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CHAPTER 1452. PHYSICIAN AND PROVIDER CREDENTIALS

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INSURANCE CODETITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGESSUBTITLE F. PHYSICIANS AND HEALTH CARE PROVIDERSCHAPTER 1452. PHYSICIAN AND PROVIDER CREDENTIALSSUBCHAPTER A. CREDENTIALING OF PHYSICIANS AND PROVIDERS BY HEALTHMAINTENANCE ORGANIZATIONSec. 1452.001.APPLICABILITY OF CERTAIN DEFINITIONS.In thissubchapter, a term defined by Section 843.002 has the meaningassigned 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 ORCERTIFICATE.The commissioner shall require a health maintenanceorganization to verify that a physician's license to practicemedicine and any other certificate the physician is required tohold, including a certificate issued by the Department of PublicSafety or the federal Drug Enforcement Administration or acertificate issued under the Medicare program, is valid as of thedate 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)Thecommissioner shall require a health maintenance organization thatconducts a site visit for the purpose of initial credentialing ofa physician or provider to evaluate during the visit a site'saccessibility, appearance, space, medical or dental recordkeepingpractices, availability of appointments, and confidentialityprocedures.(b)The commissioner may not require the health maintenanceorganization to evaluate the appropriateness of equipment duringthe site visit.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.Sec. 1452.004.LIMITATION ON COMMISSIONER'S AUTHORITY.Thecommissioner may not require a health maintenance organizationto:(1)formally recredential a physician or provider morefrequently than once in any three-year period;(2)verify the validity of a license or certificate held by aphysician as of a date other than the date of initialcredentialing or recredentialing of the physician;(3)use clinical personnel to perform a site visit for initialcredentialing of a physician or provider unless clinical reviewis needed during the site visit; or(4)require a site visit be performed for the purpose ofrecredentialing 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.Thissubchapter does not preclude a health maintenance organizationfrom conducting a site visit of a physician or provider at anytime for cause, including a complaint made by a member or anotherexternal 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 ANDPROVIDERS BY HEALTH MAINTENANCE ORGANIZATION.A rule adopted bythe commissioner under Section 843.102 that relates toimplementation and maintenance by a health maintenanceorganization of a process for selecting and retaining affiliatedphysicians and providers must comply with:(1)this subchapter; and(2)standards adopted by the National Committee for QualityAssurance, to the extent those standards do not conflict withother laws of this state.Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,2005.SUBCHAPTER B. STANDARDIZED FORMSSec. 1452.051.DEFINITIONS.In this subchapter:(1)"Advanced practice nurse" has the meaning assigned bySection 301.152, Occupations Code.(2)"Physician" means an individual licensed to practicemedicine in this state.(3)"Physician assistant" means an individual who holds alicense 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 OFCREDENTIALS.(a)The commissioner by rule shall:(1)prescribe a standardized form for the verification of thecredentials of a physician, advanced practice nurse, or physicianassistant; and(2)require a public or private hospital, a health maintenanceorganization operating under Chapter 843, or the issuer of apreferred provider benefit plan under Chapter 1301 to use theform for verification of credentials.(b)In prescribing a form under this section, the commissionershall consider any credentialing application form that is widelyused 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 PROCESSFOR CERTAIN PHYSICIANSSec. 1452.101.DEFINITIONS.In this subchapter:(1)"Applicant physician" means a physician applying forexpedited credentialing under this subchapter.(2)"Enrollee" means an individual who is eligible to receivehealth care services under a managed care plan.(3)"Health care provider" means:(A)an individual who is licensed, certified, or otherwiseauthorized to provide health care services in this state; or(B)a hospital, emergency clinic, outpatient clinic, or otherfacility providing health care services.(4)"Managed care plan" means a health benefit plan under whichhealth care services are provided to enrollees through contractswith health care providers and that requires enrollees to useparticipating providers or that provides a different level ofcoverage for enrollees who use participating providers.The termincludes 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 aspermitted under Subchapter B, Chapter 162, Occupations Code.(6)"Participating provider" means a health care provider whohas contracted with a health benefit plan issuer to provideservices 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 aphysician who joins an established medical group that has acurrent 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 forexpedited credentialing under this subchapter and payment underSection 1452.104, an applicant physician must:(1)be licensed in this state by, and in good standing with, theTexas Medical Board;(2)submit all documentation and other information required bythe issuer of the managed care plan as necessary to enable theissuer to begin the credentialing process required by the issuerto include a physician in the issuer's health benefit plannetwork; and(3)agree to comply with the terms of the managed care plan'sparticipating provider contract currently in force with theapplicant 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 DURINGCREDENTIALING PROCESS.On submission by the applicant physicianof the information required by the managed care plan issuer underSection 1452.103(2), and for payment purposes only, the issuershall treat the applicant physician as if the physician were aparticipating provider in the health benefit plan network whenthe applicant physician provides services to the managed careplan's enrollees, including:(1)authorizing the applicant physician to collect copaymentsfrom 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 anapplication submitted under Section 1452.104, the managed careplan may exclude the applicant physician from the managed careplan's directory of participating physicians, the managed careplan's website listing of participating physicians, or any otherlisting 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 CREDENTIALINGREQUIREMENTS.If, on completion of the credentialing process,the managed care plan issuer determines that the applicantphysician does not meet the issuer's credentialing requirements:(1)the managed care plan issuer may recover from the applicantphysician or the physician's medical group an amount equal to thedifference between payments for in-network benefits andout-of-network benefits; and(2)the applicant physician or the physician's medical group mayretain any copayments collected or in the process of beingcollected 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 themanaged care plan is not responsible and shall be held harmlessfor the difference between in-network copayments paid by theenrollee to a physician who is determined to be ineligible underSection 1452.106 and the managed care plan's charges forout-of-network services.The physician and the physician'smedical group may not charge the enrollee for any portion of thephysician's fee that is not paid or reimbursed by the enrollee'smanaged 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.Amanaged care plan issuer that complies with this subchapter isnot subject to liability for damages arising out of or inconnection with, directly or indirectly, the payment by theissuer of an applicant physician as if the physician were aparticipating provider in the health benefit plan network.Added by Acts 2007, 80th Leg., R.S., Ch.1203, Sec. 1, eff. September 1, 2007.
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  • 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.

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