CHAPTER 1274. ELECTRONIC TRANSMISSION OF ELIGIBILITY AND PAYMENT STATUS

State Codes and Statutes

Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1274-electronic-transmission-of-eligibility-and-payment-status

INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE C. MANAGED CARE

CHAPTER 1274. ELECTRONIC TRANSMISSION OF ELIGIBILITY AND PAYMENT

STATUS

Sec. 1274.001. DEFINITIONS. In this chapter:

(1) "Enrollee" means an individual who is eligible for coverage

under a health benefit plan, including a covered dependent.

(2) "Health benefit plan" means a group, blanket, or franchise

insurance policy, a certificate issued under a group policy, a

group hospital service contract, or a group subscriber contract

or evidence of coverage issued by a health maintenance

organization that provides benefits for health care services.

The term does not include:

(A) accident-only or disability income insurance coverage or a

combination of accident-only and disability income insurance

coverage;

(B) credit-only insurance coverage;

(D) coverage only for a specified disease or illness;

(E) Medicare services under a federal contract;

(F) Medicare supplement and Medicare Select policies regulated

in accordance with federal law;

(G) long-term care coverage or benefits, nursing home care

coverage or benefits, home health care coverage or benefits,

community-based care coverage or benefits, or any combination of

those coverages or benefits;

(H) coverage that provides limited-scope dental or vision

benefits;

(I) coverage provided by a single service health maintenance

organization;

(J) coverage issued as a supplement to liability insurance;

(K) workers' compensation insurance coverage or similar

insurance coverage;

(L) automobile medical payment insurance coverage;

(M) a jointly managed trust authorized under 29 U.S.C. Section

141 et seq. that contains a plan of benefits for employees that

is negotiated in a collective bargaining agreement governing

wages, hours, and working conditions of the employees that is

authorized under 29 U.S.C. Section 157;

(N) hospital indemnity or other fixed indemnity insurance

coverage;

(O) reinsurance contracts issued on a stop-loss, quota-share, or

similar basis;

(P) liability insurance coverage, including general liability

insurance and automobile liability insurance coverage; or

(Q) coverage that provides other limited benefits specified by

federal regulations.

(3) "Health benefit plan issuer" means a health maintenance

organization operating under Chapter 843, a preferred provider

organization operating under Chapter 1301, an approved nonprofit

health corporation that holds a certificate of authority under

Chapter 844, and any other entity that issues a health benefit

plan, including:

(A) an insurance company;

(B) a group hospital service corporation operating under Chapter

842;

(D) a stipulated premium company operating under Chapter 884.

(4) "Health care provider" means:

(A) a person, other than a physician, who is licensed or

otherwise authorized to provide a health care service in this

state, including:

(i) a pharmacist or dentist; or

(ii) a pharmacy, hospital, or other institution or organization;

(B) a person who is wholly owned or controlled by a provider or

by a group of providers who are licensed or otherwise authorized

to provide the same health care service; or

hospitals and physicians, including a physician-hospital

organization.

(5) "Participating provider" means:

(A) a physician or health care provider who contracts with a

health benefit plan issuer to provide medical care or health care

to enrollees in a health benefit plan; or

(B) a physician or health care provider who accepts and treats a

patient on a referral from a physician or provider described by

Paragraph (A).

(6) "Physician" means:

(A) an individual licensed to practice medicine in this state

under Subtitle B, Title 3, Occupations Code;

(B) a professional association organized under the Texas

Professional Association Act (Article 1528f, Vernon's Texas Civil

Statutes);

Occupations Code;

(D) a medical school or medical and dental unit, as defined or

described by Section 61.003, 61.501, or 74.601, Education Code,

that employs or contracts with physicians to teach or provide

medical services or employs physicians and contracts with

physicians in a practice plan; or

(E) another entity wholly owned by physicians.

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

880, Sec. 1, eff. September 1, 2005.

Sec. 1274.0015. EXEMPTION. This chapter does not apply to a

single-service health maintenance organization that provides

coverage only for dental or vision benefits.

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

880, Sec. 1, eff. September 1, 2005.

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;

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, Sec. 1, eff. September 1, 2005.

Sec. 1274.003. CERTAIN CHARGES PROHIBITED. A health benefit

plan issuer may not directly or indirectly charge or hold a

physician, health care provider, or enrollee responsible for a

fee for making available or accessing information under this

chapter.

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

880, Sec. 1, eff. September 1, 2005.

Sec. 1274.004. RULES. (a) The commissioner shall adopt rules

as necessary to implement this chapter.

(b) Before adopting rules under this section, the commissioner

shall consult and receive advice from the technical advisory

committee on claims processing established under Chapter 1212.

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

880, Sec. 1, eff. September 1, 2005.

Amended by:

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

730, Sec. 2G.006, eff. April 1, 2009.

Sec. 1274.005. WAIVER OF CERTAIN PROVISIONS FOR CERTAIN FEDERAL

PLANS. If the commissioner, in consultation with the

commissioner of health and human services, determines that a

provision of Section 1274.002 will cause a negative fiscal impact

on the state with respect to providing benefits or services under

Subchapter XIX, Social Security Act (42 U.S.C. Section 1396 et

seq.), or Subchapter XXI, Social Security Act (42 U.S.C. Section

1397aa et seq.), the commissioner of insurance by rule shall

waive the application of that provision to the providing of those

benefits or services.

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

880, Sec. 1, eff. September 1, 2005.

State Codes and Statutes

State Codes and Statutes

State Codes and Statutes

State Codes and Statutes

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