Texas Insurance Code Title 8, Chapter 1301 - Preferred Provider Benefit Plans

SUBCHAPTER A GENERAL PROVISIONS

• Texas Section 1301.001 - Definitions
  In this chapter: (1) "Exclusive provider benefit plan" means a benefit plan in which an insurer excludes benefits to an insured for some or all...
• Texas Section 1301.002 - Nonapplicability To Dental Care Benefits
  This chapter does not apply to a provision for dental care benefits in a health insurance policy. Added by Acts 2003, 78th Leg., ch. 1274,...
• Texas Section 1301.003 - Preferred Provider Benefit Plans And Exclusive Provider Benefit Plans Permitted
  A preferred provider benefit plan or an exclusive provider benefit plan that meets the requirements of this chapter is not: (1) unjust under Chapter 1701;...
• Texas Section 1301.0041 - Applicability
  (a) Except as otherwise specifically provided by this chapter, this chapter applies to each preferred provider benefit plan in which an insurer provides, through the...
• Texas Section 1301.0042 - Applicability Of Insurance Law
  (a) Except as provided by Subsection (b), a provision of this code or another insurance law of this state that applies to a preferred provider...
• Texas Section 1301.0045 - Construction Of Chapter
  (a) Except as provided by Section 1301.0046, this chapter may not be construed to limit the level of reimbursement or the level of coverage, including...
• Texas Section 1301.0046 - Coinsurance Requirements For Services Of Nonpreferred Providers
  The insured's coinsurance applicable to payment to nonpreferred providers may not exceed 50 percent of the total covered amount applicable to the medical or health...
• Texas Section 1301.005 - Availability Of Preferred Providers
  (a) An insurer offering a preferred provider benefit plan shall ensure that both preferred provider benefits and basic level benefits are reasonably available to all...
• Texas Section 1301.0051 - Exclusive Provider Benefit Plans: Quality Improvement And Utilization Management
  (a) An insurer that offers an exclusive provider benefit plan shall establish procedures to ensure that health care services are provided to insureds under reasonable...
• Texas Section 1301.0052 - Exclusive Provider Benefit Plans: Referrals For Medically Necessary Services
  (a) If a covered service is medically necessary and is not available through a preferred provider, the issuer of an exclusive provider benefit plan, on...
• Texas Section 1301.0053 - Exclusive Provider Benefit Plans: Emergency Care
  If a nonpreferred provider provides emergency care as defined by Section 1301.155 to an enrollee in an exclusive provider benefit plan, the issuer of the...
• Texas Section 1301.0055 - Network Adequacy Standards
  The commissioner shall by rule adopt network adequacy standards that: (1) are adapted to local markets in which an insurer offering a preferred provider benefit...
• Texas Section 1301.0056 - Examinations And Fees
  (a) The commissioner may examine an insurer to determine the quality and adequacy of a network used by an exclusive provider benefit plan offered by...
• Texas Section 1301.0057 - Access To Out-of-network Providers
  An insurer may not terminate, or threaten to terminate, an insured's participation in a preferred provider benefit plan solely because the insured uses an out-of-network...
• Texas Section 1301.0058 - Protected Communications By Preferred Providers
  (a) An insurer may not in any manner prohibit, attempt to prohibit, penalize, terminate, or otherwise restrict a preferred provider from communicating with an insured...
• Texas Section 1301.006 - Availability Of And Accessibility To Health Care Services
  (a) An insurer that markets a preferred provider benefit plan shall contract with physicians and health care providers to ensure that all medical and health...
• Texas Section 1301.0061 - Terms Of Enrollee Eligibility
  (a) A contract between an insurer and a group policyholder under a preferred provider benefit plan must provide that: (1) in addition to any other...
• Texas Section 1301.007 - Rules
  The commissioner shall adopt rules as necessary to: (1) implement this chapter; and (2) ensure reasonable accessibility and availability of preferred provider services to residents...
• Texas Section 1301.008 - Conflict With Other Law
  To the extent of any conflict between this chapter and Subchapter C, Chapter 1204, this chapter controls. Added by Acts 2005, 79th Leg., Ch. 728...

SUBCHAPTER B RELATIONS WITH PHYSICIANS OR HEALTH CARE PROVIDERS

• Texas Section 1301.009 - Annual Report
  (a) Not later than March 1 of each year, an insurer shall file with the commissioner a report relating to the preferred provider benefit plan...
• Texas Section 1301.051 - Designation As Preferred Provider
  (a) An insurer shall afford a fair, reasonable, and equivalent opportunity to apply to be and to be designated as a preferred provider to practitioners...
• Texas Section 1301.0515 - Acupuncturist Services
  (a) An insurer offering a preferred provider benefit plan that includes acupuncture in the services covered by the plan may not refuse to provide reimbursement...
• Texas Section 1301.052 - Designation Of Advanced Practice Nurse Or Physician Assistant As Preferred Provider
  An insurer offering a preferred provider benefit plan may not refuse a request made by a physician participating as a preferred provider under the plan...
• Texas Section 1301.0521 - Designation Of Certain Podiatrists As Preferred Providers
  (a) Notwithstanding Section 1301.051, an insurer may not withhold the designation of preferred provider to a podiatrist licensed by the Texas State Board of Podiatric...
• Texas Section 1301.0522 - Designation Of Certain Optometrists, Therapeutic Optometrists, And Ophthalmologists As Preferred Providers
  (a) Notwithstanding Section 1301.051, an insurer may not withhold the designation of preferred provider to an optometrist or therapeutic optometrist licensed by the Texas Optometry...
• Texas Section 1301.053 - Appeal Relating To Designation As Preferred Provider
  (a) An insurer that does not designate a practitioner as a preferred provider shall provide a reasonable mechanism for reviewing that action. The review mechanism...
• Texas Section 1301.054 - Notice To Practitioners Of Preferred Provider Benefit Plan
  (a) When sponsoring a preferred provider benefit plan, an insurer shall immediately notify each practitioner in the plan's service area of the insurer's intent to...
• Texas Section 1301.055 - Complaint Resolution
  (a) Each contract under a preferred provider benefit plan between an insurer and a physician or other practitioner or a physicians' group must have a...
• Texas Section 1301.056 - Restrictions On Payment And Reimbursement
  (a) An insurer or third-party administrator may not reimburse a physician or other practitioner, institutional provider, or organization of physicians and health care providers on...
• Texas Section 1301.057 - Termination Of Participation; Expedited Review Process
  (a) Before terminating a contract with a preferred provider, an insurer shall: (1) provide written reasons for the termination; and (2) if the affected provider...
• Texas Section 1301.058 - Economic Profiling
  An insurer that conducts, uses, or relies on economic profiling to admit or terminate the participation of physicians or health care providers in a preferred...
• Texas Section 1301.059 - Quality Assessment
  (a) In this section, "quality assessment" means a mechanism used by an insurer to evaluate, monitor, or improve the quality and effectiveness of the medical...
• Texas Section 1301.060 - Compensation On Discounted Fee Basis
  A preferred provider contract must include a provision by which the physician or health care provider agrees that if the preferred provider is compensated on...
• Texas Section 1301.061 - Preferred Provider Networks
  (a) An insurer may enter into an agreement with a preferred provider organization for the purposes of offering a network of preferred providers. The agreement...
• Texas Section 1301.062 - Preferred Provider Contracts Between Insurers And Podiatrists
  A preferred provider contract between an insurer and a podiatrist licensed by the Texas State Board of Podiatric Medical Examiners must provide that: (1) the...
• Texas Section 1301.0625 - Health Care Collaboratives
  (a) Subject to the requirements of this chapter, a health care collaborative may be designated as a preferred provider under a preferred provider benefit plan...
• Texas Section 1301.063 - Contract Provisions Relating To Use Of Hospitalist
  (a) In this section, "hospitalist" means a physician who: (1) serves as physician of record at a hospital for a hospitalized patient of another physician;...
• Texas Section 1301.064 - Contract Provisions Relating To Payment Of Claims
  Subject to Subchapter C, a preferred provider contract must provide for payment to a physician or health care provider for health care services and benefits...
• Texas Section 1301.0641 - Contract Provisions Prohibiting Rejection Of Batched Claims
  (a) If requested by a preferred provider, an insurer shall include a provision in the preferred provider's contract providing that the insurer or the insurer's...
• Texas Section 1301.065 - Shifting Of Insurer's Tort Liability Prohibited
  A preferred provider contract may not require any physician, health care provider, or physicians' group to execute a hold harmless clause to shift the insurer's...
• Texas Section 1301.066 - Retaliation Against Preferred Provider Prohibited
  An insurer may not engage in any retaliatory action against a physician or health care provider, including terminating the physician's or provider's participation in the...
• Texas Section 1301.067 - Interference With Relationship Between Patient And Physician Or Health Care Provider Prohibited
  (a) An insurer may not, as a condition of a preferred provider contract with a physician or health care provider or in any other manner,...
• Texas Section 1301.068 - Inducement To Limit Medically Necessary Services Prohibited
  (a) An insurer may not use any financial incentive or make payment to a physician or health care provider that acts directly or indirectly as...

SUBCHAPTER C PROMPT PAYMENT OF CLAIMS

• Texas Section 1301.069 - Services Provided By Certain Physicians And Health Care Providers
  The provisions of this chapter relating to prompt payment by an insurer of a physician or health care provider and to verification of medical care...
• Texas Section 1301.101 - Definition
  In this subchapter, "clean claim" means a claim that complies with Section 1301.131. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April...
• Texas Section 1301.102 - Submission Of Claim
  (a) A physician or health care provider must submit a claim to an insurer not later than the 95th day after the date the physician...
• Texas Section 1301.1021 - Receipt Of Claim
  (a) If a claim for medical care or health care services provided to a patient is mailed, the claim is presumed to have been received...
• Texas Section 1301.103 - Deadline For Action On Clean Claims
  Except as provided by Sections 1301.104 and 1301.1054, not later than the 45th day after the date an insurer receives a clean claim from a...
• Texas Section 1301.104 - Deadline For Action On Pharmacy Claims; Payment
  (a) An insurer, or a pharmacy benefit manager that administers pharmacy claims for the insurer under a preferred provider benefit plan, that affirmatively adjudicates a...
• Texas Section 1301.105 - Audited Claims
  (a) Except as provided by Section 1301.1054, an insurer that intends to audit a claim submitted by a preferred provider shall pay the charges submitted...
• Texas Section 1301.1051 - Completion Of Audit
  The insurer must complete an audit under Section 1301.105 on or before the 180th day after the date the clean claim is received by the...
• Texas Section 1301.1052 - Preferred Provider Appeal After Audit
  If a preferred provider disagrees with a refund request made by an insurer based on an audit under Section 1301.105, the insurer shall provide the...
• Texas Section 1301.1053 - Deadlines Not Extended
  The investigation and determination of payment, including any coordination of other payments, does not extend the period for determining whether a claim is payable under...
• Texas Section 1301.1054 - Requests For Additional Information
  (a) If an insurer needs additional information from a treating preferred provider to determine payment, the insurer, not later than the 30th calendar day after...
• Texas Section 1301.106 - Claims Processing Procedures And Claims Payment Processes
  (a) An insurer shall provide a preferred provider with copies of all applicable utilization review policies and claim processing policies or procedures. (b) An insurer's...
• Texas Section 1301.107 - Contractual Waiver And Other Actions Prohibited
  Except as provided by Section 1301.102(e), the provisions of this subchapter may not be waived, voided, or nullified by contract. Added by Acts 2003, 78th...
• Texas Section 1301.108 - Attorney's Fees
  A preferred provider may recover reasonable attorney's fees and court costs in an action to recover payment under this subchapter. Added by Acts 2003, 78th...

SUBCHAPTER C-1 OTHER PROVISIONS RELATING TO PAYMENT OF CLAIMS

• Texas Section 1301.109 - Applicability To Entities Contracting With Insurer
  This subchapter applies to a person, including a pharmacy benefit manager, with whom an insurer contracts to: (1) process or pay claims; (2) obtain the...
• Texas Section 1301.131 - Elements Of Clean Claim
  (a) A nonelectronic claim by a physician or health care provider, other than an institutional provider, is a "clean claim" if the claim is submitted...
• Texas Section 1301.132 - Overpayment
  (a) An insurer may recover an overpayment to a physician or health care provider if: (1) not later than the 180th day after the date...
• Texas Section 1301.133 - Verification
  (a) In this section, "verification" includes preauthorization only when preauthorization is a condition for the verification. (b) On the request of a preferred provider for...
• Texas Section 1301.134 - Coordination Of Payment
  (a) An insurer may require a physician or health care provider to retain in the physician's or provider's records updated information concerning other health benefit...
• Texas Section 1301.135 - Preauthorization Of Medical And Health Care Services
  (a) An insurer that uses a preauthorization process for medical care and health care services shall provide to each preferred provider, not later than the...
• Texas Section 1301.136 - Availability Of Coding Guidelines
  (a) A contract between an insurer and a preferred provider must provide that: (1) the preferred provider may request a description and copy of the...
• Texas Section 1301.137 - Violation Of Claims Payment Requirements; Penalty
  (a) Except as provided by this section, if a clean claim submitted to an insurer is payable and the insurer does not determine under Subchapter...
• Texas Section 1301.138 - Applicability To Entities Contracting With Insurer
  This subchapter applies to a person described by Section 1301.109. Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(b), eff. September 1,

SUBCHAPTER D RELATIONS BETWEEN INSUREDS AND PREFERRED PROVIDERS

• Texas Section 1301.139 - Legislative Declaration
  It is the intent of the legislature that the requirements contained in this subchapter regarding payment of claims to preferred providers who are pharmacists or...
• Texas Section 1301.151 - Insured's Right To Treatment
  Each insured is entitled to treatment and diagnostic techniques that are prescribed by the physician or health care provider included in the preferred provider benefit...
• Texas Section 1301.152 - Continuing Care In General
  (a) An insurer shall establish reasonable procedures for ensuring a transition of insureds to physicians or health care providers and for continuity of treatment. (b)...
• Texas Section 1301.153 - Continuity Of Care
  (a) In this section: (1) "Life-threatening" means a disease or condition for which the likelihood of death is probable unless the course of the disease...
• Texas Section 1301.154 - Obligation For Continuity Of Care Of Insurer
  (a) Except as provided by Subsection (b), Sections 1301.152 and 1301.153 do not extend an insurer's obligation to reimburse the terminated physician or provider or,...
• Texas Section 1301.155 - Emergency Care
  (a) In this section, "emergency care" means health care services provided in a hospital emergency facility, freestanding emergency medical care facility, or comparable emergency facility...
• Texas Section 1301.156 - Payment Of Claims To Insured
  An insurer shall comply with Subchapter B, Chapter 542, with respect to prompt payment to insureds. Added by Acts 2003, 78th Leg., ch. 1274, Sec....
• Texas Section 1301.157 - Plain Language Requirements
  Each health insurance policy, health benefit plan certificate, endorsement, amendment, application, or rider must: (1) be written in plain language; (2) be in a readable...
• Texas Section 1301.158 - Information Concerning Preferred Provider Benefit Plans
  (a) In this section, "prospective insured" means: (1) for group coverage, an individual or an individual's dependent who is eligible for coverage under a health...
• Texas Section 1301.1581 - Information Concerning Exclusive Provider Benefit Plans
  (a) In this section, "prospective insured" has the meaning assigned by Section 1301.158. (b) In addition to the information required to be provided under Section...
• Texas Section 1301.159 - Annual List Of Preferred Providers
  A current list of preferred providers shall be provided to each insured at least annually. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3,...
• Texas Section 1301.1591 - Preferred Provider Information On Internet
  (a) An insurer subject to this chapter that maintains an Internet site shall list on the Internet site the preferred providers, including, if appropriate, mental...
• Texas Section 1301.160 - Notification Of Termination Of Participation Of Preferred Provider
  (a) If a practitioner's participation in a preferred provider benefit plan is terminated for a reason other than at the practitioner's request, an insurer may...
• Texas Section 1301.161 - Retaliation Against Insured Prohibited
  An insurer may not engage in any retaliatory action against an insured, including canceling or refusing to renew a health insurance policy, because the insured...
• Texas Section 1301.162 - Identification Card
  An identification card or other similar document issued by an insurer regulated by this code and subject to this chapter to an individual insured must...

SUBCHAPTER E CERTAIN HEALTH CARE PROVIDERS

• Texas Section 1301.163 - Applicability Of Subchapter To Entities Contracting With Insurer
  This subchapter applies to a person to whom an insurer contracts to: (1) process or pay claims; (2) obtain the services of physicians or other...
• Texas Section 1301.201 - Contracts With And Reimbursement For Nurse First Assistants
  A preferred provider may not refuse to: (1) contract with a nurse first assistant, as defined by Section 301.1525, Occupations Code, to be included in...
• Texas Section 1301.202 - Contracts With Hospitals
  (a) An insurer that contracts with hospitals to provide services to insureds under a preferred provider benefit plan may not deny a hospital the opportunity...

Last modified: September 28, 2016