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 G. Dispute Resolution › Section 843.251. Complaint System Required; Commissioner Rules and Examination

Sec. 843.251.  COMPLAINT SYSTEM REQUIRED;  COMMISSIONER RULES AND EXAMINATION.  (a)  A health maintenance organization shall implement and maintain a complaint system that provides reasonable procedures to resolve an oral or written complaint initiated by a complainant concerning health care services.  The complaint system must include a process for the notice and appeal of a complaint.
(b)  The commissioner may adopt reasonable rules as necessary or proper to implement the provisions of this subchapter relating to the complaint system and administer matters relating to the complaint system.
(c)  The commissioner may examine a complaint system for compliance with this subchapter and may require the health maintenance organization to make corrections as the commissioner considers necessary.
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 G. Dispute Resolution › Section 843.252. Complaint Initiation and Initial Response; Deadlines for Response and Resolution

Sec. 843.252.  COMPLAINT INITIATION AND INITIAL RESPONSE;  DEADLINES FOR RESPONSE AND RESOLUTION.  (a)  If a complainant notifies a health maintenance organization of a complaint, the health maintenance organization, not later than the fifth business day after the date of receiving the complaint, shall send to the complainant a letter acknowledging the date of receipt of the complaint.
(b)  The letter required under Subsection (a) must:
(1)  include a description of the health maintenance organization's complaint procedures and time frames;  and
(2)  if the complaint is made orally, be accompanied by a one-page complaint form that prominently and clearly states that the form must be returned to the health maintenance organization for prompt resolution of the complaint.
(c)  A health maintenance organization shall acknowledge, investigate, and resolve a complaint not later than the 30th calendar day after the date the health maintenance organization receives the written complaint or one-page complaint form from the complainant.
(d)  Subsections (a)-(c) do not apply to a complaint concerning an emergency or a denial of continued hospitalization.  A health maintenance organization shall investigate and resolve a complaint concerning an emergency or a denial of continued hospitalization:
(1)  in accordance with the medical or dental immediacy of the case;  and
(2)  not later than one business day after the health maintenance organization receives the complaint.
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 G. Dispute Resolution › Section 843.253. Complaint Investigation and Resolution

Sec. 843.253.  COMPLAINT INVESTIGATION AND RESOLUTION.  (a)  A health maintenance organization shall investigate each complaint received in accordance with the health maintenance organization's policies and in compliance with this chapter.
(b)  After a health maintenance organization has investigated a complaint, the health maintenance organization shall issue a response letter to the complainant within the time prescribed by Section 843.252(c) that:
(1)  explains the health maintenance organization's resolution of the complaint;
(2)  states the specific medical and contractual reasons for the resolution;
(3)  states the specialization of any physician or other provider consulted;  and
(4)  contains a complete description of the process for appeal, including the deadlines for the appeals process and the deadlines for the final decision on the appeal.
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 G. Dispute Resolution › Section 843.254. Appeal to Complaint Appeal Panel; Deadlines

Sec. 843.254.  APPEAL TO COMPLAINT APPEAL PANEL;  DEADLINES.  (a)  A health maintenance organization shall provide an appeals process for a complainant who is not satisfied with the resolution of the complaint.  The appeals process must include the right of the complainant to:
(1)  appear in person before a complaint appeal panel at the site at which the enrollee normally receives health care services or at another site agreed to by the complainant;  or
(2)  address a written appeal to the complaint appeal panel.
(b)  The health maintenance organization shall send an acknowledgment letter to the complainant not later than the fifth business day after the date the written request for appeal is received.
(c)  The health maintenance organization shall complete the appeals process not later than the 30th calendar day after the date the written request for appeal is received.
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 G. Dispute Resolution › Section 843.255. Composition of Complaint Appeal Panel

Sec. 843.255.  COMPOSITION OF COMPLAINT APPEAL PANEL.  (a)  A health maintenance organization shall appoint members to a complaint appeal panel to advise the health maintenance organization on the resolution of a disputed decision appealed by a complainant.
(b)  A complaint appeal panel shall be composed of an equal number of health maintenance organization staff members, physicians or other providers, and enrollees.  A member of a complaint appeal panel may not have been previously involved in the disputed decision.
(c)  The physicians or other providers on a complaint appeal panel must have experience in the area of care that is in dispute and must be independent of any physician or provider who made any previous determination.  If specialty care is in dispute, the complaint appeal panel must include a person who is a specialist in the field of care to which the appeal relates.
(d)  The enrollee members of a complaint appeal panel may not be employees of the 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 G. Dispute Resolution › Section 843.256. Information Provided to Complainant Relating to Complaint Appeal Panel

Sec. 843.256.  INFORMATION PROVIDED TO COMPLAINANT RELATING TO COMPLAINT APPEAL PANEL.  Not later than the fifth business day before the date a complaint appeal panel is scheduled to meet, unless the complainant agrees otherwise, the health maintenance organization shall provide to the complainant or the complainant's designated representative:
(1)  any documentation to be presented to the complaint appeal panel by the health maintenance organization staff;
(2)  the specialization of any physicians or providers consulted during the investigation;  and
(3)  the name and affiliation of each health maintenance organization representative on the complaint appeal panel.
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 G. Dispute Resolution › Section 843.257. Rights of Complainant at Complaint Appeal Panel Meeting

Sec. 843.257.  RIGHTS OF COMPLAINANT AT COMPLAINT APPEAL PANEL MEETING.  A complainant, or a designated representative if the enrollee is a minor or is disabled, is entitled to:
(1)  appear in person before the complaint appeal panel;
(2)  present alternative expert testimony;  and
(3)  request the presence of and question any person responsible for making the disputed decision that resulted in the appeal.
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 G. Dispute Resolution › Section 843.258. Appeal Involving Ongoing Emergency or Continued Hospitalization

Sec. 843.258.  APPEAL INVOLVING ONGOING EMERGENCY OR CONTINUED HOSPITALIZATION.  (a)  The investigation and resolution of an appeal of a complaint relating to an ongoing emergency or denial of continued hospitalization shall be concluded:
(1)  in accordance with the medical or dental immediacy of the case;  and
(2)  not later than one business day after the complainant's request for appeal is received.
(b)  Because of the ongoing emergency or continued hospitalization and at the request of the complainant, the health maintenance organization shall provide, instead of a complaint appeal panel, a review by a physician or provider who:
(1)  has not previously reviewed the case;  and
(2)  is of the same or a similar specialty as the physician or provider who would typically manage the medical condition, procedure, or treatment under consideration for review in the appeal.
(c)  The physician or provider reviewing the appeal may interview the patient or the patient's designated representative and shall decide the appeal.
(d)  The physician or provider may deliver initial notice of the decision on the appeal orally if the physician or provider subsequently provides written notice of the decision not later than the third day after the date of the decision.
(e)  The investigation and resolution of an appeal after emergency care has been provided shall be conducted in accordance with the procedures otherwise established under this subchapter, including the right to review by a complaint appeal panel.
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 G. Dispute Resolution › Section 843.259. Notice of Decision on Appeal

Sec. 843.259.  NOTICE OF DECISION ON APPEAL.  (a)  A health maintenance organization shall include in a notice of the final decision on an appeal a statement of the specific medical determination, clinical basis, and contractual criteria used to reach the final decision.
(b)  The notice must include the toll-free telephone number and address of the department.
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 G. Dispute Resolution › Section 843.260. Record of Complaints

Sec. 843.260.  RECORD OF COMPLAINTS.  (a)  A health maintenance organization shall maintain a complaint and appeal log regarding each complaint.  The log must identify those complaints relating to limited provider networks and delegated entities.
(b)  A health maintenance organization shall maintain a record of and documentation on each complaint, complaint proceeding, and action taken on each complaint, including a complaint relating to a limited provider network or delegated entity, until the third anniversary of the date the complaint was received.
(c)  A complainant is entitled to a copy of the record of the complainant's complaint and any proceeding relating to that complaint.
(d)  The department, during any investigation of a health maintenance organization, may review documentation maintained under Subsection (b), including original documentation, regarding a complaint and action taken on the complaint.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.209(a), 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 G. Dispute Resolution › Section 843.261. Special Provisions for Appeals of Adverse Determinations

Sec. 843.261.  SPECIAL PROVISIONS FOR APPEALS OF ADVERSE DETERMINATIONS.  (a)  A health maintenance organization shall implement and maintain an internal appeal system that:
(1)  provides reasonable procedures for the resolution of an oral or written appeal concerning dissatisfaction or disagreement with an adverse determination; and
(2)  includes procedures for notification, review, and appeal of an adverse determination in accordance with Chapter 4201.
(b)  An appeal must be initiated by an enrollee, a person acting on behalf of an enrollee, or an enrollee's provider of record.
(c)  When an enrollee, a person acting on behalf of an enrollee, or an enrollee's provider of record expresses orally or in writing any dissatisfaction or disagreement with an adverse determination, the health maintenance organization or utilization review agent shall:
(1)  consider the expression of dissatisfaction or disagreement as an appeal of the adverse determination; and
(2)  review and resolve the appeal in accordance with Chapter 4201.
(d)  A health maintenance organization may integrate its appeal procedures related to adverse determinations with the complaint and appeal procedures established by the health maintenance organization under Section 843.251 and otherwise governed by this subchapter only if the procedures related to adverse determinations comply with this section and Chapter 4201.
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.046, 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 G. Dispute Resolution › Section 843.262. Certain Decisions Binding

Sec. 843.262.  CERTAIN DECISIONS BINDING.  (a)  If an enrollee, a person acting on behalf of an enrollee, or an enrollee's provider of record appeals an adverse determination as provided under Section 843.261 and the health maintenance organization or utilization review agent, as applicable, resolves the claim in favor of the enrollee, the decision is binding on the health maintenance organization.
(b)  After a binding decision in favor of an enrollee relating to a proposed health care service, the health maintenance organization shall provide or arrange for the health care service within a time frame that is appropriate for the treatment of the medical condition that was the subject of the appeal.
(c)  After a binding decision in favor of an enrollee relating to a health care service already provided, the health maintenance organization shall pay the cost of the service, if not already paid by the health maintenance organization, not later than the 45th day after the date the health maintenance organization receives notice of the binding decision.  A health maintenance organization that fails to pay the cost of service as required by this subsection is subject to penalties provided under Section 843.342.
(d)  This section applies only to a health care plan of a political subdivision that is exempt from application of the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.).
Added by Acts 2003, 78th Leg., ch. 348, Sec. 1, 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 H. General Provisions Regarding Complaints › Section 843.281. Retaliatory Action Prohibited

Sec. 843.281.  RETALIATORY ACTION PROHIBITED.  (a)  A health maintenance organization may not engage in retaliatory action, including refusal to renew or cancellation of coverage, against a group contract holder or enrollee because the group or enrollee or a person acting on behalf of the group or enrollee has filed a complaint against the health maintenance organization or appealed a decision of the health maintenance organization.
(b)  A health maintenance organization may not engage in retaliatory action, including refusal to renew or termination of a contract, against a physician or provider because the physician or provider has, on behalf of an enrollee, reasonably filed a complaint against the health maintenance organization or appealed a decision of the 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 H. General Provisions Regarding Complaints › Section 843.282. Submitting Complaints to Department

Sec. 843.282.  SUBMITTING COMPLAINTS TO DEPARTMENT.  (a)  Any person, including a person who has attempted to resolve a complaint through a health maintenance organization's complaint system process and is dissatisfied with the resolution, may submit a complaint to the department alleging a violation of:
(1)  this chapter;
(2)  Section 1367.053;
(3)  Subchapter A, Chapter 1452;
(4)  Subchapter B, Chapter 1507;
(5)  Chapters 222, 251, and 258, as applicable to a  health maintenance organization; or
(6)  Chapter 1271 or 1272.
(b)  The commissioner shall complete an investigation of a complaint against a health maintenance organization to determine whether a violation has occurred not later than the 60th day after the date the department receives the complaint and all information necessary for the commissioner to make a determination.
(c)  The commissioner may extend the time necessary to complete an investigation if:
(1)  additional information is needed;
(2)  an on-site review is necessary;
(3)  the health maintenance organization, the physician or provider, or the complainant does not provide all documentation necessary to complete the investigation;  or
(4)  other circumstances beyond the control of the department occur.
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.047, 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 H. General Provisions Regarding Complaints › Section 843.283. Posting of Information on Complaint Process Required

Sec. 843.283.  POSTING OF INFORMATION ON COMPLAINT PROCESS REQUIRED.  A contract between a health maintenance organization and a physician or provider must require the physician or provider to post, in the office of the physician or provider, a notice to enrollees on the process for resolving complaints with the health maintenance organization.  The notice must include the department's toll-free telephone number for filing a complaint.
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 I. Relations With Physicians and Providers › Section 843.301. Practice of Medicine Not Affected

Sec. 843.301.  PRACTICE OF MEDICINE NOT AFFECTED.  This chapter, Section 1367.053, Subchapter A, Chapter 1452, Subchapter B, Chapter 1507, Chapters 222, 251, and 258, as applicable to a health maintenance organization, and Chapters 1271 and 1272 do not:
(1)  authorize any person, other than a licensed physician or practitioner of the healing arts, acting within the scope of the person's license, to engage directly or indirectly in the practice of medicine or a healing art; or
(2)  authorize any person to regulate, interfere with, or intervene in any manner in the practice of medicine or a healing art.
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.048, 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 I. Relations With Physicians and Providers › Section 843.302. Disclosure of Application Procedures and Qualification Requirements to Physician or Provider

Sec. 843.302.  DISCLOSURE OF APPLICATION PROCEDURES AND QUALIFICATION REQUIREMENTS TO PHYSICIAN OR PROVIDER.  A health maintenance organization shall, on request, make available and disclose to a physician or provider written application procedures and qualification requirements for contracting with the 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 I. Relations With Physicians and Providers › Section 843.303. Denial of Initial Contract to Physician or Provider

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sec. 843.314.  INDUCEMENT TO LIMIT MEDICALLY NECESSARY SERVICES PROHIBITED.  (a)  A health maintenance organization may not use a financial incentive or make a payment to a physician or provider if the incentive or payment acts directly or indirectly as an inducement to limit medically necessary services.
(b)  This section does not prohibit the use of capitation as a method of payment.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
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 843.316. Alternative Capitation System

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

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

Sec. 843.318.  CERTAIN CONTRACTS OF PARTICIPATING PHYSICIAN OR PROVIDER NOT PROHIBITED.  (a)  This chapter and this code do not prohibit a physician or provider who is participating in a health maintenance organization delivery network, whether by contracting with a health maintenance organization under Section 843.101 or by subcontracting with a physician or provider in the health maintenance organization delivery network, from entering into a contractual arrangement within a health maintenance organization delivery network described by Subsections (b)-(e).
(b)  A physician may contract to provide medical care or arrange to provide medical care through subcontracts with other physicians.  A physician may contract to provide through another provider any service that is ancillary to the practice of medicine, other than hospital or other institutional or inpatient provider services.
(c)  A provider may contract to provide, or arrange to provide through a subcontract with a similarly licensed provider, any health care service that the providers are licensed to provide, other than medical care.
(d)  A provider may contract to provide, or arrange to provide through a subcontract with another provider, a health care service that the provider is not licensed to provide, other than medical care, if the contracted or subcontracted services constitute less than 15 percent of the total amount of services the provider is to provide or arrange to provide.
(e)  A contract or subcontract authorized under this section may provide for compensation under:
(1)  a fee-for-service arrangement;
(2)  a risk-sharing arrangement;  or
(3)  a capitation arrangement under which a fixed predetermined payment is made in exchange for the provision of, or for the arrangement to provide and the guaranty of the provision of, a defined set of covered services to covered persons for a specified period without regard to the quantity of services actually provided.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 3B.025, eff. September 1, 2007.
Acts 2007, 80th Leg., R.S., Ch. 921 (H.B. 3167), Sec. 9.025, eff. September 1, 2007.
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 843.319. Certain Required Contracts

Sec. 843.319.  CERTAIN REQUIRED CONTRACTS.  Notwithstanding Section 843.304, a health maintenance organization may not deny a contract to a podiatrist licensed by the Texas Department of Licensing and Regulation who joins the professional practice of a contracted physician or provider, satisfies the application procedures of the health maintenance organization, and meets the qualification and credentialing requirements for contracting with the health maintenance organization.
Added by Acts 2003, 78th Leg., ch. 237, Sec. 4, eff. Sept. 1, 2003.
Amended by:
Acts 2019, 86th Leg., R.S., Ch. 467 (H.B. 4170), Sec. 19.012, 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 I. Relations With Physicians and Providers › Section 843.320. Use of Hospitalist

Sec. 843.320.  USE OF HOSPITALIST.  (a)  In this section, "hospitalist" means a physician who:
(1)  serves as physician of record at a hospital for a hospitalized patient of another physician; and
(2)  returns the care of the patient to that other physician at the end of the patient's hospitalization.
(b)  A contract between a health maintenance organization and a physician may not require the physician to use a hospitalist for a hospitalized patient.
Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.211(a), eff. Sept. 1, 2003.