| (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.
|
| 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 |
