Texas Statutes
Title 8 - Health Insurance and Other Health Coverages
Subtitle D - Provider Plans

Section 1301.003. Preferred Provider Benefit Plans and Exclusive Provider Benefit Plans Permitted - Sec. 1301.003. PREFERRED PROVIDER BENEFIT PLANS AND EXCLUSIVE PROVIDER BENEFIT...

Section 1301.0041. Applicability - Sec. 1301.0041. APPLICABILITY. (a) Except as otherwise specifically provided by...

Section 1301.0042. Applicability of Insurance Law - Sec. 1301.0042. APPLICABILITY OF INSURANCE LAW. (a) Except as provided...

Section 1301.0045. Construction of Chapter - Sec. 1301.0045. CONSTRUCTION OF CHAPTER. (a) Except as provided by...

Section 1301.0046. Coinsurance Requirements for Services of Nonpreferred Providers - Sec. 1301.0046. COINSURANCE REQUIREMENTS FOR SERVICES OF NONPREFERRED PROVIDERS. The...

Section 1301.005. Availability of Preferred Providers - Sec. 1301.005. AVAILABILITY OF PREFERRED PROVIDERS. (a) An insurer offering...

Section 1301.0051. Exclusive Provider Benefit Plans: Quality Improvement and Utilization Management - Sec. 1301.0051. EXCLUSIVE PROVIDER BENEFIT PLANS: QUALITY IMPROVEMENT AND UTILIZATION...

Section 1301.0052. Exclusive Provider Benefit Plans: Referrals for Medically Necessary Services - Sec. 1301.0052. EXCLUSIVE PROVIDER BENEFIT PLANS: REFERRALS FOR MEDICALLY NECESSARY...

Section 1301.0053. Exclusive Provider Benefit Plans: Emergency Care - Sec. 1301.0053. EXCLUSIVE PROVIDER BENEFIT PLANS: EMERGENCY CARE. (a) If...

Section 1301.0055. Network Adequacy Standards - Sec. 1301.0055. NETWORK ADEQUACY STANDARDS. The commissioner shall by rule...

Section 1301.0056. Examinations and Fees - Sec. 1301.0056. EXAMINATIONS AND FEES. (a) The commissioner shall examine...

Section 1301.0057. Access to Out-of-Network Providers - Sec. 1301.0057. ACCESS TO OUT-OF-NETWORK PROVIDERS. An insurer may not...

Section 1301.0058. Protected Communications by Preferred Providers - Sec. 1301.0058. PROTECTED COMMUNICATIONS BY PREFERRED PROVIDERS. (a) An insurer...

Section 1301.006. Availability of and Accessibility to Health Care Services - Sec. 1301.006. AVAILABILITY OF AND ACCESSIBILITY TO HEALTH CARE SERVICES....

Section 1301.0061. Terms of Enrollee Eligibility - Sec. 1301.0061. TERMS OF ENROLLEE ELIGIBILITY. (a) A contract between...

Section 1301.007. Rules - Sec. 1301.007. RULES. The commissioner shall adopt rules as necessary...

Section 1301.008. Conflict With Other Law - Sec. 1301.008. CONFLICT WITH OTHER LAW. To the extent of...

Section 1301.009. Annual Report - Sec. 1301.009. ANNUAL REPORT. (a) Not later than March 1...

Section 1301.010. Balance Billing Prohibition Notice - Sec. 1301.010. BALANCE BILLING PROHIBITION NOTICE. (a) An insurer shall...

Subchapter B. Relations With Physicians or Health Care Providers

Section 1301.051. Designation as Preferred Provider - Sec. 1301.051. DESIGNATION AS PREFERRED PROVIDER. (a) An insurer shall...

Section 1301.0515. Acupuncturist Services - Sec. 1301.0515. ACUPUNCTURIST SERVICES. (a) An insurer offering a preferred...

Section 1301.0516. Chiropractic Services - Sec. 1301.0516. CHIROPRACTIC SERVICES. (a) An insurer offering a preferred...

Section 1301.052. Designation of Advanced Practice Nurse or Physician Assistant as Preferred Provider - Sec. 1301.052. DESIGNATION OF ADVANCED PRACTICE NURSE OR PHYSICIAN ASSISTANT...

Section 1301.0521. Designation of Certain Podiatrists as Preferred Providers - Sec. 1301.0521. DESIGNATION OF CERTAIN PODIATRISTS AS PREFERRED PROVIDERS. (a)...

Section 1301.0522. Designation of Certain Optometrists, Therapeutic Optometrists, and Ophthalmologists as Preferred Providers - Sec. 1301.0522. DESIGNATION OF CERTAIN OPTOMETRISTS, THERAPEUTIC OPTOMETRISTS, AND OPHTHALMOLOGISTS...

Section 1301.053. Appeal Relating to Designation as Preferred Provider - Sec. 1301.053. APPEAL RELATING TO DESIGNATION AS PREFERRED PROVIDER. (a)...

Section 1301.054. Notice to Practitioners of Preferred Provider Benefit Plan - Sec. 1301.054. NOTICE TO PRACTITIONERS OF PREFERRED PROVIDER BENEFIT PLAN....

Section 1301.055. Complaint Resolution - Sec. 1301.055. COMPLAINT RESOLUTION. (a) Each contract under a preferred...

Section 1301.056. Restrictions on Payment and Reimbursement - Sec. 1301.056. RESTRICTIONS ON PAYMENT AND REIMBURSEMENT. (a) An insurer...

Section 1301.057. Termination of Participation; Expedited Review Process - Sec. 1301.057. TERMINATION OF PARTICIPATION; EXPEDITED REVIEW PROCESS. (a) Before...

Section 1301.058. Economic Profiling - Sec. 1301.058. ECONOMIC PROFILING. An insurer that conducts, uses, or...

Section 1301.059. Quality Assessment - Sec. 1301.059. QUALITY ASSESSMENT. (a) In this section, "quality assessment"...

Section 1301.060. Compensation on Discounted Fee Basis - Sec. 1301.060. COMPENSATION ON DISCOUNTED FEE BASIS. A preferred provider...

Section 1301.061. Preferred Provider Networks - Sec. 1301.061. PREFERRED PROVIDER NETWORKS. (a) An insurer may enter...

Section 1301.062. Preferred Provider Contracts Between Insurers and Podiatrists - Sec. 1301.062. PREFERRED PROVIDER CONTRACTS BETWEEN INSURERS AND PODIATRISTS. A...

Section 1301.0625. Health Care Collaboratives - Sec. 1301.0625. HEALTH CARE COLLABORATIVES. (a) Subject to the requirements...

Section 1301.063. Contract Provisions Relating to Use of Hospitalist - Sec. 1301.063. CONTRACT PROVISIONS RELATING TO USE OF HOSPITALIST. (a)...

Section 1301.064. Contract Provisions Relating to Payment of Claims - Sec. 1301.064. CONTRACT PROVISIONS RELATING TO PAYMENT OF CLAIMS. Subject...

Section 1301.0641. Contract Provisions Prohibiting Rejection of Batched Claims - Sec. 1301.0641. CONTRACT PROVISIONS PROHIBITING REJECTION OF BATCHED CLAIMS. (a)...

Section 1301.065. Shifting of Insurer's Tort Liability Prohibited - Sec. 1301.065. SHIFTING OF INSURER'S TORT LIABILITY PROHIBITED. A preferred...

Section 1301.066. Retaliation Against Preferred Provider Prohibited - Sec. 1301.066. RETALIATION AGAINST PREFERRED PROVIDER PROHIBITED. An insurer may...

Section 1301.067. Interference With Relationship Between Patient and Physician or Health Care Provider Prohibited - Sec. 1301.067. INTERFERENCE WITH RELATIONSHIP BETWEEN PATIENT AND PHYSICIAN OR...

Section 1301.068. Inducement to Limit Medically Necessary Services Prohibited - Sec. 1301.068. INDUCEMENT TO LIMIT MEDICALLY NECESSARY SERVICES PROHIBITED. (a)...

Section 1301.069. Services Provided by Certain Physicians and Health Care Providers - Sec. 1301.069. SERVICES PROVIDED BY CERTAIN PHYSICIANS AND HEALTH CARE...

Subchapter C. Prompt Payment of Claims

Section 1301.101. Definition - Sec. 1301.101. DEFINITION. In this subchapter, "clean claim" means a...

Section 1301.102. Submission of Claim - Sec. 1301.102. SUBMISSION OF CLAIM. (a) A physician or health...

Section 1301.1021. Receipt of Claim - Sec. 1301.1021. RECEIPT OF CLAIM. (a) If a claim for...

Section 1301.103. Deadline for Action on Clean Claims - Sec. 1301.103. DEADLINE FOR ACTION ON CLEAN CLAIMS. Except as...

Section 1301.104. Deadline for Action on Pharmacy Claims; Payment - Sec. 1301.104. DEADLINE FOR ACTION ON PHARMACY CLAIMS; PAYMENT. (a)...

Section 1301.105. Audited Claims - Sec. 1301.105. AUDITED CLAIMS. (a) Except as provided by Section...

Section 1301.1051. Completion of Audit - Sec. 1301.1051. COMPLETION OF AUDIT. The insurer must complete an...

Section 1301.1052. Preferred Provider Appeal After Audit - Sec. 1301.1052. PREFERRED PROVIDER APPEAL AFTER AUDIT. If a preferred...

Section 1301.1053. Deadlines Not Extended - Sec. 1301.1053. DEADLINES NOT EXTENDED. The investigation and determination of...

Section 1301.1054. Requests for Additional Information - Sec. 1301.1054. REQUESTS FOR ADDITIONAL INFORMATION. (a) If an insurer...

Section 1301.106. Claims Processing Procedures and Claims Payment Processes - Sec. 1301.106. CLAIMS PROCESSING PROCEDURES AND CLAIMS PAYMENT PROCESSES. (a)...

Section 1301.107. Contractual Waiver and Other Actions Prohibited - Sec. 1301.107. CONTRACTUAL WAIVER AND OTHER ACTIONS PROHIBITED. Except as...

Section 1301.108. Attorney's Fees - Sec. 1301.108. ATTORNEY'S FEES. A preferred provider may recover reasonable...

Section 1301.109. Applicability to Entities Contracting With Insurer - Sec. 1301.109. APPLICABILITY TO ENTITIES CONTRACTING WITH INSURER. This subchapter...

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...

Section 1301.132. Overpayment - Sec. 1301.132. OVERPAYMENT. (a) An insurer may recover an overpayment...

Section 1301.133. Verification - Sec. 1301.133. VERIFICATION. (a) In this section, "verification" includes preauthorization...

Section 1301.134. Coordination of Payment - Sec. 1301.134. COORDINATION OF PAYMENT. (a) An insurer may require...

Section 1301.135. Preauthorization of Medical and Health Care Services - Sec. 1301.135. PREAUTHORIZATION OF MEDICAL AND HEALTH CARE SERVICES. (a)...

Section 1301.1351. Posting of Preauthorization Requirements - Sec. 1301.1351. POSTING OF PREAUTHORIZATION REQUIREMENTS. (a) An insurer that...

Section 1301.1353. Remedy for Noncompliance - Sec. 1301.1353. REMEDY FOR NONCOMPLIANCE. (a) In addition to any...

Section 1301.136. Availability of Coding Guidelines - Sec. 1301.136. AVAILABILITY OF CODING GUIDELINES. (a) A contract between...

Section 1301.137. Violation of Claims Payment Requirements; Penalty - Sec. 1301.137. VIOLATION OF CLAIMS PAYMENT REQUIREMENTS; PENALTY. (a) Except...

Section 1301.138. Applicability to Entities Contracting With Insurer - Sec. 1301.138. APPLICABILITY TO ENTITIES CONTRACTING WITH INSURER. This subchapter...

Section 1301.139. Legislative Declaration - Sec. 1301.139. LEGISLATIVE DECLARATION. It is the intent of the...

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...

Section 1301.152. Continuing Care in General - Sec. 1301.152. CONTINUING CARE IN GENERAL. (a) An insurer shall...

Section 1301.153. Continuity of Care - Sec. 1301.153. CONTINUITY OF CARE. (a) In this section: (1)...

Section 1301.154. Obligation for Continuity of Care of Insurer - Sec. 1301.154. OBLIGATION FOR CONTINUITY OF CARE OF INSURER. (a)...

Section 1301.155. Emergency Care - Sec. 1301.155. EMERGENCY CARE. (a) In this section, "emergency care"...

Section 1301.156. Payment of Claims to Insured - Sec. 1301.156. PAYMENT OF CLAIMS TO INSURED. An insurer shall...

Section 1301.157. Plain Language Requirements - Sec. 1301.157. PLAIN LANGUAGE REQUIREMENTS. Each health insurance policy, health...

Section 1301.158. Information Concerning Preferred Provider Benefit Plans - Sec. 1301.158. INFORMATION CONCERNING PREFERRED PROVIDER BENEFIT PLANS. (a) In...

Section 1301.1581. Information Concerning Exclusive Provider Benefit Plans - Sec. 1301.1581. INFORMATION CONCERNING EXCLUSIVE PROVIDER BENEFIT PLANS. (a) In...

Section 1301.159. Annual List of Preferred Providers - Sec. 1301.159. ANNUAL LIST OF PREFERRED PROVIDERS. A current list...

Section 1301.1591. Preferred Provider Information on Internet - Sec. 1301.1591. PREFERRED PROVIDER INFORMATION ON INTERNET. (a) An insurer...

Section 1301.160. Notification of Termination of Participation of Preferred Provider - Sec. 1301.160. NOTIFICATION OF TERMINATION OF PARTICIPATION OF PREFERRED PROVIDER....

Section 1301.161. Retaliation Against Insured Prohibited - Sec. 1301.161. RETALIATION AGAINST INSURED PROHIBITED. An insurer may not...

Section 1301.162. Identification Card - Sec. 1301.162. IDENTIFICATION CARD. An identification card or other similar...

Section 1301.163. Applicability of Subchapter to Entities Contracting With Insurer - Sec. 1301.163. APPLICABILITY OF SUBCHAPTER TO ENTITIES CONTRACTING WITH INSURER....

Section 1301.164. Out-of-Network Facility-Based Providers - Sec. 1301.164. OUT-OF-NETWORK FACILITY-BASED PROVIDERS. (a) In this section, "facility-based...

Section 1301.165. Out-of-Network Diagnostic Imaging Provider or Laboratory Service Provider - Sec. 1301.165. OUT-OF-NETWORK DIAGNOSTIC IMAGING PROVIDER OR LABORATORY SERVICE PROVIDER....

Subchapter E. Certain Health Care Providers

Section 1301.201. Contracts With and Reimbursement for Nurse First Assistants - Sec. 1301.201. CONTRACTS WITH AND REIMBURSEMENT FOR NURSE FIRST ASSISTANTS....

Section 1301.202. Contracts With Hospitals - Sec. 1301.202. CONTRACTS WITH HOSPITALS. (a) An insurer that contracts...

Chapter 1305 - Workers' Compensation Health Care Networks

Subchapter A. General Provisions

Section 1305.001. Short Title - Sec. 1305.001. SHORT TITLE. This chapter may be cited as...

Section 1305.002. Purpose - Sec. 1305.002. PURPOSE. The purpose of this chapter is to:...

Section 1305.003. Limitations on Applicability - Sec. 1305.003. LIMITATIONS ON APPLICABILITY. (a) This chapter does not...

Section 1305.004. Definitions - Sec. 1305.004. DEFINITIONS. (a) In this chapter, unless the context...

Section 1305.005. Participation in Network; Notice of Network Requirements - Sec. 1305.005. PARTICIPATION IN NETWORK; NOTICE OF NETWORK REQUIREMENTS. (a)...

Section 1305.006. Insurance Carrier Liability for Out-of-Network Health Care - Sec. 1305.006. INSURANCE CARRIER LIABILITY FOR OUT-OF-NETWORK HEALTH CARE. An...

Section 1305.007. Rules - Sec. 1305.007. RULES. The commissioner may adopt rules as necessary...

Section 1305.008. Administrator Certificate of Authority Required - Sec. 1305.008. ADMINISTRATOR CERTIFICATE OF AUTHORITY REQUIRED. A person that...

Subchapter B. Certification

Section 1305.051. Certification Required - Sec. 1305.051. CERTIFICATION REQUIRED. (a) A person may not operate...

Section 1305.052. Certificate Application - Sec. 1305.052. CERTIFICATE APPLICATION. (a) A person who seeks to...

Section 1305.053. Contents of Application - Sec. 1305.053. CONTENTS OF APPLICATION. Each certificate application must include:...

Section 1305.054. Action on Application; Renewal of Certification - Sec. 1305.054. ACTION ON APPLICATION; RENEWAL OF CERTIFICATION. (a) The...

Section 1305.055. Use of Certain Insurance Terms by Network Prohibited - Sec. 1305.055. USE OF CERTAIN INSURANCE TERMS BY NETWORK PROHIBITED....

Section 1305.056. Restraint of Trade; Application of Certain Laws - Sec. 1305.056. RESTRAINT OF TRADE; APPLICATION OF CERTAIN LAWS. (a)...

Subchapter C. General Powers and Duties of Workers' Compensation Health Care Networks

Section 1305.101. Providing or Arranging for Health Care - Sec. 1305.101. PROVIDING OR ARRANGING FOR HEALTH CARE. (a) Except...

Section 1305.102. Management Contracts - Sec. 1305.102. MANAGEMENT CONTRACTS. (a) A network may not enter...

Section 1305.103. Treating Doctor; Referrals - Sec. 1305.103. TREATING DOCTOR; REFERRALS. (a) A network shall determine...

Section 1305.104. Selection of Treating Doctor - Sec. 1305.104. SELECTION OF TREATING DOCTOR. (a) An injured employee...

Section 1305.105. Treatment by a Primary Care Physician or Provider Under Chapter 843; Recommendations Regarding Use of Preferred Provider Plan - Sec. 1305.105. TREATMENT BY A PRIMARY CARE PHYSICIAN OR PROVIDER...

Section 1305.106. Payment of Health Care Provider - Sec. 1305.106. PAYMENT OF HEALTH CARE PROVIDER. Notwithstanding any other...

Section 1305.107. Telephone Access - Sec. 1305.107. TELEPHONE ACCESS. (a) Each network shall have appropriate...

Subchapter D. Contracting Provisions

Section 1305.151. Transfer of Risk - Sec. 1305.151. TRANSFER OF RISK. A contract under this subchapter...

Section 1305.152. Network Contracts With Providers - Sec. 1305.152. NETWORK CONTRACTS WITH PROVIDERS. (a) A network shall...

Section 1305.153. Provider Reimbursement - Sec. 1305.153. PROVIDER REIMBURSEMENT. (a) The amount of reimbursement for...

Section 1305.154. Network-Carrier Contracts - Sec. 1305.154. NETWORK-CARRIER CONTRACTS. (a) Except for emergencies and out-of-network...

Section 1305.1545. Restrictions on Payment and Reimbursement - Sec. 1305.1545. RESTRICTIONS ON PAYMENT AND REIMBURSEMENT. (a) An insurance...

Section 1305.155. Compliance Requirements - Sec. 1305.155. COMPLIANCE REQUIREMENTS. (a) An insurance carrier that becomes...

Subchapter E. Financial Requirements

Section 1305.201. Network Financial Requirements - Sec. 1305.201. NETWORK FINANCIAL REQUIREMENTS. (a) Each network shall prepare...

Subchapter F. Examinations

Section 1305.251. Examination of Network - Sec. 1305.251. EXAMINATION OF NETWORK. (a) As often as the...

Section 1305.252. Examination of Provider or Third Party - Sec. 1305.252. EXAMINATION OF PROVIDER OR THIRD PARTY. If requested...

Subchapter G. Provision of Services by Network; Quality Improvement Program

Section 1305.301. Network Organization; Service Areas - Sec. 1305.301. NETWORK ORGANIZATION; SERVICE AREAS. (a) The chief executive...

Section 1305.302. Accessibility and Availability Requirements - Sec. 1305.302. ACCESSIBILITY AND AVAILABILITY REQUIREMENTS. (a) All services specified...

Section 1305.303. Quality of Care Requirements - Sec. 1305.303. QUALITY OF CARE REQUIREMENTS. (a) A network shall...

Section 1305.304. Guidelines and Protocols - Sec. 1305.304. GUIDELINES AND PROTOCOLS. Each network shall adopt treatment...

Subchapter H. Utilization Review

Section 1305.351. Utilization Review in Network - Sec. 1305.351. UTILIZATION REVIEW IN NETWORK. (a) The requirements of...

Section 1305.353. Notice of Certain Utilization Review Determinations; Preauthorization Requirements - Sec. 1305.353. NOTICE OF CERTAIN UTILIZATION REVIEW DETERMINATIONS; PREAUTHORIZATION REQUIREMENTS....

Section 1305.354. Reconsideration of Adverse Determination - Sec. 1305.354. RECONSIDERATION OF ADVERSE DETERMINATION. (a) A utilization review...

Section 1305.355. Independent Review of Adverse Determination - Sec. 1305.355. INDEPENDENT REVIEW OF ADVERSE DETERMINATION. (a) The utilization...

Section 1305.356. Contested Case Hearing on and Judicial Review of Independent Review - Sec. 1305.356. CONTESTED CASE HEARING ON AND JUDICIAL REVIEW OF...

Subchapter I. Complaint Resolution

Section 1305.401. Complaint System Required - Sec. 1305.401. COMPLAINT SYSTEM REQUIRED. (a) Each network shall implement...

Section 1305.402. Complaint Initiation and Initial Response; Deadlines for Response and Resolution - Sec. 1305.402. COMPLAINT INITIATION AND INITIAL RESPONSE; DEADLINES FOR RESPONSE...

Section 1305.403. Record of Complaints - Sec. 1305.403. RECORD OF COMPLAINTS. (a) Each network shall maintain...

Section 1305.404. Retaliatory Action Prohibited - Sec. 1305.404. RETALIATORY ACTION PROHIBITED. A network may not engage...

Section 1305.405. Posting of Information on Complaint Process Required - Sec. 1305.405. POSTING OF INFORMATION ON COMPLAINT PROCESS REQUIRED. (a)...

Subchapter J. Employee Information and Responsibilities

Section 1305.451. Employee Information; Responsibilities of Employee - Sec. 1305.451. EMPLOYEE INFORMATION; RESPONSIBILITIES OF EMPLOYEE. (a) An insurance...

Subchapter K. Evaluation of Networks; Consumer Report Card

Section 1305.502. Consumer Report Cards - Sec. 1305.502. CONSUMER REPORT CARDS. (a) Not later than December...

Section 1305.503. Confidentiality Requirements - Sec. 1305.503. CONFIDENTIALITY REQUIREMENTS. (a) As necessary to implement this...

Subchapter L. Disciplinary Actions

Section 1305.551. Determination of Violation; Notice - Sec. 1305.551. DETERMINATION OF VIOLATION; NOTICE. (a) If the commissioner...

Section 1305.552. Disciplinary Actions - Sec. 1305.552. DISCIPLINARY ACTIONS. If under Section 1305.551 the commissioner...

<< Previous

Next >>

Texas Statutes Title 8 - Health Insurance and Other Health Coverages Subtitle D - Provider Plans

Texas Statutes
Title 8 - Health Insurance and Other Health Coverages
Subtitle D - Provider Plans