State Codes and Statutes

Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1213-electronic-health-care-transactions

INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE A. HEALTH COVERAGE IN GENERAL

CHAPTER 1213. ELECTRONIC HEALTH CARE TRANSACTIONS

Sec. 1213.001. DEFINITION OF HEALTH BENEFIT PLAN. (a) In this

chapter, "health benefit plan" means a plan that provides

benefits for medical, surgical, or other treatment expenses

incurred as a result of a health condition, a mental health

condition, an accident, sickness, or substance abuse, including

an individual, group, blanket, or franchise insurance policy or

insurance agreement, a group hospital service contract, or an

individual or group evidence of coverage or similar coverage

document that is offered by:

(1) an insurance company;

(2) a group hospital service corporation operating under Chapter

842;

(3) a fraternal benefit society operating under Chapter 885;

(4) a stipulated premium insurance company operating under

Chapter 884;

(5) a Lloyd's plan operating under Chapter 941;

(6) an exchange operating under Chapter 942;

(7) a health maintenance organization operating under Chapter

843;

(8) a multiple employer welfare arrangement that holds a

certificate of authority under Chapter 846; or

(9) an approved nonprofit health corporation that holds a

certificate of authority under Chapter 844.

(b) The term includes:

(1) a small employer health benefit plan written under Chapter

1501; and

(2) a health benefit plan offered under Chapter 1551, 1575,

1579, or 1601.

Added by Acts 2005, 79th Leg., Ch.

728, Sec. 11.029(a), eff. September 1, 2005.

Sec. 1213.002. ELECTRONIC SUBMISSION OF CLAIMS. (a) The issuer

of a health benefit plan by contract may require that a health

care professional licensed or registered under the Occupations

Code or a health care facility licensed under the Health and

Safety Code electronically submit a health care claim or

equivalent encounter information, a referral certification, or an

authorization or eligibility transaction. The health benefit

plan issuer shall comply with the standards for electronic

transactions required by this section and established by the

commissioner by rule.

(b) The issuer of a health benefit plan by contract shall

establish a default method to submit claims in a nonelectronic

format if there is a system failure or failures or a catastrophic

event substantially interferes with the normal business

operations of the physician, provider, or health benefit plan or

its agents. The health benefit plan issuer shall comply with the

standards for nonelectronic transactions established by the

commissioner by rule.

Added by Acts 2005, 79th Leg., Ch.

728, Sec. 11.029(a), eff. September 1, 2005.

Sec. 1213.003. ELECTRONIC SUBMISSION OF CLAIMS: WAIVER. (a) A

contract between the issuer of a health benefit plan and a health

care professional or health care facility must provide for a

waiver of any requirement for electronic submission established

under this chapter.

(b) The commissioner shall establish circumstances under which a

waiver is required, including:

(1) circumstances in which no method is available for the

submission of claims in electronic form;

(2) the operation of small physician practices;

(3) the operation of other small health care provider practices;

(4) undue hardship, including fiscal or operational hardship; or

(5) any other special circumstance that would justify a waiver.

(c) Any health care professional or health care facility that is

denied a waiver by the issuer of a health benefit plan may appeal

the denial to the commissioner. The commissioner shall determine

whether a waiver must be granted.

(d) The issuer of a health benefit plan may not refuse to

contract or renew a contract with a health care professional or

health care facility based in whole or in part on the

professional or facility requesting or receiving a waiver or

appealing a waiver determination.

Added by Acts 2005, 79th Leg., Ch.

728, Sec. 11.029(a), eff. September 1, 2005.

Sec. 1213.004. MODE OF TRANSMISSION. The issuer of a health

benefit plan may not by contract limit the mode of electronic

transmission that a health care professional or health care

facility may use to submit information under this chapter.

Added by Acts 2005, 79th Leg., Ch.

728, Sec. 11.029(a), eff. September 1, 2005.

Sec. 1213.005. CERTAIN CHARGES PROHIBITED. A health benefit

plan may not directly or indirectly charge or hold a health care

professional, health care facility, or person enrolled in a

health benefit plan responsible for a fee for the adjudication of

a claim.

Added by Acts 2005, 79th Leg., Ch.

728, Sec. 11.029(a), eff. September 1, 2005.

Sec. 1213.006. RULES. The commissioner may adopt rules as

necessary to implement this chapter. The commissioner may not

require any data element for electronically filed claims that is

not required to comply with federal law.

Added by Acts 2005, 79th Leg., Ch.

728, Sec. 11.029(a), eff. September 1, 2005.

State Codes and Statutes

Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1213-electronic-health-care-transactions

INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE A. HEALTH COVERAGE IN GENERAL

CHAPTER 1213. ELECTRONIC HEALTH CARE TRANSACTIONS

Sec. 1213.001. DEFINITION OF HEALTH BENEFIT PLAN. (a) In this

chapter, "health benefit plan" means a plan that provides

benefits for medical, surgical, or other treatment expenses

incurred as a result of a health condition, a mental health

condition, an accident, sickness, or substance abuse, including

an individual, group, blanket, or franchise insurance policy or

insurance agreement, a group hospital service contract, or an

individual or group evidence of coverage or similar coverage

document that is offered by:

(1) an insurance company;

(2) a group hospital service corporation operating under Chapter

842;

(3) a fraternal benefit society operating under Chapter 885;

(4) a stipulated premium insurance company operating under

Chapter 884;

(5) a Lloyd's plan operating under Chapter 941;

(6) an exchange operating under Chapter 942;

(7) a health maintenance organization operating under Chapter

843;

(8) a multiple employer welfare arrangement that holds a

certificate of authority under Chapter 846; or

(9) an approved nonprofit health corporation that holds a

certificate of authority under Chapter 844.

(b) The term includes:

(1) a small employer health benefit plan written under Chapter

1501; and

(2) a health benefit plan offered under Chapter 1551, 1575,

1579, or 1601.

Added by Acts 2005, 79th Leg., Ch.

728, Sec. 11.029(a), eff. September 1, 2005.

Sec. 1213.002. ELECTRONIC SUBMISSION OF CLAIMS. (a) The issuer

of a health benefit plan by contract may require that a health

care professional licensed or registered under the Occupations

Code or a health care facility licensed under the Health and

Safety Code electronically submit a health care claim or

equivalent encounter information, a referral certification, or an

authorization or eligibility transaction. The health benefit

plan issuer shall comply with the standards for electronic

transactions required by this section and established by the

commissioner by rule.

(b) The issuer of a health benefit plan by contract shall

establish a default method to submit claims in a nonelectronic

format if there is a system failure or failures or a catastrophic

event substantially interferes with the normal business

operations of the physician, provider, or health benefit plan or

its agents. The health benefit plan issuer shall comply with the

standards for nonelectronic transactions established by the

commissioner by rule.

Added by Acts 2005, 79th Leg., Ch.

728, Sec. 11.029(a), eff. September 1, 2005.

Sec. 1213.003. ELECTRONIC SUBMISSION OF CLAIMS: WAIVER. (a) A

contract between the issuer of a health benefit plan and a health

care professional or health care facility must provide for a

waiver of any requirement for electronic submission established

under this chapter.

(b) The commissioner shall establish circumstances under which a

waiver is required, including:

(1) circumstances in which no method is available for the

submission of claims in electronic form;

(2) the operation of small physician practices;

(3) the operation of other small health care provider practices;

(4) undue hardship, including fiscal or operational hardship; or

(5) any other special circumstance that would justify a waiver.

(c) Any health care professional or health care facility that is

denied a waiver by the issuer of a health benefit plan may appeal

the denial to the commissioner. The commissioner shall determine

whether a waiver must be granted.

(d) The issuer of a health benefit plan may not refuse to

contract or renew a contract with a health care professional or

health care facility based in whole or in part on the

professional or facility requesting or receiving a waiver or

appealing a waiver determination.

Added by Acts 2005, 79th Leg., Ch.

728, Sec. 11.029(a), eff. September 1, 2005.

Sec. 1213.004. MODE OF TRANSMISSION. The issuer of a health

benefit plan may not by contract limit the mode of electronic

transmission that a health care professional or health care

facility may use to submit information under this chapter.

Added by Acts 2005, 79th Leg., Ch.

728, Sec. 11.029(a), eff. September 1, 2005.

Sec. 1213.005. CERTAIN CHARGES PROHIBITED. A health benefit

plan may not directly or indirectly charge or hold a health care

professional, health care facility, or person enrolled in a

health benefit plan responsible for a fee for the adjudication of

a claim.

Added by Acts 2005, 79th Leg., Ch.

728, Sec. 11.029(a), eff. September 1, 2005.

Sec. 1213.006. RULES. The commissioner may adopt rules as

necessary to implement this chapter. The commissioner may not

require any data element for electronically filed claims that is

not required to comply with federal law.

Added by Acts 2005, 79th Leg., Ch.

728, Sec. 11.029(a), eff. September 1, 2005.


State Codes and Statutes


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State Codes and Statutes

Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1213-electronic-health-care-transactions

INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE A. HEALTH COVERAGE IN GENERAL

CHAPTER 1213. ELECTRONIC HEALTH CARE TRANSACTIONS

Sec. 1213.001. DEFINITION OF HEALTH BENEFIT PLAN. (a) In this

chapter, "health benefit plan" means a plan that provides

benefits for medical, surgical, or other treatment expenses

incurred as a result of a health condition, a mental health

condition, an accident, sickness, or substance abuse, including

an individual, group, blanket, or franchise insurance policy or

insurance agreement, a group hospital service contract, or an

individual or group evidence of coverage or similar coverage

document that is offered by:

(1) an insurance company;

(2) a group hospital service corporation operating under Chapter

842;

(3) a fraternal benefit society operating under Chapter 885;

(4) a stipulated premium insurance company operating under

Chapter 884;

(5) a Lloyd's plan operating under Chapter 941;

(6) an exchange operating under Chapter 942;

(7) a health maintenance organization operating under Chapter

843;

(8) a multiple employer welfare arrangement that holds a

certificate of authority under Chapter 846; or

(9) an approved nonprofit health corporation that holds a

certificate of authority under Chapter 844.

(b) The term includes:

(1) a small employer health benefit plan written under Chapter

1501; and

(2) a health benefit plan offered under Chapter 1551, 1575,

1579, or 1601.

Added by Acts 2005, 79th Leg., Ch.

728, Sec. 11.029(a), eff. September 1, 2005.

Sec. 1213.002. ELECTRONIC SUBMISSION OF CLAIMS. (a) The issuer

of a health benefit plan by contract may require that a health

care professional licensed or registered under the Occupations

Code or a health care facility licensed under the Health and

Safety Code electronically submit a health care claim or

equivalent encounter information, a referral certification, or an

authorization or eligibility transaction. The health benefit

plan issuer shall comply with the standards for electronic

transactions required by this section and established by the

commissioner by rule.

(b) The issuer of a health benefit plan by contract shall

establish a default method to submit claims in a nonelectronic

format if there is a system failure or failures or a catastrophic

event substantially interferes with the normal business

operations of the physician, provider, or health benefit plan or

its agents. The health benefit plan issuer shall comply with the

standards for nonelectronic transactions established by the

commissioner by rule.

Added by Acts 2005, 79th Leg., Ch.

728, Sec. 11.029(a), eff. September 1, 2005.

Sec. 1213.003. ELECTRONIC SUBMISSION OF CLAIMS: WAIVER. (a) A

contract between the issuer of a health benefit plan and a health

care professional or health care facility must provide for a

waiver of any requirement for electronic submission established

under this chapter.

(b) The commissioner shall establish circumstances under which a

waiver is required, including:

(1) circumstances in which no method is available for the

submission of claims in electronic form;

(2) the operation of small physician practices;

(3) the operation of other small health care provider practices;

(4) undue hardship, including fiscal or operational hardship; or

(5) any other special circumstance that would justify a waiver.

(c) Any health care professional or health care facility that is

denied a waiver by the issuer of a health benefit plan may appeal

the denial to the commissioner. The commissioner shall determine

whether a waiver must be granted.

(d) The issuer of a health benefit plan may not refuse to

contract or renew a contract with a health care professional or

health care facility based in whole or in part on the

professional or facility requesting or receiving a waiver or

appealing a waiver determination.

Added by Acts 2005, 79th Leg., Ch.

728, Sec. 11.029(a), eff. September 1, 2005.

Sec. 1213.004. MODE OF TRANSMISSION. The issuer of a health

benefit plan may not by contract limit the mode of electronic

transmission that a health care professional or health care

facility may use to submit information under this chapter.

Added by Acts 2005, 79th Leg., Ch.

728, Sec. 11.029(a), eff. September 1, 2005.

Sec. 1213.005. CERTAIN CHARGES PROHIBITED. A health benefit

plan may not directly or indirectly charge or hold a health care

professional, health care facility, or person enrolled in a

health benefit plan responsible for a fee for the adjudication of

a claim.

Added by Acts 2005, 79th Leg., Ch.

728, Sec. 11.029(a), eff. September 1, 2005.

Sec. 1213.006. RULES. The commissioner may adopt rules as

necessary to implement this chapter. The commissioner may not

require any data element for electronically filed claims that is

not required to comply with federal law.

Added by Acts 2005, 79th Leg., Ch.

728, Sec. 11.029(a), eff. September 1, 2005.


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