CHAPTER 1660. ELECTRONIC DATA EXCHANGE

State Codes and Statutes

Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1660-electronic-data-exchange

INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE J. HEALTH INFORMATION TECHNOLOGY

CHAPTER 1660. ELECTRONIC DATA EXCHANGE

SUBCHAPTER A. GENERAL PROVISIONS

Sec. 1660.001. FINDINGS AND PURPOSE. (a) The legislature finds

that patients deserve accurate, instantaneous information about

coverage and financial responsibility to make well-informed

decisions about their treatment and spending.

(b) The legislature finds that the ability of health benefit

plan issuers and administrators to exchange eligibility and

benefit information with physicians, health care providers,

hospitals, and patients will ensure a more efficient and

effective health care delivery system.

information will reduce the amount of time and resources spent on

administrative functions, prevent abuse and fraud, streamline and

simplify processing of insurance claims, and increase

transparency in premium cost and health care cost.

(d) The legislature finds that patients often request

information about their health care coverage from their health

care providers and that health care providers therefore need

access to real-time information about their patients' eligibility

to receive health care under the health benefit plan, coverage of

health care under the health benefit plan, and the benefits

associated with the health benefit plan.

(e) The legislature finds that adoption of technology by

insurers, health maintenance organizations, and health care

providers to facilitate use of electronic data exchange standards

currently available will make coverage and health care electronic

transactions more predictable, reliable, and consistent.

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

209, Sec. 1, eff. May 25, 2007.

Sec. 1660.002. DEFINITIONS. In this chapter:

(1) "Administrator" has the meaning assigned by Section

4151.001.

(2) "Advisory committee" means the technical advisory committee

on electronic data exchange.

(3) "Enrollee" means an individual who is insured by or enrolled

in a health benefit plan.

(4) "Health benefit plan" means an individual, group, blanket,

or franchise insurance policy or insurance agreement, a group

hospital service contract, or an evidence of coverage that

provides health insurance or health care benefits.

(5) "Transaction standards" means the Health Insurance

Portability and Accountability Act of 1996 (Pub. L. No. 104-191)

transaction standards of the Centers for Medicare and Medicaid

Services under 45 C.F.R. Part 162.

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

209, Sec. 1, eff. May 25, 2007.

Sec. 1660.003. APPLICABILITY. (a) This chapter applies only to

a health benefit plan that provides benefits for medical or

surgical expenses incurred as a result of a health condition,

accident, or sickness, 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 reciprocal exchange operating under Chapter 942;

(6) a health maintenance organization operating under Chapter

843;

(7) a multiple employer welfare arrangement that holds a

certificate of authority under Chapter 846; or

(8) an approved nonprofit health corporation that holds a

certificate of authority under Chapter 844.

(b) This chapter does not apply to:

(1) a Medicaid managed care program operated under Chapter 533,

Government Code;

(2) a Medicaid program operated under Chapter 32, Human

Resources Code;

(3) the state child health plan or any similar plan operated

under Chapter 62 or 63, Health and Safety Code; or

(4) a health benefit plan offered by an insurer or health

maintenance organization that provides coverage only for dental

services.

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

209, Sec. 1, eff. May 25, 2007.

Sec. 1660.004. GENERAL RULEMAKING. The commissioner may adopt

rules as necessary to implement this chapter, including rules

requiring the implementation and provision of the technology

recommended by the advisory committee.

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

209, Sec. 1, eff. May 25, 2007.

SUBCHAPTER B. ADVISORY COMMITTEE

Sec. 1660.051. ADVISORY COMMITTEE; COMPOSITION. (a) The

commissioner shall appoint a technical advisory committee on

electronic data exchange.

(b) The advisory committee is composed of:

(1) at least one representative from each of the following

groups or entities:

(A) health benefit coverage consumers;

(B) physicians;

(D) representatives of medical units of institutions of higher

education;

(E) representatives of health benefit plan issuers;

(F) health care providers; and

(G) administrators; and

(2) representatives from:

(A) the office of public insurance counsel;

(B) the Texas Health Insurance Risk Pool; and

compensation.

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

209, Sec. 1, eff. May 25, 2007.

Sec. 1660.052. APPLICABILITY OF CERTAIN LAWS. The following

laws do not apply to the advisory committee:

(1) Section 39.003(a); and

(2) Chapter 2110, Government Code.

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

209, Sec. 1, eff. May 25, 2007.

Sec. 1660.053. ADVISORY COMMITTEE POWERS AND DUTIES. The

advisory committee shall advise the commissioner on technical

aspects of using the transaction standards and the rules of the

Council for Affordable Quality Healthcare Committee on Operating

Rules for Information Exchange to require health benefit plan

issuers and administrators to provide access to information

technology that will enable physicians and other health care

providers, at the point of service, to generate a request for

eligibility information that is compliant with the transaction

standards.

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

209, Sec. 1, eff. May 25, 2007.

Sec. 1660.054. DATA ELEMENTS. (a) The advisory committee shall

advise the commissioner on data elements required to be made

available by health benefit plan issuers and administrators. To

the extent possible, the committee shall use the framework

adopted by the Council for Affordable Quality Healthcare

Committee on Operating Rules for Information Exchange.

(b) The advisory committee shall consider inclusion in the

required information of the following data elements:

(1) the name, date of birth, member identification number, and

coverage status of the patient;

(2) identification of the payor, insurer, issuer, and

administrator, as applicable;

(3) the name and telephone number of the payor's contact

person;

(4) the payor's address;

(5) the name and address of the subscriber;

(6) the patient's relationship to the subscriber;

(7) the type of service;

(8) the type of health benefit plan or product;

(9) the effective date of the coverage;

(10) for professional services:

(A) copayment amounts;

(B) individual deductible amounts;

(D) benefit limitations and maximums;

(11) for facility services:

(A) copayment and coinsurance amounts;

(B) individual deductible amounts;

(D) benefit limitations and maximums;

(12) precertification or prior authorization requirements;

(13) policy maximum limits;

(14) patient liability for a proposed service; and

(15) the health benefit plan coverage amount for a proposed

service.

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

209, Sec. 1, eff. May 25, 2007.

Sec. 1660.055. RECOMMENDATIONS REGARDING ADOPTION OF CERTAIN

TECHNOLOGIES; REPORT. (a) The advisory committee shall:

(1) make recommendations regarding the use by health benefit

plan issuers or administrators of Internet website technologies,

smart card technologies, magnetic strip technologies, biometric

technologies, or other information technologies to facilitate the

generation of a request for eligibility information that is

compliant with the transaction standards and the rules of the

Council for Affordable Quality Healthcare Committee on Operating

Rules for Information Exchange;

(2) ensure that a recommendation made under Subdivision (1) does

not endorse or otherwise confine health benefit plan issuers and

administrators to any single product or vendor; and

(3) recommend time frames for implementation of the

recommendations.

(b) The advisory committee shall:

(1) recommend specific provisions that could be included in a

department-issued request for information relating to electronic

data exchange, including identification card programs;

(2) provide those recommendations to the commissioner not later

than four months after the date on which the committee is

appointed; and

(3) issue a final report to the commissioner containing the

committee's recommendations for implementation by December 1,

2008.

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

209, Sec. 1, eff. May 25, 2007.

SUBCHAPTER C. IDENTIFICATION CARD PILOT PROGRAM

Sec. 1660.101. PILOT PROGRAM. (a) The commissioner shall

designate a county or counties for initial participation in an

identification card pilot program to begin not later than May 1,

2008.

(b) The commissioner shall require the issuer of a health

benefit plan that is offered in the county or counties selected

for initial participation in the identification card pilot

program to issue identification cards that comply with

commissioner rules to each enrollee of the plan.

program before, during, or simultaneously with the appointment

and formation of the advisory committee.

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

209, Sec. 1, eff. May 25, 2007.

Sec. 1660.102. PILOT PROGRAM RULES. (a) The commissioner shall

adopt rules as necessary to implement the identification card

pilot program, including the coordination of a testing phase and

incorporation of changes identified in the testing phase.

(b) The commissioner may consider the recommendations of the

advisory committee or any information provided in response to a

department-issued request for information relating to electronic

data exchange, including identification card programs, before

adopting rules regarding:

(1) information to be included on the identification cards;

(2) technology to be used to implement the identification card

pilot program; and

(3) confidentiality and accuracy of the information required to

be included on the identification cards.

federal program requiring health benefit plan issuers and

administrators to provide point-of-service access to physicians

and other health care providers regarding eligibility information

before adopting rules to implement this section.

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

209, Sec. 1, eff. May 25, 2007.

Sec. 1660.103. REQUESTS FOR INFORMATION. The commissioner may

issue requests for information as needed to implement the

identification card pilot program under this subchapter.

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

209, Sec. 1, eff. May 25, 2007.

Sec. 1660.104. HEALTH BENEFIT PLAN ISSUER COMPLIANCE. (a) Each

issuer of a health benefit plan that offers a health benefit plan

in a county or counties designated by the commissioner under

Section 1660.101 for initial participation in the identification

card pilot program shall comply with this subchapter and rules

adopted under this subchapter.

(b) To ensure timely compliance with the requirements of this

subchapter, the commissioner may require the issuer of a health

benefit plan to submit its procedures for implementation of the

requirements to the department in the form prescribed by the

commissioner.

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

209, Sec. 1, eff. May 25, 2007.

State Codes and Statutes

State Codes and Statutes

State Codes and Statutes

State Codes and Statutes

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