| (a) An insurer marketing a preferred provider benefit
plan must contract with physicians and health care providers to ensure
that all medical and health care services and items contained in the
package of benefits for which coverage is provided, including treatment
of illnesses and injuries, will be provided under the plan in a manner
that ensures both availability and accessibility of adequate personnel,
specialty care, and facilities. Each contract must meet the following
requirements:
(1) A contract between a preferred provider and an
insurer may not restrict a physician or health care provider from
contracting with other insurers, preferred provider plans, preferred
provider networks or organizations, exclusive provider benefit plans,
exclusive provider networks or organizations, health care collaboratives,
or HMOs.
(2) Any term or condition limiting participation on
the basis of quality that is contained in a contract between a preferred
provider and an insurer is required to be consistent with established
standards of care for the profession.
(3) In the case of physicians or practitioners with
hospital or institutional provider privileges who provide a significant
portion of care in a hospital or institutional provider setting, a
contract between a preferred provider and an insurer may contain terms
and conditions that include the possession of practice privileges
at preferred hospitals or institutions, except that if no preferred
hospital or institution offers privileges to members of a class of
physicians or practitioners, the contract may not provide that the
lack of hospital or institutional provider privileges may be a basis
for denial of participation as a preferred provider to such physicians
or practitioners of that class.
(4) A contract between an insurer and a hospital or
institutional provider must not, as a condition of staff membership
or privileges, require a physician or practitioner to enter into a
preferred provider contract. This prohibition does not apply to requirements
concerning practice conditions other than conditions of membership
or privileges.
(5) A contract between a preferred provider and an
insurer may provide that the preferred provider will not bill the
insured for unnecessary care, if a physician or practitioner panel
has determined the care was unnecessary, but the contract may not
require the preferred provider to pay hospital, institutional, laboratory,
X-ray, or like charges resulting from the provision of services lawfully
ordered by a physician or health care provider, even though such service
may be determined to be unnecessary.
(6) A contract between a preferred provider and an
insurer may not:
(A) contain restrictions on the classes of physicians
and practitioners who may refer an insured to another physician or
practitioner; or
(B) require a referring physician or practitioner to
bear the expenses of a referral for specialty care in or out of the
preferred provider panel. Savings from cost-effective utilization
of health services by contracting physicians or health care providers
may be shared with physicians or health care providers in the aggregate.
(7) A contract between a preferred provider and an
insurer may not contain any financial incentives to a physician or
a health care provider which act directly or indirectly as an inducement
to limit medically necessary services. This subsection does not prohibit
the savings from cost-effective utilization of health services by
contracting physicians or health care providers from being shared
with physicians or health care providers in the aggregate.
(8) An insurer's contract with a physician, physician
group, or practitioner must have a mechanism for the resolution of
complaints initiated by an insured, a physician, physician group,
or practitioner. The mechanism must provide for reasonable due process,
including, in an advisory role only, a review panel selected as specified
in §3.3706(b)(2) of this title (relating to Designation as a
Preferred Provider, Decision to Withhold Designation, Termination
of a Preferred Provider, Review of Process).
(9) A contract between a preferred provider and an
insurer may not require any health care provider, physician, or physician
group to execute hold harmless clauses that shift an insurer's tort
liability resulting from acts or omissions of the insurer to the preferred
provider.
(10) A contract between a preferred provider and an
insurer must require a preferred provider who is compensated by the
insurer on a discounted fee basis to agree to bill the insured only
on the discounted fee and not the full charge.
(11) A contract between a preferred provider and an
insurer must require the insurer to comply with all applicable statutes
and rules pertaining to prompt payment of clean claims with respect
to payment to the provider for covered services rendered to insureds.
(12) A contract between a preferred provider and an
insurer must require the provider to comply with the Insurance Code §§1301.152
- 1301.154, which relates to Continuity of Care.
(13) A contract between a preferred provider and an
insurer may not prohibit, penalize, permit retaliation against, or
terminate the provider for communicating with any individual listed
in Insurance Code §1301.067, concerning Interference with Relationship
Between Patient and Physician or Health Care Provider Prohibited,
about any of the matters set forth in the contract.
(14) A contract between a preferred provider and an
insurer conducting, using, or relying upon economic profiling to terminate
physicians or health care providers from a plan must require the insurer
to inform the provider of the insurer's obligation to comply with
Insurance Code §1301.058, concerning Economic Profiling.
(15) A contract between a preferred provider and an
insurer that engages in quality assessment is required to disclose
in the contract all requirements of Insurance Code §1301.059(b),
concerning Quality Assessment.
(16) A contract between a preferred provider and an
insurer may not require a physician to issue an immunization or vaccination
protocol for an immunization or vaccination to be administered to
an insured by a pharmacist.
(17) A contract between a preferred provider and an
insurer may not prohibit a pharmacist from administering immunizations
or vaccinations if they are administered in accordance with the Texas
Pharmacy Act, Chapters 551 - 566 and Chapters 568 - 569 of the Occupations
Code, and implementing rules.
(18) A contract between a preferred provider and an
insurer must require a provider that voluntarily terminates the contract
to provide reasonable notice to the insured, and must require the
insurer to provide assistance to the provider as set forth in Insurance
Code §1301.160(b), concerning Notification of Termination of
Participation of Preferred Provider.
(19) A contract between a preferred provider and an
insurer must require written notice to the provider on termination
of the contract by the insurer, and in the case of termination of
a contract between an insurer and a physician or practitioner, the
notice must include the provider's right to request a review, as specified
in §3.3706(d) of this title.
(20) A contract between a preferred provider and an
insurer must include provisions that will entitle the preferred provider
upon request to all information necessary to determine that the preferred
provider is being compensated in accordance with the contract. A preferred
provider may make the request for information by any reasonable and
verifiable means. The information 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 according to the terms of the contract for covered services that
are rendered to insureds. The insurer may provide the required information
by any reasonable method through which the preferred provider can
access the information, including email, computer disks, paper, or
access to an electronic database. Amendments, revisions, or substitutions
of any information provided in accordance with this paragraph are
required to be made under subparagraph (D) of this paragraph and,
when applicable subparagraph (J) of this paragraph. The insurer is
required to provide the fee schedules and other required information
by the 30th day after the date the insurer receives the preferred
provider's request.
(A) This information is required to include a preferred
provider specific summary and explanation of all payment and reimbursement
methods that will be used to pay claims submitted by the preferred
provider. At a minimum, the information is required to include:
(i) a fee schedule, including, if applicable, CPT,
HCPCS, ICD-9-CM codes or successor codes, and modifiers:
(I) by which all claims for covered services submitted
by or on behalf of the preferred provider will be calculated and paid;
or
Cont'd... |
