| (a) Physician and provider contracts, subcontracts,
and arrangements must include provisions regarding a hold-harmless
clause as described in Insurance Code §843.361 of this title
(concerning Enrollees Held Harmless).
(1) A hold-harmless clause is a provision in a physician
or health care provider agreement that obligates the physician or
provider to look only to the HMO and not its enrollees for payment
for covered services (except as described in the evidence of coverage
issued to the enrollee).
(2) In compliance with Insurance Code §843.002
(concerning Definitions) relating to an "uncovered expense," if a
physician or health care provider agreement contains a hold-harmless
clause, then the costs of the services will not be considered uncovered
health care expenses in determining amounts of deposits necessary
for insolvency protection under Insurance Code §843.405 (concerning
Deposit with Comptroller).
(3) The following is an example of an approvable hold-harmless
clause: "(Physician or Provider) hereby agrees that in no event, including,
but not limited to nonpayment by the HMO, HMO insolvency, or breach
of this agreement, may (Physician or Provider) bill, charge, collect
a deposit from, seek compensation, remuneration, or reimbursement
from, or have any recourse against subscriber, enrollee, or persons
other than the HMO acting on their behalf for services provided under
this agreement. This provision does not prohibit collection of supplemental
charges or copayments made in compliance with the terms of (applicable
agreement) between HMO and subscriber or enrollee. (Physician or Provider)
further agrees that:
(A) this provision will survive the termination of
this agreement regardless of the cause giving rise to termination
and must be construed to be for the benefit of the HMO subscriber
or enrollee; and
(B) this provision supersedes any oral or written contrary
agreement now existing or hereafter entered into between (Physician
or Provider) and subscriber, enrollee, or persons acting on their
behalf. Any modification, addition, or deletion to the provisions
of this clause will be effective on a date no earlier than 15 days
after the commissioner has received written notice of the proposed
changes."
(b) Physician and provider contracts, subcontracts,
and arrangements must include provisions:
(1) regarding retaliation as described in Insurance
Code §843.281 (concerning Retaliatory Action Prohibited);
(2) regarding continuity of treatment, if applicable,
as described in Insurance Code §843.309 (concerning Contracts
with Physicians or Providers; Notice to Certain Enrollees of Termination
of Physician or Provider Participation Plan) and §843.362 (concerning
Continuity of Care; Obligation of Health Maintenance Organization);
(3) regarding written notification to enrollees receiving
care from a physician or provider of the termination of that physician
or provider in compliance with Insurance Code §843.308 (concerning
Notification of Patients of Deselected Physician or Provider) and §843.309
(concerning Contracts With Physicians or Providers: Notice to Certain
Enrollees of Termination of Physician or Provider Participation in
a Plan);
(4) regarding posting of complaint notices in physician
or provider offices as described in Insurance Code §843.283 (concerning
Posting of Information on Complaint Process Required), provided that
a representative notice that complies with this requirement may be
obtained from the Managed Care Quality Assurance Office, Mail Code
103-6A, Texas Department of Insurance, P.O. Box 149104, Austin, Texas
78714-9104, or the department's website at www.tdi.texas.gov;
(5) regarding indemnification of the HMO as described
in Insurance Code §843.310 (concerning Contracts with Physicians
or Providers; Certain Indemnity Clauses Prohibited);
(6) regarding prompt payment of claims as described
in Insurance Code Chapter 542, Subchapter B, (concerning Prompt Payment
of Claims); §1271.005 (concerning Applicability of Other Law);
and all applicable statutes and rules pertaining to prompt payment
of clean claims, including Insurance Code Chapter 843, Subchapter
J, (concerning Payment of Claims to Physicians and Providers); and
Chapter 21, Subchapter T, of this title (relating to Submission of
Clean Claims) with respect to payment to the physician or provider
for covered services rendered to enrollees;
(7) regarding capitation, if applicable, as described
in Insurance Code §843.315 (concerning Payment of Capitation;
Assignment of Primary Care Physician or Provider) and §843.316
(concerning Alternative Capitation System);
(8) regarding selection of a primary care physician
or provider, if applicable, as described in Insurance Code §843.203
(concerning Selection of Primary Care Physician or Provider);
(9) providing that a podiatrist, practicing within
the scope of the law regulating podiatry, is permitted to furnish
X-rays and non-prefabricated orthotics covered by the evidence of
coverage as described in Insurance Code §843.311 (concerning
Contracts with Podiatrists);
(10) regarding the requirements of §21.3701 of
this title (relating to Electronic Claims Filing Requirements) if
the contract requires electronic submission of any information described
by that section;
(11) requiring the preferred provider to comply with
all applicable requirements of Insurance Code §1661.005 (concerning
Refunds of Overpayments); and
(12) requiring a contracting physician or provider
to retain in the contracting physician's or provider's records updated
information concerning a patient's other health benefit plan coverage.
(c) Physician and provider contracts and arrangements
must include provisions entitling the physician or provider, on request,
to all information necessary to determine that the physician or provider
is being compensated in compliance with the contract. A physician
or provider may make the request for information by any reasonable
and verifiable means. The information provided must include a level
of detail sufficient to enable a reasonable person with sufficient
training, experience, and competence in claims processing to determine
the payment to be made under the terms of the contract for covered
services rendered to enrollees. The HMO may provide the required information
by any reasonable method through which the physician or provider can
access the information, including email, computer disks, or other
electronic storage and transfer technology, paper, or access to an
electronic database. Amendments, revisions, or substitutions of any
information provided under this paragraph must comply with paragraph
(4) of this subsection. The HMO must provide the fee schedules and
other required information by the 30th day after the date the HMO
receives the physician's or provider's request.
(1) The information provided must include a physician-specific
or provider-specific summary and explanation of all payment and reimbursement
methodologies that will be used to pay claims submitted by a physician
or provider, including at a minimum, the:
(A) fee schedule, including, if applicable, CPT, HCPCS,
CDT, ICD-9-CM, ICD-10-CM, and successor codes, and modifiers:
(i) by which the HMO will calculate and pay all claims
for covered services submitted by or on behalf of the contracting
physician or provider; or
(ii) that pertains to the range of health care services
reasonably expected to be delivered under the contract by that contracting
physician or provider on a routine basis, along with a toll-free number
or electronic address through which the contracting physician or provider
may request the fee schedules applicable to any covered services that
the physician or provider intends to provide to an enrollee, and any
other information required by this subsection, that pertains to the
service for which the fee schedule is being requested if the HMO has
not previously provided that information to the physician or provider;
(B) all applicable coding methodologies;
(C) all applicable bundling processes, which must be
consistent with nationally recognized and generally accepted bundling
edits and logic;
(D) all applicable downcoding policies;
(E) a description of any other applicable policy or
procedure the HMO may use that affects the payment of specific claims
submitted by or on behalf of the contracting physician or provider,
including recoupment;
(F) any addenda, schedules, exhibits, or policies used
by the HMO in carrying out the payment of claims submitted by or on
behalf of the contracting physician or provider that are necessary
to provide a reasonable understanding of the information provided
under this subsection; and
Cont'd... |
