1305.154
(a) Except for emergencies and out-of-network referrals, a network may provide health care services to employees only through a written contract with an insurance carrier. A network-carrier contract under this section is confidential and is not subject to disclosure as public information under Chapter 552, Government Code. (b) A carrier and a network may negotiate […]
1305.053
Each certificate application must include: (1) a description or a copy of the applicant’s basic organizational structure documents and other related documents, including organizational charts or lists that show: (A) the relationships and contracts between the applicant and any affiliates of the applicant; and (B) the internal organizational structure of the applicant’s management and administrative […]
4201.502
Repealed by Acts 2009, 81st Leg., ch. 1330, § 19(3), eff. Sept. 1, 2009 Added by Acts 2005, 79th Leg., ch. 727, § 4, eff. April 1, 2007.
4201.501
Repealed by Acts 2009, 81st Leg., ch. 1330, § 19(3), eff. Sept. 1, 2009 Added by Acts 2005, 79th Leg., ch. 727, § 4, eff. April 1, 2007.
4201.401
(a) A utilization review agent shall allow any party whose appeal of an adverse determination is denied by the agent to seek review of that determination by an independent review organization assigned to the appeal in accordance with Chapter 4202. (b) The utilization review agent shall comply with the independent review organization’s determination regarding the […]
4201.305
(a) Notwithstanding Sections 4201.302 and 4201.304, if a retrospective utilization review is conducted, the utilization review agent shall provide notice of an adverse determination under the retrospective utilization review in writing to the provider of record and the patient within a reasonable period, but not later than 30 days after the date on which the […]
4201.051
This chapter does not apply to a person who: (1) provides information to an enrollee about scope of coverage or benefits provided under a health insurance policy or health benefit plan; and (2) does not determine whether a particular health care service provided or to be provided to an enrollee is: (A) medically necessary or […]
1305.056
(a) A network that contracts with a provider or providers practicing individually or as a group is not, because of the contract or arrangement, considered to have entered into a conspiracy in restraint of trade in violation of Chapter 15, Business & Commerce Code. (b) Notwithstanding any other law, a person who contracts under this […]
1305.251
(a) As often as the commissioner considers necessary, the commissioner or the commissioner’s designated representative may review the operations of a network to determine compliance with this chapter. The review may include on-site visits to the network’s premises. (b) During on-site visits, the network must make available to the department all records relating to the […]
1305.1545
(a) An insurance carrier or administrator may not reimburse a doctor or other health care provider, an institutional provider, or an organization of doctors and health care providers on a discounted fee basis for services that are provided to an injured employee unless: (1) the carrier or administrator has contracted with either: (A) the doctor […]