEAN CLAIMS.  Except as provided by Sections 1301.104 and 1301.1054, not later than the 45th day after the date an insurer receives a clean claim from a preferred provider in a nonelectronic format or the 30th day after the date an insurer receives a clean claim from a preferred provider that is electronically submitted, the insurer shall make a determination of whether the claim is payable and:
(1)  if the insurer determines the entire claim is payable, pay the total amount of the claim in accordance with the contract between the preferred provider and the insurer;
(2)  if the insurer determines a portion of the claim is payable, pay the portion of the claim that is not in dispute and notify the preferred provider in writing why the remaining portion of the claim will not be paid; or
(3)  if the insurer determines that the claim is not payable, notify the preferred provider in writing why the claim will not be paid.
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. 11.037(a), eff. September 1, 2005.
Acts 2011, 82nd Leg., R.S., Ch. 798 (H.B. 2292), Sec. 8, eff. September 1, 2011.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter C. Prompt Payment of Claims › Section 1301.104. Deadline for Action on Pharmacy Claims; Payment

Sec. 1301.104.  DEADLINE FOR ACTION ON PHARMACY CLAIMS; PAYMENT.  (a) An  insurer, or a pharmacy benefit manager that administers pharmacy claims for the insurer under a preferred provider benefit plan, 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)  An insurer, or a pharmacy benefit manager that administers pharmacy claims for the insurer under a preferred provider benefit plan, 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 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(a), eff. September 1, 2005.
Acts 2011, 82nd Leg., R.S., Ch. 798 (H.B. 2292), Sec. 9, eff. September 1, 2011.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter C. Prompt Payment of Claims › Section 1301.105. Audited Claims

Sec. 1301.105.  AUDITED CLAIMS.  (a)  Except as provided by Section 1301.1054, an insurer that intends to audit a claim submitted by a preferred provider shall pay the charges submitted at 100 percent of the contracted rate on the claim not later than:
(1)  the 30th day after the date the insurer receives the clean claim from the preferred provider if the claim is submitted electronically; or
(2)  the 45th day after the date the insurer receives the clean claim from the preferred provider if the claim is submitted nonelectronically.
(b)  The insurer shall clearly indicate on the explanation of payment statement in the manner prescribed by the commissioner by rule that the clean claim is being paid at 100 percent of the contracted rate, subject to completion of the audit.
(c)  If the insurer requests additional information to complete the audit, the request must describe with specificity the clinical information requested and relate only to information the insurer in good faith can demonstrate is specific to the claim or episode of care.  The insurer may not request as a part of the audit information 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 preferred provider.
(d)  If the preferred provider does not supply information reasonably requested by the insurer in connection with the audit, the insurer may:
(1)  notify the provider in writing that the provider must provide the information not later than the 45th day after the date of the notice or forfeit the amount of the claim; and
(2)  if the provider does not provide the information required by this section, recover the amount of the claim.
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. 11.037(a), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter C. Prompt Payment of Claims › Section 1301.1051. Completion of Audit

Sec. 1301.1051.  COMPLETION OF AUDIT.  The insurer must complete an audit under Section 1301.105 on or before the 180th day after the date the clean claim is received by the insurer, and any additional payment due a preferred provider or any refund due the insurer shall be made not later than the 30th day after the completion of the audit.
Amended by:
Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(a), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter C. Prompt Payment of Claims › Section 1301.1052. Preferred Provider Appeal After Audit

Sec. 1301.1052.  PREFERRED PROVIDER APPEAL AFTER AUDIT.  If a preferred provider disagrees with a refund request made by an insurer based on an audit under Section 1301.105, the insurer shall provide the provider with an opportunity to appeal, and the insurer may not attempt to recover the payment until all appeal rights are exhausted.
Amended by:
Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(a), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter C. Prompt Payment of Claims › Section 1301.1053. Deadlines Not Extended

Sec. 1301.1053.  DEADLINES NOT EXTENDED.  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 1301.103 or 1301.104 or for auditing a claim under Section 1301.105.
Amended by:
Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(a), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter C. Prompt Payment of Claims › Section 1301.1054. Requests for Additional Information

Sec. 1301.1054.  REQUESTS FOR ADDITIONAL INFORMATION.  (a)  If an insurer needs additional information from a treating preferred provider to determine payment, the insurer, not later than the 30th calendar day after the date the insurer receives a clean claim, shall request in writing that the preferred provider provide an attachment to the claim that is relevant and necessary for clarification of the claim.  The request must describe with specificity the clinical information requested and relate only to information the insurer can demonstrate is specific to the claim or the claim's related episode of care.  The preferred 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 preferred provider.
(b)  An insurer that requests an attachment under Subsection (a) shall determine whether the claim is payable on or before the later of the 15th day after the date the insurer receives the requested attachment or the latest date for determining whether the claim is payable under Section 1301.103 or 1301.104.
(c)  An insurer may not make more than one request under Subsection (a) in connection with a claim.  Sections 1301.102(b) and 1301.1021 apply to a request for and submission of an attachment under Subsection (a).
(d)  If an insurer requests an attachment or other information from a person other than the preferred provider who submitted the claim, the insurer shall provide notice containing the name of the physician or health care provider from whom the insurer is requesting information to the preferred provider who submitted the claim.  The insurer 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 insurer determines that there was an error in payment of the claim, the insurer may recover any overpayment under Section 1301.132.
(e)  The commissioner shall adopt rules under which an insurer can easily identify attachments or other information submitted by a physician or health care provider under this section.
Amended by:
Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(a), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter C. Prompt Payment of Claims › Section 1301.106. Claims Processing Procedures and Claims Payment Processes

Sec. 1301.106.  CLAIMS PROCESSING PROCEDURES AND CLAIMS PAYMENT PROCESSES.  (a)  An insurer shall provide a preferred provider with copies of all applicable utilization review policies and claim processing policies or procedures.
(b)  An insurer'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 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(a), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter C. Prompt Payment of Claims › Section 1301.107. Contractual Waiver and Other Actions Prohibited

Sec. 1301.107.  CONTRACTUAL WAIVER AND OTHER ACTIONS PROHIBITED.  Except as provided by Section 1301.102(e), the provisions of this subchapter may not be waived, voided, or nullified by contract.
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. 11.037(a), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter C. Prompt Payment of Claims › Section 1301.108. Attorney's Fees

Sec. 1301.108.  ATTORNEY'S FEES.  A preferred provider may recover reasonable attorney's fees and court costs in an action to recover payment under this subchapter.
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. 11.037(a), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter C. Prompt Payment of Claims › Section 1301.109. Applicability to Entities Contracting With Insurer

Sec. 1301.109.  APPLICABILITY TO ENTITIES CONTRACTING WITH INSURER.  This subchapter applies to a person, including a pharmacy benefit manager, with whom an insurer contracts to:
(1)  process or pay claims;
(2)  obtain the services of physicians and health care providers to provide health care services to insureds; or
(3)  issue verifications or preauthorizations.
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. 11.037(a), eff. September 1, 2005.
Acts 2011, 82nd Leg., R.S., Ch. 798 (H.B. 2292), Sec. 11, eff. September 1, 2011.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter C. -1. Other Provisions Relating to Payment of Claims › Section 1301.131. Elements of Clean Claim

Sec. 1301.131.  ELEMENTS OF CLEAN CLAIM.  (a)  A nonelectronic claim by a physician or health care 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 the committee's 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 the center's successor.
(b)  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 the committee's 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 the centers' successor.
(c)  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.
(d)  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.
(e)  An insurer and a preferred provider may agree by contract to use fewer data elements than are required in an electronic transaction set needed to comply with federal law.
(f)  An otherwise clean claim submitted by a physician or health care 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 chapter.
(g)  Except as provided by Subsection (e), the provisions of this section may not be waived, voided, or nullified by contract.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(b), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter C. -1. Other Provisions Relating to Payment of Claims › Section 1301.132. Overpayment

Sec. 1301.132.  OVERPAYMENT.  (a)  An insurer may recover an overpayment to a physician or health care provider if:
(1)  not later than the 180th day after the date the physician or provider receives the payment, the insurer 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 health care provider disagrees with a request for recovery of an overpayment, the insurer shall provide the physician or provider with an opportunity to appeal, and the insurer may not attempt to recover the overpayment until all appeal rights are exhausted.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(b), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter C. -1. Other Provisions Relating to Payment of Claims › Section 1301.133. Verification

Sec. 1301.133.  VERIFICATION.  (a)  In this section, "verification" includes preauthorization only when preauthorization is a condition for the verification.
(b)  On the request of a preferred provider for verification of a particular medical care or health care service the preferred provider proposes to provide to a particular patient, the insurer shall inform the preferred provider without delay whether the service, if provided to that patient, will be paid by the insurer and shall specify any deductibles, copayments, or coinsurance for which the insured is responsible.
(c)  An insurer shall have appropriate personnel reasonably available at a toll-free telephone number to provide a verification under this section between 6 a.m. and 6 p.m. central time Monday through Friday on each day that is not a legal holiday and between 9 a.m. and noon central time on Saturday, Sunday, and legal holidays.  An insurer must have a telephone system capable of accepting or recording incoming phone calls for verifications after 6 p.m. central time Monday through Friday and after noon central time on Saturday, Sunday, and legal holidays and responding to each of those calls on or before the second calendar day after the date the call is received.
(d)  An insurer may decline to determine eligibility for payment if the insurer notifies the physician or preferred provider who requested the verification of the specific reason the determination was not made.
(e)  An insurer may establish a specific period during which the verification is valid of not less than 30 days.
(f)  An insurer that declines to provide a verification shall notify the physician or provider who requested the verification of the specific reason the verification was not provided.
(g)  If an insurer has provided a verification for proposed medical care or health care services, the insurer may not deny or reduce payment to the physician or provider for those medical care or health care services if provided to the insured on or before the 30th day after the date the verification was provided unless the physician or provider has materially misrepresented the proposed medical care or health care services or has substantially failed to perform the proposed medical care or health care services.
(h)  The provisions of this section may not be waived, voided, or nullified by contract.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(b), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter C. -1. Other Provisions Relating to Payment of Claims › Section 1301.134. Coordination of Payment

Sec. 1301.134.  COORDINATION OF PAYMENT.  (a)  An insurer may require a physician or health care 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 insurer on the applicable form described by Section 1301.131.  Except as provided by this subsection, an insurer may not require a physician or provider to investigate coordination of other health benefit plan coverage.
(b)  Coordination of payment under this section does not extend the period for determining whether a service is eligible for payment under Section 1301.103 or 1301.104 or for auditing a claim under Section 1301.105.
(c)  A physician or health care provider who submits a claim for particular medical care or 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), an insurer shall coordinate and determine the appropriate payment for each health maintenance organization or insurer to make to the physician or health care provider.
(e)  Except as provided by Subsection (f), if an insurer is a secondary payor and pays a portion of a claim that should have been paid by the insurer or health maintenance organization 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 insurer was also paid by the primary health maintenance organization or insurer, the secondary insurer may recover the amount of overpayment under Section 1301.132 from the physician or health care provider who received the payment.  An insurer 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)  An insurer may share information with a health maintenance organization or another insurer to the extent necessary to coordinate appropriate payment obligations on a specific claim.
(h)  The provisions of this section may not be waived, voided, or nullified by contract.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(b), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter C. -1. Other Provisions Relating to Payment of Claims › Section 1301.1353. Remedy for Noncompliance

Sec. 1301.1353.  REMEDY FOR NONCOMPLIANCE.  (a)  In addition to any other penalty or remedy provided by law, an insurer that uses a preauthorization process for medical care or 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 medical care or health care service affected by the violation.
(b)  The provisions of this section may not be waived, voided, or nullified by contract.
Added by Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 2.04, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter C. -1. Other Provisions Relating to Payment of Claims › Section 1301.136. Availability of Coding Guidelines

Sec. 1301.136.  AVAILABILITY OF CODING GUIDELINES.  (a)  A contract between an insurer and a preferred provider must provide that:
(1)  the preferred 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 preferred provider will receive under the contract;
(2)  the insurer or the insurer's agent will provide the coding guidelines and fee schedules not later than the 30th day after the date the insurer receives the request;
(3)  the insurer or the insurer's agent will provide notice of changes to the coding guidelines and fee schedules that will result in a change of payment to the preferred 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 preferred provider on or before the 30th day after the date the preferred provider receives information requested under this subsection without penalty or discrimination in participation in other health care products or plans.
(b)  A preferred 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 insurer shall, on request of the preferred provider, provide the name, edition, and model version of the software that the insurer 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 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(b), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter C. -1. Other Provisions Relating to Payment of Claims › Section 1301.138. Applicability to Entities Contracting With Insurer

Sec. 1301.138.  APPLICABILITY TO ENTITIES CONTRACTING WITH INSURER.  This subchapter applies to a person described by Section 1301.109.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(b), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter C. -1. Other Provisions Relating to Payment of Claims › Section 1301.139. Legislative Declaration

Sec. 1301.139.  LEGISLATIVE DECLARATION.  It is the intent of the legislature that the requirements contained in this subchapter regarding payment of claims to preferred providers who are pharmacists or pharmacies apply to all insurers and pharmacy benefit managers unless otherwise prohibited by federal law.
Added by Acts 2011, 82nd Leg., R.S., Ch. 798 (H.B. 2292), Sec. 12, eff. September 1, 2011.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter C. -1. Other Provisions Relating to Payment of Claims › Section 1301.140. Out-of-Pocket Expense Credit

Sec. 1301.140.  OUT-OF-POCKET EXPENSE CREDIT.  (a) An insurer shall credit toward an insured's deductible and annual maximum out-of-pocket expenses an amount the insured pays directly to any physician or health care provider for a medically necessary covered medical or health care service or supply if a claim for the service or supply is not submitted to the insurer and the amount paid by the insured to the physician or health care provider is less than the average discounted rate for the service or supply paid to an equivalently licensed or authorized preferred provider under the insured's preferred provider benefit plan.
(b)  An insurer shall:
(1)  establish a procedure by which an insured may claim a credit under Subsection (a); and
(2)  identify documentation necessary to support a claim for a credit under Subsection (a).
(c)  Information about the procedure and documentation described by Subsection (b) must be readily accessible to an insured on the insurer's Internet website.
Added by Acts 2023, 88th Leg., R.S., Ch. 437 (H.B. 2002), Sec. 1, eff. September 1, 2023.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter D. Relations Between Insureds and Preferred Providers › Section 1301.151. Insured's Right to Treatment

Sec. 1301.151.  INSURED'S RIGHT TO TREATMENT.  Each insured is entitled to treatment and diagnostic techniques that are prescribed by the physician or health care provider included in the preferred provider benefit plan.
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 D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter D. Relations Between Insureds and Preferred Providers › Section 1301.152. Continuing Care in General

Sec. 1301.152.  CONTINUING CARE IN GENERAL.  (a)  An insurer shall establish reasonable procedures for ensuring a transition of insureds to physicians or health care providers and for continuity of treatment.
(b)  An insurer shall:
(1)  provide, subject to Section 1301.160, reasonable advance notice to an insured of the impending termination of the participation in the plan of a physician or health care provider who is currently treating the insured;  and
(2)  in the event of termination of a preferred provider's participation in the plan, make available to the insured a current listing of preferred providers.
(c)  A contract between an insurer and a physician or health care provider must include a procedure for resolving disputes regarding the necessity for continued treatment by the 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 D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter D. Relations Between Insureds and Preferred Providers › Section 1301.153. Continuity of Care

Sec. 1301.153.  CONTINUITY OF CARE.  (a)  In this section:
(1)  "Life-threatening" means a disease or condition for which the likelihood of death is probable unless the course of the disease or condition is interrupted.
(2)  "Special circumstances" means a condition regarding which the treating physician or health care provider reasonably believes that discontinuing care by the treating physician or provider could cause harm to the insured.  Examples of an insured who has a special circumstance include an insured with a disability, acute condition, or life-threatening illness or an insured who is past the 24th week of pregnancy.
(b)  Each contract between an insurer and a physician or health care provider must provide that the termination of the physician's or provider's participation in a preferred provider benefit plan, except for reason of medical competence or professional behavior, does not:
(1)  release the physician or health care provider from the generally recognized obligation to:
(A)  treat an insured whom the physician or provider is currently treating;  and
(B)  cooperate in arranging for appropriate referrals;  or
(2)  release the insurer from the obligation to reimburse the physician or health care provider or, if applicable, the insured, at the same preferred provider rate if, at the time a physician's or provider's participation is terminated, an insured whom the physician or provider is currently treating has special circumstances in accordance with the dictates of medical prudence.
(c)  The treating physician or health care provider shall identify a special circumstance.  The treating physician or health care provider shall:
(1)  request that the insured be permitted to continue treatment under the physician's or provider's care;  and
(2)  agree not to seek payment from the insured of any amount for which the insured would not be responsible if the physician or provider were still a preferred 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 D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter D. Relations Between Insureds and Preferred Providers › Section 1301.154. Obligation for Continuity of Care of Insurer

Sec. 1301.154.  OBLIGATION FOR CONTINUITY OF CARE OF INSURER.  (a)  Except as provided by Subsection (b), Sections 1301.152 and 1301.153 do not extend an insurer's obligation to reimburse the terminated physician or provider or, if applicable, the insured at the preferred provider level of coverage for ongoing treatment of an insured after:
(1)  the 90th day after the effective date of the termination;  or
(2)  if the insured has been diagnosed as having a terminal illness at the time of the termination, the expiration of the nine-month period after the effective date of the termination.
(b)  If an insured is past the 24th week of pregnancy at the time of termination, an insurer's obligation to reimburse, at the preferred provider level of coverage, the physician or provider or, if applicable, the insured, extends through delivery of the child, immediate postpartum care, and the follow-up checkup within the six-week period after delivery.
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 D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter D. Relations Between Insureds and Preferred Providers › Section 1301.156. Payment of Claims to Insured

Sec. 1301.156.  PAYMENT OF CLAIMS TO INSURED.  An insurer shall comply with Subchapter B, Chapter 542, with respect to prompt payment to insureds.
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 D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter D. Relations Between Insureds and Preferred Providers › Section 1301.157. Plain Language Requirements

Sec. 1301.157.  PLAIN LANGUAGE REQUIREMENTS.  Each health insurance policy, health benefit plan certificate, endorsement, amendment, application, or rider must:
(1)  be written in plain language;
(2)  be in a readable and understandable format;  and
(3)  comply with all applicable requirements relating to minimum readability requirements.
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 D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter D. Relations Between Insureds and Preferred Providers › Section 1301.158. Information Concerning Preferred Provider Benefit Plans

Sec. 1301.158.  INFORMATION CONCERNING PREFERRED PROVIDER BENEFIT PLANS.  (a)  In this section, "prospective insured" means:
(1)  for group coverage, an individual or an individual's dependent who is eligible for coverage under a health insurance policy issued to the group;  or
(2)  for individual coverage, an individual or an individual's dependent who is eligible for coverage and who has expressed an interest in purchasing an individual health insurance policy.
(b)  An insurer shall provide to a current or prospective group contract holder or current or prospective insured on request an accurate written description of the terms of the health insurance policy to allow the current or prospective group contract holder or current or prospective insured to make comparisons and an informed decision before selecting among health care plans.  The description must be in a readable and understandable format as prescribed by the commissioner and must include a current list of preferred providers.  The insurer may satisfy this requirement by providing its handbook if:
(1)  the handbook's content is substantively similar to and achieves the same level of disclosure as the written description prescribed by the commissioner;  and
(2)  the current list of preferred providers is provided.
(c)  An insurer or an agent or representative of an insurer may not use or distribute, or permit the use or distribution of, information for prospective insureds that is untrue or misleading.
(d)  An insurer shall provide to an insured on request information on:
(1)  whether a physician or other health care provider is a participating provider in the insurer's preferred provider network;
(2)  whether proposed health care services are covered by the health insurance policy;
(3)  what the insured's personal responsibility will be for payment of applicable copayment or deductible amounts; and
(4)  coinsurance amounts owed based on the provider's contracted rate for in-network services or the insurer's usual and customary reimbursement rate for out-of-network services.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 997 (S.B. 1731), Sec. 14, eff. September 1, 2007.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter D. Relations Between Insureds and Preferred Providers › Section 1301.1581. Information Concerning Exclusive Provider Benefit Plans

Sec. 1301.1581.  INFORMATION CONCERNING EXCLUSIVE PROVIDER BENEFIT PLANS.  (a) In this section, "prospective insured" has the meaning assigned by Section 1301.158.
(b)  In addition to the information required to be provided under Section 1301.158, an insurer that offers an exclusive provider benefit plan shall provide to a current or prospective group contract holder or current or prospective insured notice that the benefit plan includes limited coverage for services provided by a physician or health care provider that is not a preferred provider.
(c)  An identification card or similar document issued by an insurer to an insured in an exclusive provider benefit plan must display:
(1)  the first date on which the insured became insured under the plan;
(2)  a toll-free number that a physician or health care provider may use to obtain the date on which the insured became insured under the plan; and
(3)  the acronym "EPO" or the phrase "Exclusive Provider Organization" on the card in a location of the insurer's choice.
Added by Acts 2011, 82nd Leg., R.S., Ch. 288 (H.B. 1772), Sec. 10, eff. September 1, 2011.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter D. Relations Between Insureds and Preferred Providers › Section 1301.159. Annual List of Preferred Providers

Sec. 1301.159.  ANNUAL LIST OF PREFERRED PROVIDERS.  A current list of preferred providers shall be provided to each insured at least annually.
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 D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter D. Relations Between Insureds and Preferred Providers › Section 1301.1591. Preferred Provider Information on Internet

Sec. 1301.1591.  PREFERRED PROVIDER INFORMATION ON INTERNET.  (a)  An insurer subject to this chapter that maintains an Internet site shall list on the Internet site the preferred providers, including, if appropriate, mental health providers and substance abuse treatment providers, that insureds may use in accordance with the terms of the insured's preferred provider benefit plan.  The listing must identify those preferred providers who continue to be available to provide services to new patients or clients.
(b)  The insurer shall update at least quarterly an Internet site subject to this section.
(c)  The commissioner may adopt rules as necessary to implement this section.  The rules may govern the form and content of the information required to be provided under Subsection (a).
(d)  Notwithstanding any other provision of this chapter, this section applies to an entity subject to Chapter 941 or 942 and to a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.036(a), eff. September 1, 2005.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter D. Relations Between Insureds and Preferred Providers › Section 1301.160. Notification of Termination of Participation of Preferred Provider

Sec. 1301.160.  NOTIFICATION OF TERMINATION OF PARTICIPATION OF PREFERRED PROVIDER.  (a)  If a practitioner's participation in a preferred provider benefit plan is terminated for a reason other than at the practitioner's request, an insurer may not notify insureds of the termination until the later of:
(1)  the effective date of the termination;  or
(2)  the time at which a review panel makes a formal recommendation regarding the termination.
(b)  A physician or health care provider that voluntarily terminates the physician's or provider's participation in a preferred provider benefit plan shall provide reasonable notice to each insured under the physician's or provider's care.  The insurer shall provide assistance to the physician or provider in ensuring that the notice requirements of this subsection are met.
(c)  If a practitioner's participation in a preferred provider benefit plan is terminated for reasons related to imminent harm, an insurer may notify insureds immediately.
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 D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter D. Relations Between Insureds and Preferred Providers › Section 1301.161. Retaliation Against Insured Prohibited

Sec. 1301.161.  RETALIATION AGAINST INSURED PROHIBITED.  An insurer may not engage in any retaliatory action against an insured, including canceling or refusing to renew a health insurance policy, because the insured or a person acting on the insured's behalf has:
(1)  filed a complaint against the insurer or against a preferred provider;  or
(2)  appealed a decision of the insurer.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.