28 Tex. Admin. Code § 11.901 - Required and Prohibited Provisions
(a)
Physician and provider contracts, subcontracts, and arrangements must include
provisions regarding a hold-harmless clause as described in Insurance Code §
843.361, concerning
Enrollees Held Harmless.
(1) A hold-harmless
clause is a provision in a physician or health care provider agreement that
obligates the physician or provider to look only to the HMO and not its
enrollees for payment for covered services (except as described in the evidence
of coverage issued to the enrollee).
(2) In compliance with Insurance Code §
843.002, concerning
Definitions, relating to an "uncovered expense," if a physician or health care
provider agreement contains a hold-harmless clause, then the costs of the
services will not be considered uncovered health care expenses in determining
amounts of deposits necessary for insolvency protection under Insurance Code §
843.405, concerning
Deposit with Comptroller.
(3) The
following is an example of an approvable hold-harmless clause: "(Physician or
Provider) agrees that in no event, including, but not limited to, nonpayment by
the HMO, HMO insolvency, or breach of this agreement, may (Physician or
Provider) bill, charge, collect a deposit from, seek compensation,
remuneration, or reimbursement from, or have any recourse against subscriber,
enrollee, or persons other than the HMO acting on their behalf for services
provided under this agreement. This provision does not prohibit collection of
supplemental charges or copayments made in compliance with the terms of
(applicable agreement) between the HMO and subscriber or enrollee. (Physician
or Provider) further agrees that:
(A) this
provision will survive the termination of this agreement regardless of the
cause giving rise to termination and must be construed to be for the benefit of
the HMO subscriber or enrollee; and
(B) this provision supersedes any oral or
written contrary agreement now existing or later entered into between
(Physician or Provider) and subscriber, enrollee, or persons acting on their
behalf. Any modification, addition, or deletion to the provisions of this
clause will be effective on a date no earlier than 15 days after the
commissioner has received written notice of the proposed
changes."
(b)
Physician and provider contracts, subcontracts, and arrangements must include
provisions:
(1) regarding retaliation as
described in Insurance Code §
843.281, concerning
Retaliatory Action Prohibited;
(2)
regarding continuity of treatment, if applicable, as described in Insurance
Code §
843.309, concerning
Contracts with Physicians or Providers: Notice to Certain Enrollees of
Termination of Physician or Provider Participation in Plan, and §843.362,
concerning Continuity of Care; Obligation of Health Maintenance
Organization;
(3) regarding written
notification to enrollees receiving care from a physician or provider of the
termination of that physician or provider in compliance with Insurance Code §
843.308, concerning
Notification of Patients of Deselected Physician or Provider, and
§843.309;
(4) regarding posting of
complaint notices in physician or provider offices as described in Insurance
Code §
843.283, concerning
Posting of Information on Complaint Process Required, provided that a
representative notice that complies with this requirement may be obtained from
the Managed Care Quality Assurance Office, MC: LH-MCQA, Texas Department of
Insurance, P.O. Box 12030, Austin, Texas 78711-2030, or the department's
website at www.tdi.texas.gov;
(5) regarding indemnification of the HMO as
described in Insurance Code §
843.310, concerning
Contracts with Physicians or Providers: Certain Indemnity Clauses
Prohibited;
(6) regarding prompt
payment of claims as described in Insurance Code Chapter 542, Subchapter B,
concerning Prompt Payment of Claims; §1271.005, concerning Applicability of
Other Law; and all applicable statutes and rules pertaining to prompt payment
of clean claims, including Insurance Code Chapter 843, Subchapter J, concerning
Payment of Claims to Physicians and Providers; and Chapter 21, Subchapter T, of
this title (relating to Submission of Clean Claims) with respect to payment to
the physician or provider for covered services rendered to enrollees;
(7) regarding capitation, if applicable, as
described in Insurance Code §
843.315, concerning
Payment of Capitation; Assignment of Primary Care Physician or Provider, and
§843.316, concerning Alternative Capitation System;
(8) regarding selection of a primary care
physician or provider, if applicable, as described in Insurance Code §
843.203, concerning
Selection of Primary Care Physician or Provider;
(9) providing that a podiatrist, practicing
within the scope of the law regulating podiatry, is permitted to furnish X-rays
and non-prefabricated orthotics covered by the evidence of coverage as
described in Insurance Code §
843.311, concerning
Contracts with Podiatrists;
(10)
regarding the requirements of §
21.3701 of this title (relating to
Electronic Claims Filing Requirements) if the contract requires electronic
submission of any information described by that section;
(11) requiring the preferred provider to
comply with all applicable requirements of Insurance Code §
1661.005, concerning
Refund of Overpayment; and
(12)
requiring a contracting physician or provider to retain in the contracting
physician's or provider's records updated information concerning a patient's
other health benefit plan coverage.
(c) Physician and provider contracts and
arrangements must include provisions entitling the physician or provider, on
request, to all information necessary to determine that the physician or
provider is being compensated in compliance with the contract. A physician or
provider may make the request for information by any reasonable and verifiable
means. The information provided must include a level of detail sufficient to
enable a reasonable person with sufficient training, experience, and competence
in claims processing to determine the payment to be made under the terms of the
contract for covered services rendered to enrollees. The HMO may provide the
required information by any reasonable method through which the physician or
provider can access the information, including email, computer disks, or other
electronic storage and transfer technology, paper, or access to an electronic
database. Amendments, revisions, or substitutions of any information provided
under this paragraph must comply with paragraph (4) of this subsection. The HMO
must provide the fee schedules and other required information by the 30th day
after the date the HMO receives the physician's or provider's request.
(1) The information provided must include a
physician-specific or provider-specific summary and explanation of all payment
and reimbursement methodologies that will be used to pay claims submitted by a
physician or provider, including at a minimum, the:
(A) fee schedule, including, if applicable,
CPT, HCPCS, CDT, ICD-9-CM, ICD-10-CM, ICD-11-CM, and successor codes, and
modifiers:
(i) by which the HMO will calculate
and pay all claims for covered services submitted by or on behalf of the
contracting physician or provider; or
(ii) that pertains to the range of health
care services reasonably expected to be delivered under the contract by that
contracting physician or provider on a routine basis, along with a toll-free
number or electronic address through which the contracting physician or
provider may request the fee schedules applicable to any covered services that
the physician or provider intends to provide to an enrollee, and any other
information required by this subsection that pertains to the service for which
the fee schedule is being requested if the HMO has not previously provided that
information to the physician or provider;
(B) all applicable coding
methodologies;
(C) all applicable
bundling processes, which must be consistent with nationally recognized and
generally accepted bundling edits and logic;
(D) all applicable downcoding
policies;
(E) a description of any
other applicable policy or procedure the HMO may use that affects the payment
of specific claims submitted by or on behalf of the contracting physician or
provider, including recoupment;
(F)
any addenda, schedules, exhibits, or policies used by the HMO in carrying out
the payment of claims submitted by or on behalf of the contracting physician or
provider that are necessary to provide a reasonable understanding of the
information provided under this subsection; and
(G) the published product name and version of
any software the HMO uses to determine bundling and unbundling of
claims.
(2) In the case
of a reference to source information outside the control of the HMO as the
basis for fee computation, such as state Medicaid or federal Medicare fee
schedules, the information the HMO provides must clearly identify the source
and explain the procedure by which the physician or provider may readily access
the source electronically, telephonically, or as otherwise agreed to by the
parties.
(3) Nothing in this
subsection may be construed to require an HMO to provide specific information
that would violate any applicable copyright law or licensing agreement.
However, the HMO must supply, instead of any information withheld on the basis
of copyright law or licensing agreement, a summary of the information that will
allow a reasonable person with sufficient training, experience, and competence
in claims processing to determine the payment to be made under the terms of the
contract for covered services that are rendered to enrollees as required by
paragraph (1) of this subsection.
(4) No amendment, revision, or substitution
of any of the claims payment procedures or any of the information required to
be provided by this subsection will be effective as to the contracting
physician or provider, unless the HMO provides at least 90-calendar-days'
written notice to the contracting physician or provider identifying with
specificity the amendment, revision, or substitution. An HMO may not make
retroactive changes to claims payment procedures or any of the information
required to be provided by this subsection. Where a contract specifies mutual
agreement of the parties as the sole mechanism for requiring amendment,
revision, or substitution of the information required by this subsection, the
written notice specified in this section does not supersede the requirement for
mutual agreement.
(5) The HMO must
provide the information required by paragraphs (1) - (4) of this subsection to
the contracting physician or provider by the 30th day after the date the HMO
receives the contracting physician's or provider's request.
(6) A physician or provider receiving
information under this subsection may not:
(A) use or disclose the information for any
purpose other than:
(i) the physician's or
provider's practice management;
(ii) billing activities;
(iii) other business operations; or
(iv) communications with a governmental
agency involved in the regulation of health care or
insurance;
(B) use the
information to knowingly submit a claim for payment that does not accurately
represent the level, type, or amount of services that were actually provided to
an enrollee or to misrepresent any aspect of the services; or
(C) rely on information provided under this
paragraph about a service as a representation that an enrollee is covered for
that service under the terms of the enrollee's evidence of
coverage.
(7) A physician
or provider that receives information under this subsection may terminate the
contract on or before the 30th day after the date the physician or provider
receives the information without penalty or discrimination in participation in
other health care products or plans. The contract between the HMO and physician
or provider must provide for reasonable advance notice to enrollees being
treated by the physician or provider before the termination consistent with
Insurance Code §
843.309.
(8) The provisions of this subsection may not
be waived, voided, or nullified by contract.
(d) Physician and provider contracts,
subcontracts, and arrangements must include provisions regarding written
notification of termination to a physician or provider in compliance with
Insurance Code §
843.306, concerning
Termination of Participation; Advisory Review Panel, and §843.307, concerning
Expedited Review Process on Termination or Deselection, including provisions
providing that:
(1) the HMO must provide
notice of termination by the HMO to the physician or provider at least 90 days
before the effective date of the termination;
(2) not later than 30 days following receipt
of the written notification of termination, a physician or provider may request
a review by the HMO's advisory review panel except in a case involving:
(A) imminent harm to patient
health;
(B) an action by a state
medical or dental board, another medical or dental licensing board, or another
licensing board or government agency that effectively impairs the physician's
or provider's ability to practice medicine, dentistry, or another profession;
or
(C) fraud or malfeasance;
and
(3) within 60 days
after receipt of the physician or provider's request for review, the advisory
review panel must make its formal recommendation and the HMO must communicate
its decision to the physician or provider.
(e) On request by a participating physician
or provider, an HMO must include a provision in the physician's or provider's
contract providing that the HMO and the HMO's clearinghouse may not refuse to
process or pay an electronically submitted clean claim because the claim is
submitted together with or in a batch submission with a claim that is
deficient. As used in this section, the term "batch submission" means "a group
of electronic claims submitted for processing at the same time within a Health
Insurance Portability and Accountability Act (HIPAA) standard ASC X12N 837
Transaction Set and identified by a batch control number." This subsection
applies to a contract entered into or renewed on or after August 1, 2017. For a
contract entered into or renewed before August 1, 2017, the law and regulations
in effect at the time the contract was entered or renewed, whichever is later,
governs.
(f) A contract between an
HMO and a dentist may not limit the fee the dentist may charge for a service
that is not a covered service under Insurance Code §
843.3115, concerning
Contracts with Dentists.
(g) A
contract between an HMO and a provider, as that term is defined in Insurance
Code §
1458.001, concerning
General Definitions, must comply with Insurance Code §
1458.101, concerning
Contract Requirements, to the extent applicable.
Notes
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