28 Tex. Admin. Code § 11.900 - Nonprimary Care Physician Specialist as Primary Care Physician

(a) An HMO must allow an enrollee with chronic, disabling, or life threatening illnesses to apply to the HMO's medical director to use a nonprimary care physician specialist as a primary care physician, provided that:

(1) the enrollee makes a request for special consideration that includes:

(A) a certification by the nonprimary care physician specialist of the medical need for the enrollee to use the nonprimary care physician specialist as a primary care physician;

(B) a statement signed by the nonprimary care physician specialist that the specialist is willing to accept responsibility for the coordination of all of the enrollee's health care needs; and

(C) the signature of the enrollee;

(2) the nonprimary care physician specialist meets the HMO's requirements for primary care physician participation, including credentialing;

(3) the HMO has ensured that the contractual obligations of the nonprimary care physician specialist are consistent with the contractual obligations of the HMO's primary care physicians; and

(4) the HMO must provide the nonprimary care physician specialist with a current directory of participating specialist physicians and providers.

(b) An HMO must approve or deny the request for special consideration and provide written notification of the decision to the enrollee not later than 30 days after receiving the request. If the HMO denies the request, the HMO must provide the reasons for denial in the written notification. An HMO must establish written criteria for determining medical need for an enrollee to use a nonprimary care physician specialist as a primary care provider, and must include the criteria in the provider manual.

(c) If the HMO denies a request for special consideration, an enrollee may appeal the decision through the HMO's established complaint and appeal process.

Notes

28 Tex. Admin. Code § 11.900

The provisions of this §11.900 adopted to be effective November 2, 1998, 23 TexReg 11347; Adopted by Texas Register, Volume 42, Number 16, April 21, 2017, TexReg 2246, eff. 8/1/2017