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Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1452-physician-and-provider-credentials

INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE F. PHYSICIANS AND HEALTH CARE PROVIDERS

CHAPTER 1452. PHYSICIAN AND PROVIDER CREDENTIALS

SUBCHAPTER A. CREDENTIALING OF PHYSICIANS AND PROVIDERS BY HEALTH

MAINTENANCE ORGANIZATION

Sec. 1452.001. APPLICABILITY OF CERTAIN DEFINITIONS. In this

subchapter, a term defined by Section 843.002 has the meaning

assigned by that section.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1452.002. VERIFICATION OF PHYSICIAN’S LICENSE OR

CERTIFICATE. The commissioner shall require a health maintenance

organization to verify that a physician’s license to practice

medicine and any other certificate the physician is required to

hold, including a certificate issued by the Department of Public

Safety or the federal Drug Enforcement Administration or a

certificate issued under the Medicare program, is valid as of the

date of:

(1) initial credentialing of the physician; and

(2) each recredentialing.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1452.003. SITE VISIT FOR INITIAL CREDENTIALING. (a) The

commissioner shall require a health maintenance organization that

conducts a site visit for the purpose of initial credentialing of

a physician or provider to evaluate during the visit a site’s

accessibility, appearance, space, medical or dental recordkeeping

practices, availability of appointments, and confidentiality

procedures.

(b) The commissioner may not require the health maintenance

organization to evaluate the appropriateness of equipment during

the site visit.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1452.004. LIMITATION ON COMMISSIONER’S AUTHORITY. The

commissioner may not require a health maintenance organization

to:

(1) formally recredential a physician or provider more

frequently than once in any three-year period;

(2) verify the validity of a license or certificate held by a

physician as of a date other than the date of initial

credentialing or recredentialing of the physician;

(3) use clinical personnel to perform a site visit for initial

credentialing of a physician or provider unless clinical review

is needed during the site visit; or

(4) require a site visit be performed for the purpose of

recredentialing of a physician or provider.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1452.005. SITE VISIT FOR CAUSE NOT PRECLUDED. This

subchapter does not preclude a health maintenance organization

from conducting a site visit of a physician or provider at any

time for cause, including a complaint made by a member or another

external complaint made to the health maintenance organization.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1452.006. RULES RELATED TO SELECTION OF PHYSICIANS AND

PROVIDERS BY HEALTH MAINTENANCE ORGANIZATION. A rule adopted by

the commissioner under Section 843.102 that relates to

implementation and maintenance by a health maintenance

organization of a process for selecting and retaining affiliated

physicians and providers must comply with:

(1) this subchapter; and

(2) standards adopted by the National Committee for Quality

Assurance, to the extent those standards do not conflict with

other laws of this state.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

SUBCHAPTER B. STANDARDIZED FORMS

Sec. 1452.051. DEFINITIONS. In this subchapter:

(1) “Advanced practice nurse” has the meaning assigned by

Section 301.152, Occupations Code.

(2) “Physician” means an individual licensed to practice

medicine in this state.

(3) “Physician assistant” means an individual who holds a

license issued under Chapter 204, Occupations Code.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Amended by:

Acts 2005, 79th Leg., Ch.

728, Sec. 11.045(a), eff. September 1, 2005.

Sec. 1452.052. STANDARDIZED FORM FOR VERIFICATION OF

CREDENTIALS. (a) The commissioner by rule shall:

(1) prescribe a standardized form for the verification of the

credentials of a physician, advanced practice nurse, or physician

assistant; and

(2) require a public or private hospital, a health maintenance

organization operating under Chapter 843, or the issuer of a

preferred provider benefit plan under Chapter 1301 to use the

form for verification of credentials.

(b) In prescribing a form under this section, the commissioner

shall consider any credentialing application form that is widely

used in this state or any form currently used by the department.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Amended by:

Acts 2005, 79th Leg., Ch.

728, Sec. 11.045(a), eff. September 1, 2005.

SUBCHAPTER C. EXPEDITED CREDENTIALING PROCESS

FOR CERTAIN PHYSICIANS

Sec. 1452.101. DEFINITIONS. In this subchapter:

(1) “Applicant physician” means a physician applying for

expedited credentialing under this subchapter.

(2) “Enrollee” means an individual who is eligible to receive

health care services under a managed care plan.

(3) “Health care provider” means:

(A) an individual who is licensed, certified, or otherwise

authorized to provide health care services in this state; or

(B) a hospital, emergency clinic, outpatient clinic, or other

facility providing health care services.

(4) “Managed care plan” means a health benefit plan under which

health care services are provided to enrollees through contracts

with health care providers and that requires enrollees to use

participating providers or that provides a different level of

coverage for enrollees who use participating providers. The term

includes a health benefit plan issued by:

(A) a health maintenance organization;

(B) a preferred provider benefit plan issuer; or

(C) any other entity that issues a health benefit plan,

including an insurance company.

(5) “Medical group” means:

(A) a single legal entity owned by two or more physicians;

(B) a professional association composed of licensed physicians;

or

(C) any other business entity composed of licensed physicians as

permitted under Subchapter B, Chapter 162, Occupations Code.

(6) “Participating provider” means a health care provider who

has contracted with a health benefit plan issuer to provide

services to enrollees.

Added by Acts 2007, 80th Leg., R.S., Ch.

1203, Sec. 1, eff. September 1, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

296, Sec. 1, eff. September 1, 2009.

Sec. 1452.102. APPLICABILITY. This subchapter applies only to a

physician who joins an established medical group that has a

current contract in force with a managed care plan.

Added by Acts 2007, 80th Leg., R.S., Ch.

1203, Sec. 1, eff. September 1, 2007.

Sec. 1452.103. ELIGIBILITY REQUIREMENTS. To qualify for

expedited credentialing under this subchapter and payment under

Section 1452.104, an applicant physician must:

(1) be licensed in this state by, and in good standing with, the

Texas Medical Board;

(2) submit all documentation and other information required by

the issuer of the managed care plan as necessary to enable the

issuer to begin the credentialing process required by the issuer

to include a physician in the issuer’s health benefit plan

network; and

(3) agree to comply with the terms of the managed care plan’s

participating provider contract currently in force with the

applicant physician’s established medical group.

Added by Acts 2007, 80th Leg., R.S., Ch.

1203, Sec. 1, eff. September 1, 2007.

Sec. 1452.104. PAYMENT OF APPLICANT PHYSICIAN DURING

CREDENTIALING PROCESS. On submission by the applicant physician

of the information required by the managed care plan issuer under

Section 1452.103(2), and for payment purposes only, the issuer

shall treat the applicant physician as if the physician were a

participating provider in the health benefit plan network when

the applicant physician provides services to the managed care

plan’s enrollees, including:

(1) authorizing the applicant physician to collect copayments

from the enrollees; and

(2) making payments to the applicant physician.

Added by Acts 2007, 80th Leg., R.S., Ch.

1203, Sec. 1, eff. September 1, 2007.

Sec. 1452.105. DIRECTORY ENTRIES. Pending the approval of an

application submitted under Section 1452.104, the managed care

plan may exclude the applicant physician from the managed care

plan’s directory of participating physicians, the managed care

plan’s website listing of participating physicians, or any other

listing of participating physicians.

Added by Acts 2007, 80th Leg., R.S., Ch.

1203, Sec. 1, eff. September 1, 2007.

Sec. 1452.106. EFFECT OF FAILURE TO MEET CREDENTIALING

REQUIREMENTS. If, on completion of the credentialing process,

the managed care plan issuer determines that the applicant

physician does not meet the issuer’s credentialing requirements:

(1) the managed care plan issuer may recover from the applicant

physician or the physician’s medical group an amount equal to the

difference between payments for in-network benefits and

out-of-network benefits; and

(2) the applicant physician or the physician’s medical group may

retain any copayments collected or in the process of being

collected as of the date of the issuer’s determination.

Added by Acts 2007, 80th Leg., R.S., Ch.

1203, Sec. 1, eff. September 1, 2007.

Sec. 1452.107. ENROLLEE HELD HARMLESS. An enrollee in the

managed care plan is not responsible and shall be held harmless

for the difference between in-network copayments paid by the

enrollee to a physician who is determined to be ineligible under

Section 1452.106 and the managed care plan’s charges for

out-of-network services. The physician and the physician’s

medical group may not charge the enrollee for any portion of the

physician’s fee that is not paid or reimbursed by the enrollee’s

managed care plan.

Added by Acts 2007, 80th Leg., R.S., Ch.

1203, Sec. 1, eff. September 1, 2007.

Sec. 1452.108. LIMITATION ON MANAGED CARE ISSUER LIABILITY. A

managed care plan issuer that complies with this subchapter is

not subject to liability for damages arising out of or in

connection with, directly or indirectly, the payment by the

issuer of an applicant physician as if the physician were a

participating provider in the health benefit plan network.

Added by Acts 2007, 80th Leg., R.S., Ch.

1203, Sec. 1, eff. September 1, 2007.