| (a) The purpose of this section is to implement Insurance
Code Chapter 1213. This section applies to a contract between an issuer
of a health benefit plan and a health care professional or health
care facility (hereinafter referred to as "physicians or providers").
(b) Consistent with Insurance Code Chapter 1213 and
this section, the issuer of a health benefit plan may, by contract,
require physicians and providers to electronically submit the following:
(1) health care claims or equivalent encounter information;
(2) referral certifications; and/or
(3) any authorization or eligibility transactions.
(c) An issuer of a health benefit plan must give 90
calendar days written notice prior to requiring electronic filing
of any information described in subsection (b) of this section.
(d) A contract between the issuer of a health benefit
plan and a physician or provider that requires electronic submission
of any information described in subsection (b) of this section must
include a provision stating that in the event of a systems failure
or a catastrophic event as defined in §21.2802 of this title
(relating to Definitions) that substantially interferes with the business
operations of the physician or provider, the physician or provider
may submit non-electronic claims in accordance with the requirements
in this subchapter and for the number of calendar days during which
substantial interference with business operations occurs as of the
date of the catastrophic event or systems failure. A physician or
provider must provide written notice of the physician's or provider's
intent to submit non-electronic claims to the issuer of the health
benefit plan within five calendar days of the catastrophic event or
systems failure.
(e) A contract between the issuer of a health benefit
plan and a physician or provider that requires electronic submission
of the information described in subsection (b) of this section must
include a provision allowing for a waiver of the electronic submission
requirements in any of the following circumstances:
(1) No method available for the submission of claims
in electronic form. This exception applies to situations in which
the federal standards for electronic submissions (45 C.F.R., Parts
160 and 162) do not support all of the information necessary to process
the claim.
(2) The operation of small physician and provider practices.
This exception applies to those physicians and providers with fewer
than 10 full-time-equivalent employees, consistent with 42 C.F.R. §424.32(d)(1)(viii).
(3) Demonstrable undue hardship, including fiscal or
operational hardship.
(4) Any other special circumstances that would justify
a waiver.
(f) The physician's or provider's request for a waiver
must be in writing and must include documentation supporting the issuance
of a waiver.
(g) Upon receipt of a request for a waiver from a physician
or provider, the issuer of a health benefit plan must, within 14 calendar
days, issue or deny a waiver.
(h) A waiver or denial of a waiver must be issued in
writing to the requesting physician or provider. A written waiver
must contain any restrictions, conditions, or limitations related
to the waiver. A written denial of a request for a waiver or the issuance
of a qualified or conditional waiver must include the reason for the
denial or any restrictions, conditions, or limitations, and notice
of the physician's or provider's right to appeal the determination
to the department.
(i) A physician or provider that is denied a waiver
of the electronic submission requirements or granted a waiver with
restrictions, conditions, or limitations, may, within 14 calendar
days of receipt, appeal the waiver determination. The request for
appeal and accompanying documentation must be sent to the Director
of MCQA, MC-LH-MCQA, P.O. Box 12030, Austin, Texas 78711-2030 and
to the issuer of the health benefit plan. The information must include:
(1) the physician's or provider's initial request for
a waiver sent to the issuer of the health benefit plan, including
the documentation required by subsection (f) of this section;
(2) the waiver determination received from the issuer
of the health benefit plan;
(3) any additional documentation supporting issuance
of a waiver or removal of restrictions, conditions or limitations
of a granted waiver; and
(4) any additional information necessary for the determination
of the appeal.
(j) Upon receipt of notice of a request for appeal
under this section, an issuer of a health benefit plan must, within
14 calendar days, submit to the department and to the physician or
provider:
(1) documentation supporting the waiver determination
issued to the physician or provider; and
(2) any additional information necessary for the determination
of the appeal.
(k) The department may request additional information
from either party and may request the parties to appear at a hearing.
Either party may choose to attend a hearing conducted at the department
or participate in a hearing via telephone.
(l) Upon receipt of all information required by subsections
(i) and (j) of this section, the Director of Managed Care Quality
Assurance will issue a determination within 14 calendar days of the
later of the receipt of all necessary information or the conclusion
of the hearing.
(m) Either party may request a hearing before the Deputy
Commissioner of Life and Health for reconsideration of the Director
of the Managed Care Quality Assurance Office's determination. Either
party may choose to attend a hearing conducted at the department or
participate in a hearing via telephone. A request for reconsideration
must be received by the Chief Clerk at MC-GC-CCO, P.O. Box 12030,
Austin, Texas 78711-2030 within 14 calendar days of receiving notice
of the appeal determination.
(n) The physician or provider requesting or receiving
a waiver, appealing a waiver determination, or requesting reconsideration
of an appeal determination under this section may elect to file the
required electronic transactions in a non-electronic format until
a final determination on the request is made.
(o) The issuer of a health benefit plan may not refuse
to contract or to renew a contract with a physician or provider based
in whole or in part on the physician or provider requesting or receiving
a waiver, appealing a waiver determination, or requesting reconsideration
of an appeal determination under this section.
(p) This section applies to:
(1) a contract between a physician or provider and
an issuer of a health benefit plan that requires electronic submission
of the information described in subsection (b) of this section and
entered into or renewed on or after September 1, 2004; and
(2) existing contracts to the extent that any contract
provisions related to electronic submission of the information described
in subsection (b) of this section are made applicable to a physician
or provider on or after September 1, 2004.
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