Texas Statutes
Subtitle C - Life, Health, and Accident Insurers and Related Entities
Chapter 843 - Health Maintenance Organizations

Section 843.003. Powers of Insurers and Group Hospital Service Corporations - Sec. 843.003. POWERS OF INSURERS AND GROUP HOSPITAL SERVICE CORPORATIONS....

Section 843.004. Governing Body of Health Maintenance Organization - Sec. 843.004. GOVERNING BODY OF HEALTH MAINTENANCE ORGANIZATION. The governing...

Section 843.005. Use of Insurance-Related Terms by Health Maintenance Organization - Sec. 843.005. USE OF INSURANCE-RELATED TERMS BY HEALTH MAINTENANCE ORGANIZATION....

Section 843.006. Public Documents - Sec. 843.006. PUBLIC DOCUMENTS. (a) Except as provided by Subsection...

Section 843.007. Confidentiality of Medical and Health Information - Sec. 843.007. CONFIDENTIALITY OF MEDICAL AND HEALTH INFORMATION. (a) Any...

Section 843.008. Costs of Administering Health Maintenance Organization Laws - Sec. 843.008. COSTS OF ADMINISTERING HEALTH MAINTENANCE ORGANIZATION LAWS. Money...

Section 843.009. Appeals; Judicial Review - Sec. 843.009. APPEALS; JUDICIAL REVIEW. (a) A person who is...

Section 843.010. Applicability of Certain Provisions to Governmental Health Benefit Plans - Sec. 843.010. APPLICABILITY OF CERTAIN PROVISIONS TO GOVERNMENTAL HEALTH BENEFIT...

Subchapter B. Applicability of and Construction With Other Laws

Section 843.051. Applicability of Insurance and Group Hospital Service Corporation Laws - Sec. 843.051. APPLICABILITY OF INSURANCE AND GROUP HOSPITAL SERVICE CORPORATION...

Section 843.052. Laws Relating to Solicitation or Advertising - Sec. 843.052. LAWS RELATING TO SOLICITATION OR ADVERTISING. (a) Solicitation...

Section 843.053. Laws Relating to Restraint of Trade - Sec. 843.053. LAWS RELATING TO RESTRAINT OF TRADE. (a) A...

Section 843.054. Laws Requiring Certificate of Need for Health Care Facility or Service - Sec. 843.054. LAWS REQUIRING CERTIFICATE OF NEED FOR HEALTH CARE...

Section 843.055. Laws Relating to Practice of Medicine - Sec. 843.055. LAWS RELATING TO PRACTICE OF MEDICINE. (a) This...

Section 843.056. Inapplicability of Bankruptcy Law - Sec. 843.056. INAPPLICABILITY OF BANKRUPTCY LAW. By applying for and...

Subchapter C. Authority to Engage in Business

Section 843.071. Certificate of Authority Required; Use of "Health Maintenance Organization" or "Hmo" - Sec. 843.071. CERTIFICATE OF AUTHORITY REQUIRED; USE OF "HEALTH MAINTENANCE...

Section 843.072. Authorization Required to Act as Health Maintenance Organization - Sec. 843.072. AUTHORIZATION REQUIRED TO ACT AS HEALTH MAINTENANCE ORGANIZATION....

Section 843.073. Certificate of Authority Requirement: Applicability to Physicians and Providers - Sec. 843.073. CERTIFICATE OF AUTHORITY REQUIREMENT: APPLICABILITY TO PHYSICIANS AND...

Section 843.074. Certificate of Authority Requirement: Applicability to Medical School and Medical and Dental Unit - Sec. 843.074. CERTIFICATE OF AUTHORITY REQUIREMENT: APPLICABILITY TO MEDICAL SCHOOL...

Section 843.075. Certificate of Authority for Single Health Care Service Plan - Sec. 843.075. CERTIFICATE OF AUTHORITY FOR SINGLE HEALTH CARE SERVICE...

Section 843.076. Application - Sec. 843.076. APPLICATION. (a) Any person may apply to the...

Section 843.077. Eligibility of Foreign Corporation - Sec. 843.077. ELIGIBILITY OF FOREIGN CORPORATION. A foreign corporation may...

Section 843.078. Contents of Application - Sec. 843.078. CONTENTS OF APPLICATION. (a) An application for a...

Section 843.079. Contents of Application: Limited Health Care Service Plan - Sec. 843.079. CONTENTS OF APPLICATION: LIMITED HEALTH CARE SERVICE PLAN....

Section 843.080. Modification or Amendment of Application Information - Sec. 843.080. MODIFICATION OR AMENDMENT OF APPLICATION INFORMATION. (a) The...

Section 843.082. Requirements for Approval of Application - Sec. 843.082. REQUIREMENTS FOR APPROVAL OF APPLICATION. The commissioner shall...

Section 843.083. Denial of Certificate of Authority - Sec. 843.083. DENIAL OF CERTIFICATE OF AUTHORITY. (a) If the...

Section 843.084. Duration of Certificate of Authority - Sec. 843.084. DURATION OF CERTIFICATE OF AUTHORITY. A certificate of...

Section 843.085. Change in Control: Commissioner Approval - Sec. 843.085. CHANGE IN CONTROL: COMMISSIONER APPROVAL. Any change in...

Subchapter D. General Powers and Duties of Health Maintenance Organizations

Section 843.101. Providing or Arranging for Care - Sec. 843.101. PROVIDING OR ARRANGING FOR CARE. (a) A health...

Section 843.102. Health Maintenance Organization Quality Assurance - Sec. 843.102. HEALTH MAINTENANCE ORGANIZATION QUALITY ASSURANCE. (a) A health...

Section 843.103. Acquisition and Operation of Facilities; Certain Loans; Commissioner Approval of Affiliate Transactions - Sec. 843.103. ACQUISITION AND OPERATION OF FACILITIES; CERTAIN LOANS; COMMISSIONER...

Section 843.104. Contracts for Certain Administrative Functions - Sec. 843.104. CONTRACTS FOR CERTAIN ADMINISTRATIVE FUNCTIONS. A health maintenance...

Section 843.105. Management and Exclusive Agency Contracts - Sec. 843.105. MANAGEMENT AND EXCLUSIVE AGENCY CONTRACTS. (a) A health...

Section 843.106. Insurance, Reinsurance, Indemnity, and Reimbursement - Sec. 843.106. INSURANCE, REINSURANCE, INDEMNITY, AND REIMBURSEMENT. A health maintenance...

Section 843.107. Indemnity Benefits; Point-of-Service Provisions - Sec. 843.107. INDEMNITY BENEFITS; POINT-OF-SERVICE PROVISIONS. A health maintenance organization...

Section 843.108. Point-of-Service Rider - Sec. 843.108. POINT-OF-SERVICE RIDER. (a) In this section, "point-of-service rider"...

Section 843.109. Payment by Governmental or Private Entity - Sec. 843.109. PAYMENT BY GOVERNMENTAL OR PRIVATE ENTITY. A health...

Section 843.110. Corporation, Partnership, or Association Powers - Sec. 843.110. CORPORATION, PARTNERSHIP, OR ASSOCIATION POWERS. A health maintenance...

Section 843.111. Group Model Health Maintenance Organizations - Sec. 843.111. GROUP MODEL HEALTH MAINTENANCE ORGANIZATIONS. (a) In this...

Section 843.112. Dental Point-of-Service Option - Sec. 843.112. DENTAL POINT-OF-SERVICE OPTION. (a) In this section: (1)...

Section 843.113. Specified Powers Not Exclusive - Sec. 843.113. SPECIFIED POWERS NOT EXCLUSIVE. The powers of a...

Subchapter E. Regulation of Health Maintenance Organizations

Section 843.151. Rules - Sec. 843.151. RULES. The commissioner may adopt reasonable rules as...

Section 843.152. Subpoena Authority - Sec. 843.152. SUBPOENA AUTHORITY. In implementing this chapter and the...

Section 843.153. Authority to Contract - Sec. 843.153. AUTHORITY TO CONTRACT. In performing duties under this...

Section 843.154. Fees - Sec. 843.154. FEES. (a) The commissioner shall, within the limits...

Section 843.155. Annual Report - Sec. 843.155. ANNUAL REPORT. (a) Not later than March 1...

Section 843.156. Examinations - Sec. 843.156. EXAMINATIONS. (a) The commissioner may examine the quality...

Section 843.157. Rehabilitation, Liquidation, Supervision, or Conservation of Health Maintenance Organization - Sec. 843.157. REHABILITATION, LIQUIDATION, SUPERVISION, OR CONSERVATION OF HEALTH MAINTENANCE...

Subchapter F. Relations With Enrollees and Group Contract Holders

Section 843.201. Disclosure of Information About Health Care Plan Terms - Sec. 843.201. DISCLOSURE OF INFORMATION ABOUT HEALTH CARE PLAN TERMS....

Section 843.2015. Information Available Through Internet Site - Sec. 843.2015. INFORMATION AVAILABLE THROUGH INTERNET SITE. (a) A health...

Section 843.202. Disclosure of Information to Medicare Recipients - Sec. 843.202. DISCLOSURE OF INFORMATION TO MEDICARE RECIPIENTS. (a) Before...

Section 843.203. Selection of Primary Care Physician or Provider - Sec. 843.203. SELECTION OF PRIMARY CARE PHYSICIAN OR PROVIDER. (a)...

Section 843.204. Untrue or Misleading Information - Sec. 843.204. UNTRUE OR MISLEADING INFORMATION. (a) A health maintenance...

Section 843.205. Member's Handbook; Information About Complaints and Appeals - Sec. 843.205. MEMBER'S HANDBOOK; INFORMATION ABOUT COMPLAINTS AND APPEALS. (a)...

Section 843.206. Notice of Change in Payment Arrangements - Sec. 843.206. NOTICE OF CHANGE IN PAYMENT ARRANGEMENTS. A health...

Section 843.207. Notice of Change in Operations - Sec. 843.207. NOTICE OF CHANGE IN OPERATIONS. A health maintenance...

Section 843.2071. Notice of Increase in Charge for Coverage - Sec. 843.2071. NOTICE OF INCREASE IN CHARGE FOR COVERAGE. (a)...

Section 843.208. Cancellation or Nonrenewal of Coverage - Sec. 843.208. CANCELLATION OR NONRENEWAL OF COVERAGE. A health maintenance...

Section 843.209. Identification Card - Sec. 843.209. IDENTIFICATION CARD. An identification card or other similar...

Section 843.210. Terms of Enrollee Eligibility - Sec. 843.210. TERMS OF ENROLLEE ELIGIBILITY. (a) A contract between...

Section 843.211. Applicability of Subchapter to Entities Contracting With Health Maintenance Organization - Sec. 843.211. APPLICABILITY OF SUBCHAPTER TO ENTITIES CONTRACTING WITH HEALTH...

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)...

Section 843.252. Complaint Initiation and Initial Response; Deadlines for Response and Resolution - Sec. 843.252. COMPLAINT INITIATION AND INITIAL RESPONSE; DEADLINES FOR RESPONSE...

Section 843.253. Complaint Investigation and Resolution - Sec. 843.253. COMPLAINT INVESTIGATION AND RESOLUTION. (a) A health maintenance...

Section 843.254. Appeal to Complaint Appeal Panel; Deadlines - Sec. 843.254. APPEAL TO COMPLAINT APPEAL PANEL; DEADLINES. (a) A...

Section 843.255. Composition of Complaint Appeal Panel - Sec. 843.255. COMPOSITION OF COMPLAINT APPEAL PANEL. (a) A health...

Section 843.256. Information Provided to Complainant Relating to Complaint Appeal Panel - Sec. 843.256. INFORMATION PROVIDED TO COMPLAINANT RELATING TO COMPLAINT APPEAL...

Section 843.257. Rights of Complainant at Complaint Appeal Panel Meeting - Sec. 843.257. RIGHTS OF COMPLAINANT AT COMPLAINT APPEAL PANEL MEETING....

Section 843.258. Appeal Involving Ongoing Emergency or Continued Hospitalization - Sec. 843.258. APPEAL INVOLVING ONGOING EMERGENCY OR CONTINUED HOSPITALIZATION. (a)...

Section 843.259. Notice of Decision on Appeal - Sec. 843.259. NOTICE OF DECISION ON APPEAL. (a) A health...

Section 843.260. Record of Complaints - Sec. 843.260. RECORD OF COMPLAINTS. (a) A health maintenance organization...

Section 843.261. Special Provisions for Appeals of Adverse Determinations - Sec. 843.261. SPECIAL PROVISIONS FOR APPEALS OF ADVERSE DETERMINATIONS. (a)...

Section 843.262. Certain Decisions Binding - Sec. 843.262. CERTAIN DECISIONS BINDING. (a) If an enrollee, a...

Subchapter H. General Provisions Regarding Complaints

Section 843.281. Retaliatory Action Prohibited - Sec. 843.281. RETALIATORY ACTION PROHIBITED. (a) A health maintenance organization...

Section 843.282. Submitting Complaints to Department - Sec. 843.282. SUBMITTING COMPLAINTS TO DEPARTMENT. (a) Any person, including...

Section 843.283. Posting of Information on Complaint Process Required - Sec. 843.283. POSTING OF INFORMATION ON COMPLAINT PROCESS REQUIRED. A...

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...

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...

Section 843.303. Denial of Initial Contract to Physician or Provider - Sec. 843.303. DENIAL OF INITIAL CONTRACT TO PHYSICIAN OR PROVIDER....

Section 843.304. Exclusion of Provider Based on Type of License Prohibited - Sec. 843.304. EXCLUSION OF PROVIDER BASED ON TYPE OF LICENSE...

Section 843.3041. Acupuncturist Services - Sec. 843.3041. ACUPUNCTURIST SERVICES. (a) A health maintenance organization that...

Section 843.3042. Chiropractic Services - Sec. 843.3042. CHIROPRACTIC SERVICES. (a) A health maintenance organization offering...

Section 843.3045. Nurse First Assistant - Sec. 843.3045. NURSE FIRST ASSISTANT. A health maintenance organization may...

Section 843.305. Annual Application Period for Physicians and Providers to Contract - Sec. 843.305. ANNUAL APPLICATION PERIOD FOR PHYSICIANS AND PROVIDERS TO...

Section 843.306. Termination of Participation; Advisory Review Panel - Sec. 843.306. TERMINATION OF PARTICIPATION; ADVISORY REVIEW PANEL. (a) Before...

Section 843.307. Expedited Review Process on Termination or Deselection - Sec. 843.307. EXPEDITED REVIEW PROCESS ON TERMINATION OR DESELECTION. On...

Section 843.308. Notification of Patients of Deselected Physician or Provider - Sec. 843.308. NOTIFICATION OF PATIENTS OF DESELECTED PHYSICIAN OR PROVIDER....

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...

Section 843.310. Contracts With Physicians or Providers: Certain Indemnity Clauses Prohibited - Sec. 843.310. CONTRACTS WITH PHYSICIANS OR PROVIDERS: CERTAIN INDEMNITY CLAUSES...

Section 843.311. Contracts With Podiatrists - Sec. 843.311. CONTRACTS WITH PODIATRISTS. A contract between a health...

Section 843.3115. Contracts With Dentists - Sec. 843.3115. CONTRACTS WITH DENTISTS. (a) In this section, "covered...

Section 843.312. Physician Assistants and Advanced Practice Nurses - Sec. 843.312. PHYSICIAN ASSISTANTS AND ADVANCED PRACTICE NURSES. (a) A...

Section 843.313. Economic Profiling - Sec. 843.313. ECONOMIC PROFILING. (a) A health maintenance organization that...

Section 843.314. Inducement to Limit Medically Necessary Services Prohibited - Sec. 843.314. INDUCEMENT TO LIMIT MEDICALLY NECESSARY SERVICES PROHIBITED. (a)...

Section 843.315. Payment of Capitation; Assignment of Primary Care Physician or Provider - Sec. 843.315. PAYMENT OF CAPITATION; ASSIGNMENT OF PRIMARY CARE PHYSICIAN...

Section 843.316. Alternative Capitation System - Sec. 843.316. ALTERNATIVE CAPITATION SYSTEM. As an alternative to the...

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...

Section 843.318. Certain Contracts of Participating Physician or Provider Not Prohibited - Sec. 843.318. CERTAIN CONTRACTS OF PARTICIPATING PHYSICIAN OR PROVIDER NOT...

Section 843.319. Certain Required Contracts - Sec. 843.319. CERTAIN REQUIRED CONTRACTS. Notwithstanding Section 843.304, a health...

Section 843.320. Use of Hospitalist - Sec. 843.320. USE OF HOSPITALIST. (a) In this section, "hospitalist"...

Section 843.321. Availability of Coding Guidelines - Sec. 843.321. AVAILABILITY OF CODING GUIDELINES. (a) A contract between...

Section 843.323. Contract Provisions Prohibiting Rejection of Batched Claims - Sec. 843.323. CONTRACT PROVISIONS PROHIBITING REJECTION OF BATCHED CLAIMS. (a)...

Subchapter J. Payment of Claims to Physicians and Providers

Section 843.336. Definition - Sec. 843.336. DEFINITION. (a) In this subchapter, "clean claim" means...

Section 843.337. Time for Submission of Claim; Duplicate Claims; Acknowledgment of Receipt of Claim - Sec. 843.337. TIME FOR SUBMISSION OF CLAIM; DUPLICATE CLAIMS; ACKNOWLEDGMENT...

Section 843.338. Deadline for Action on Clean Claims - Sec. 843.338. DEADLINE FOR ACTION ON CLEAN CLAIMS. Except as...

Section 843.3385. Additional Information - Sec. 843.3385. ADDITIONAL INFORMATION. (a) If a health maintenance organization...

Section 843.339. Deadline for Action on Prescription Claims; Payment - Sec. 843.339. DEADLINE FOR ACTION ON PRESCRIPTION CLAIMS; PAYMENT. (a)...

Section 843.340. Audited Claims - Sec. 843.340. AUDITED CLAIMS. (a) Except as provided by Section...

Section 843.3405. Investigation and Determination of Payment - Sec. 843.3405. INVESTIGATION AND DETERMINATION OF PAYMENT. The investigation and...

Section 843.341. Claims Processing Procedures - Sec. 843.341. CLAIMS PROCESSING PROCEDURES. (a) A health maintenance organization...

Section 843.342. Violation of Certain Claims Payment Provisions; Penalties - Sec. 843.342. VIOLATION OF CERTAIN CLAIMS PAYMENT PROVISIONS; PENALTIES. (a)...

Section 843.343. Attorney's Fees - Sec. 843.343. ATTORNEY'S FEES. A physician or provider may recover...

Section 843.344. Applicability of Subchapter to Entities Contracting With Health Maintenance Organization - Sec. 843.344. APPLICABILITY OF SUBCHAPTER TO ENTITIES CONTRACTING WITH HEALTH...

Section 843.345. Exception - Sec. 843.345. EXCEPTION. This subchapter does not apply to a...

Section 843.346. Payment of Claims - Sec. 843.346. PAYMENT OF CLAIMS. Except as provided by this...

Section 843.347. Verification - Sec. 843.347. VERIFICATION. (a) In this section, "verification" means a...

Section 843.348. Preauthorization of Health Care Services - Sec. 843.348. PREAUTHORIZATION OF HEALTH CARE SERVICES. (a) In this...

Section 843.3481. Posting of Preauthorization Requirements - Sec. 843.3481. POSTING OF PREAUTHORIZATION REQUIREMENTS. (a) A health maintenance...

Section 843.3483. Remedy for Noncompliance - Sec. 843.3483. REMEDY FOR NONCOMPLIANCE. In addition to any other...

Section 843.349. Coordination of Payment - Sec. 843.349. COORDINATION OF PAYMENT. (a) A health maintenance organization...

Section 843.350. Overpayment - Sec. 843.350. OVERPAYMENT. (a) A health maintenance organization may recover...

Section 843.351. Services Provided by Certain Physicians and Providers - Sec. 843.351. SERVICES PROVIDED BY CERTAIN PHYSICIANS AND PROVIDERS. The...

Section 843.352. Conflict With Other Law - Sec. 843.352. CONFLICT WITH OTHER LAW. To the extent of...

Section 843.353. Waiver Prohibited - Sec. 843.353. WAIVER PROHIBITED. Except as provided by Sections 843.336(f)...

Section 843.354. Legislative Declaration - Sec. 843.354. LEGISLATIVE DECLARATION. It is the intent of the...

Subchapter K. Relations Between Enrollee and Physician or Provider

Section 843.361. Enrollees Held Harmless - Sec. 843.361. ENROLLEES HELD HARMLESS. A contract or other agreement...

Section 843.362. Continuity of Care; Obligation of Health Maintenance Organization - Sec. 843.362. CONTINUITY OF CARE; OBLIGATION OF HEALTH MAINTENANCE ORGANIZATION....

Section 843.363. Protected Physician or Provider Communications With Patients - Sec. 843.363. PROTECTED PHYSICIAN OR PROVIDER COMMUNICATIONS WITH PATIENTS. (a)...

Subchapter L. Financial Regulation of Health Maintenance Organizations

Section 843.401. Fiduciary Responsibility - Sec. 843.401. FIDUCIARY RESPONSIBILITY. A director, officer, member, employee, or...

Section 843.402. Officers' and Employees' Bond - Sec. 843.402. OFFICERS' AND EMPLOYEES' BOND. (a) A health maintenance...

Section 843.403. Minimum Net Worth - Sec. 843.403. MINIMUM NET WORTH. (a) A health maintenance organization...

Section 843.404. Additional Net Worth Requirements - Sec. 843.404. ADDITIONAL NET WORTH REQUIREMENTS. (a) The commissioner may...

Section 843.405. Deposit With Comptroller - Sec. 843.405. DEPOSIT WITH COMPTROLLER. (a) Unless otherwise provided by...

Section 843.406. Hazardous Financial Condition - Sec. 843.406. HAZARDOUS FINANCIAL CONDITION. (a) If the financial condition...

Section 843.407. Receivership and Delinquency Proceedings - Sec. 843.407. RECEIVERSHIP AND DELINQUENCY PROCEEDINGS. (a) In addition to...

Section 843.408. Insolvency and Allocation to Other Health Maintenance Organizations - Sec. 843.408. INSOLVENCY AND ALLOCATION TO OTHER HEALTH MAINTENANCE ORGANIZATIONS....

Section 843.409. Examination Expenses - Sec. 843.409. EXAMINATION EXPENSES. (a) A credit against the amount...

Section 843.410. Assessments - Sec. 843.410. ASSESSMENTS. (a) To provide funds for the administrative...

Subchapter N. Enforcement

Section 843.461. Enforcement Actions - Sec. 843.461. ENFORCEMENT ACTIONS. (a) After notice and opportunity for...

Section 843.462. Operations During Suspension or After Revocation of Certificate of Authority - Sec. 843.462. OPERATIONS DURING SUSPENSION OR AFTER REVOCATION OF CERTIFICATE...

Section 843.463. Injunctions - Sec. 843.463. INJUNCTIONS. If the commissioner believes that a health...

Section 843.464. Criminal Penalty - Sec. 843.464. CRIMINAL PENALTY. (a) A person, including an agent...

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Texas Statutes Subtitle C - Life, Health, and Accident Insurers and Related Entities Chapter 843 - Health Maintenance Organizations

Texas Statutes
Subtitle C - Life, Health, and Accident Insurers and Related Entities
Chapter 843 - Health Maintenance Organizations