28 Tex. Admin. Code § 3.9204 - Contracting with Health Care Providers

(a) An issuer shall notify, by publication or in writing, all health care providers in the service area of its intent to offer an EPP and of the opportunity to participate. The issuer shall provide such notice prior to issuance of the initial EPP and yearly thereafter.

(b) An issuer shall on request make available and disclose to any health care provider the issuer's written application procedures, qualifications and information concerning requirements for participation as an exclusive provider. An issuer shall provide written notice of the reasons it denied the application to each health care provider who applies to contract and who is denied.

(c) An issuer may not, on the sole basis of category or specific type of license or authorization, deny to any health care provider licensed or otherwise authorized to practice in this state, participation to provide health care services that are covered by the issuer, and within the scope of licensure or authorization of that health care provider.

(d) This subsection does not prohibit the issuer from rejecting an application from a health care provider based on the determination that the plan has sufficient qualified health care providers.

(e) Each exclusive provider contract (or subcontract) must provide that, before terminating a contract with an exclusive provider, the contracting entity must provide a written explanation to the exclusive provider of the reasons for termination. On request and before the effective date of the termination, but within a period not to exceed 60 days, a provider will be entitled to a review of the issuer's proposed termination by an advisory review panel, except in a case in which there is imminent harm to patient health or an action by a state medical or dental board, other medical or dental licensing board, or other licensing board or other government entity, that effectively impairs the health care provider's ability to practice medicine, dentistry, or another profession, or in a case of fraud or malfeasance. The advisory review panel shall be composed of exclusive providers, including at least one representative in the health care provider's specialty or a similar specialty, if available, appointed to serve on the standing quality assurance committee or utilization review committee of the issuer. The issuer must consider the decision of the advisory review panel, but it is not binding on the issuer. The issuer will provide to the affected health care provider, on request, a copy of the recommendation of the advisory review panel and the issuer's determination.

(f) Each exclusive provider contract (or subcontract) must provide that an issuer or provider shall give reasonable advance notice to an insured of the impending termination from the plan of an exclusive provider who is currently treating the insured. Each contract must also provide that the termination of the exclusive provider's contract, except for reason of medical competence or professional behavior, does not release the issuer from the obligation to reimburse the exclusive provider who is treating a patient of special circumstance, such as a person who has a disability, acute condition, or life-threatening illness or is past the twenty-fourth week of pregnancy, at no less than the contract rate for that insured's care in exchange for continuity of ongoing treatment of an insured then receiving medically necessary treatment in accordance with the dictates of medical prudence. For purposes of this subsection, "special circumstance" means a condition such that the treating health care provider reasonably believes that discontinuing care by the treating health care provider could cause harm to the patient. The treating health care provider must identify the special circumstance and must request that the insured be permitted to continue treatment under the health care provider's care and agree not to seek payment from the patient of any amounts for which the insured would not be responsible if the exclusive provider were still in the EPP network. Each exclusive provider contract shall provide procedures for resolving disputes regarding the necessity for continued treatment by the exclusive provider. This section does not extend the obligation of the issuer to reimburse the terminated health care provider for ongoing treatment of an insured beyond the 90th day after the effective date of the termination, or beyond nine months in the case of an insured who at the time of the termination has been diagnosed with a terminal illness. However, the obligation of the issuer to reimburse the terminated health care provider for services to an insured who at the time of the termination is past the 24th week of pregnancy, extends through delivery of the child, immediate postpartum care, and any follow-up checkup within the first six weeks of delivery.

(g) On request by the exclusive provider, an issuer must provide an expedited review process to any exclusive provider who is terminated or deselected. If the exclusive provider is deselected for reasons other than at the provider's request, the issuer may not notify insureds of the exclusive provider's deselection until the effective date of the termination or the time a review panel makes a formal recommendation. If an exclusive provider is deselected for reasons related to imminent harm, the issuer may notify insureds immediately.

(h) An exclusive provider contract (or subcontract) may not contain any clause purporting to indemnify the issuer for any tort liability resulting from acts or omissions of the issuer.

(i) An exclusive provider contract (or subcontract) shall specify that the exclusive provider will hold an insured harmless for payment of the cost of covered health care services in the event the issuer fails to pay the provider for health care services.

(j) An issuer that conducts or uses economic profiling of exclusive providers must make available upon request from a network provider the economic profile of that provider, including the standards by which the provider is measured. An economic profile must recognize the characteristics of an exclusive provider's practice that may account for variations from expected costs.

(k) An exclusive provider contract must require the health care provider to post, in the office of the health care provider, a notice to insureds of the process for resolving complaints with the issuer. The notice must include the Texas Department of Insurance's toll-free telephone number for filing non-Medicaid complaints.

(l) An exclusive provider contract may not prohibit, attempt to prohibit, or discourage an exclusive provider from discussing with or communicating in good faith to a current, prospective, or former patient, or a party designated by a patient, with respect to:

(1) information or opinions regarding the patient's health care, including the patient's medical condition or treatment options;

(2) information or opinions regarding the provisions, terms, requirements, or services of the EPP as they relate to the medical needs of the patient; or

(3) the fact that the exclusive provider's contract has terminated or that the exclusive provider will otherwise no longer be providing health care services under the EPP.

(m) An issuer may not in any way penalize, terminate, or refuse to compensate an exclusive provider for communicating with a current, prospective, or former patient, or a party designated by a patient, in any manner protected by this subchapter.

Notes

28 Tex. Admin. Code § 3.9204

The provisions of this §3.9204 adopted to be effective September 17, 2003, 28 TexReg 7993