| by this
paragraph that pertains to the service for which the fee schedule
is being requested if that information has not previously been provided
to the preferred provider;
(ii) all applicable coding methodologies;
(iii) all applicable bundling processes, which are
required to be consistent with nationally recognized and generally
accepted bundling edits and logic;
(iv) all applicable downcoding policies;
(v) a description of any other applicable policy or
procedure the insurer may use that affects the payment of specific
claims submitted by or on behalf of the preferred provider, including
recoupment;
(vi) any addenda, schedules, exhibits, or policies
used by the insurer in carrying out the payment of claims submitted
by or on behalf of the preferred provider that are necessary to provide
a reasonable understanding of the information provided pursuant to
this paragraph; and
(vii) the publisher, product name, and version of any
software the insurer uses to determine bundling and unbundling of
claims.
(B) In the case of a reference to source information
as the basis for fee computation that is outside the control of the
insurer, such as state Medicaid or federal Medicare fee schedules,
the information provided by the insurer is required to clearly identify
the source and explain the procedure by which the preferred provider
may readily access the source electronically, telephonically, or as
otherwise agreed to by the parties.
(C) Nothing in this paragraph may be construed to require
an insurer to provide specific information that would violate any
applicable copyright law or licensing agreement. However, the insurer
is required to supply, in lieu of any information withheld on the
basis of copyright law or licensing agreement, a summary of the information
that will allow a reasonable person with sufficient training, experience,
and competence in claims processing to determine the payment to be
made according to the terms of the contract for covered services that
are rendered to insureds as required by subparagraph (A) of this paragraph.
(D) No amendment, revision, or substitution of claims
payment procedures or any of the information required to be provided
by this paragraph will be effective as to the preferred provider,
unless the insurer provides at least 90 calendar days written notice
to the preferred provider identifying with specificity the amendment,
revision or substitution. An insurer may not make retroactive changes
to claims payment procedures or any of the information required to
be provided by this paragraph. Where a contract specifies mutual agreement
of the parties as the sole mechanism for requiring amendment, revision
or substitution of the information required by this paragraph, the
written notice specified in this section does not supersede the requirement
for mutual agreement.
(E) Failure to comply with this paragraph constitutes
a violation as set forth in subsection (b) of this section.
(F) This paragraph applies to all contracts entered
into or renewed on or after the effective date of this paragraph.
Upon receipt of a request, the insurer is required to provide the
information required by subparagraphs (A) - (D) of this paragraph
to the preferred provider by the 30th day after the date the insurer
receives the preferred provider's request.
(G) A preferred provider that receives information
under this paragraph:
(i) may not use or disclose the information for any
purpose other than:
(I) the preferred provider's practice management;
(II) billing activities;
(III) other business operations; or
(IV) communications with a governmental agency involved
in the regulation of health care or insurance;
(ii) may not use this information to knowingly submit
a claim for payment that does not accurately represent the level,
type or amount of services that were actually provided to an insured
or to misrepresent any aspect of the services; and
(iii) may not rely upon information provided pursuant
to this paragraph about a service as a representation that an insured
is covered for that service under the terms of the insured's policy
or certificate.
(H) A preferred provider that receives information
under this paragraph may terminate the contract on or before the 30th
day after the date the preferred provider receives information requested
under this paragraph without penalty or discrimination in participation
in other health care products or plans. If a preferred provider chooses
to terminate the contract, the insurer is required to assist the preferred
provider in providing the notice required by paragraph (18) of this
subsection.
(I) The provisions of this paragraph may not be waived,
voided, or nullified by contract.
(21) An insurer may require a preferred provider to
retain in the preferred provider's records updated information concerning
a patient's other health benefit plan coverage.
(22) Upon request by a preferred provider, an insurer
is required to include a provision in the preferred provider's contract
providing that the insurer and the insurer's clearinghouse may not
refuse to process or pay an electronically submitted clean claim because
the claim is submitted together with or in a batch submission with
a claim that is deficient. As used in this section, the term batch
submission is a group of electronic claims submitted for processing
at the same time within a HIPAA standard ASC X12N 837 Transaction
Set and identified by a batch control number. This paragraph applies
to a contract entered into or renewed on or after January 1, 2006.
(23) A contract between an insurer and a preferred
provider other than an institutional provider may contain a provision
requiring a referring physician or provider, or a designee, to disclose
to the insured:
(A) that the physician, provider, or facility to whom
the insured is being referred might not be a preferred provider; and
(B) if applicable, that the referring physician or
provider has an ownership interest in the facility to which the insured
is being referred.
(24) A contract provision that requires notice as specified
in paragraph (23)(A) of this subsection is required to allow for exceptions
for emergency care and as necessary to avoid interruption or delay
of medically necessary care and may not limit access to nonpreferred
providers.
(25) A contract between an insurer and a preferred
provider must require the preferred provider to comply with all applicable
requirements of the Insurance Code §1661.005 (relating to refunds
of overpayments from enrollees).
(26) A contract between an insurer and a facility must
require that the facility give notice to the insurer of the termination
of a contract between the facility and a facility-based physician
group that is a preferred provider for the insurer as soon as reasonably
practicable, but not later than the fifth business day following termination
of the contract.
(27) A contract between an insurer and a preferred
provider must require, except for instances of emergency care as defined
under Insurance Code §1301.155(a), that a physician or provider
referring an insured to a facility for surgery:
(A) notify the insured of the possibility that out-of-network
providers may provide treatment and that the insured can contact the
insurer for more information;
(B) notify the insurer that surgery has been recommended;
and
(C) notify the insurer of the facility that has been
recommended for the surgery.
(28) A contract between an insurer and a facility must
require, except for instances of emergency care as defined under Insurance
Code §1301.155(a), that the facility, when scheduling surgery:
(A) notify the insured of the possibility that out-of-network
providers may provide treatment and that the insured can contact the
insurer for more information; and
(B) notify the insurer that surgery has been scheduled.
(b) In addition to all other contract rights, violations
of these rules will be treated for purposes of complaint and action
in accordance with Insurance Code Chapter 542, Subchapter A, and the
provisions of that subchapter will be utilized insofar as practicable,
as it relates to the power of the department, hearings, orders, enforcement,
and penalties.
(c) An insurer may enter into an agreement with a preferred
provider organization, an exclusive provider network, or a health
care collaborative for the purpose of offering a network of preferred
providers, provided that it remains the insurer's responsibility to:
(1) meet the requirements of Insurance Code Chapter
1301 and this subchapter;
(2) ensure that the requirements of Insurance Code
Chapter 1301 and this subchapter are met; and
(3) provide all documentation to demonstrate compliance
with all applicable rules on request by the department.
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| Source Note: The provisions of this §3.3703 adopted to be effective July 1, 1986, 11 TexReg 2810; amended to be effective December 6, 1995, 20 TexReg 9697; amended to be effective July 15, 1999, 24 TexReg 5204; amended to be effective October 8, 2002, 27 TexReg 9328; amended to be effective October 5, 2003, 28 TexReg 8623; amended to be effective January 19, 2006, 31 TexReg 289; amended to be effective December 6, 2011, 36 TexReg 3411; amended to be effective February 21, 2013, 38 TexReg 827 |
