Sec. 1274.002. TRANSMISSION OF ENROLLEE ELIGIBILITY AND PAYMENT STATUS. (a) Each health benefit plan issuer shall, upon the participating provider's submission of the patient's name, relationship to the primary enrollee, and birth date, make available telephonically, electronically, or by an Internet website portal to each participating provider information maintained in the ordinary course of business and sufficient for the provider to determine at the time of the enrollee's visit information concerning:
(1) the enrollee, including:
(A) the enrollee's identification number assigned by the health benefit plan issuer;
(B) the name of the enrollee and all covered dependents, if appropriate;
(C) the birth date of the enrollee and the birth dates of all covered dependents, if appropriate;
(D) the gender of the enrollee and the gender of each covered dependent, if appropriate; and
(E) the current enrollment and eligibility status of the enrollee under the health benefit plan;
(2) the enrollee's benefits, including:
(A) whether a specific type or category of service is a covered benefit; and
(B) excluded benefits or limitations, both group and individual; and
(3) the enrollee's financial information, including:
(A) copayment requirements, if any; and
(B) the unmet amount of the enrollee's deductible or enrollee financial responsibility.
(b) Information required to be made available under this section may be made available only to a participating provider who is authorized under state and federal law to receive personally identifiable information on an enrollee or dependent.
Added by Acts 2005, 79th Leg., Ch. 880 (S.B. 1149), Sec. 1, eff. September 1, 2005.
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