CHAPTER 1213. ELECTRONIC HEALTH CARE TRANSACTIONS
INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE A. HEALTH COVERAGE IN GENERAL
CHAPTER 1213. ELECTRONIC HEALTH CARE TRANSACTIONS
Sec. 1213.001. DEFINITION OF HEALTH BENEFIT PLAN. (a) In this
chapter, "health benefit plan" means a plan that provides
benefits for medical, surgical, or other treatment expenses
incurred as a result of a health condition, a mental health
condition, an accident, sickness, or substance abuse, 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 Lloyd's plan operating under Chapter 941;
(6) an exchange operating under Chapter 942;
(7) a health maintenance organization operating under Chapter
843;
(8) a multiple employer welfare arrangement that holds a
certificate of authority under Chapter 846; or
(9) an approved nonprofit health corporation that holds a
certificate of authority under Chapter 844.
(b) The term includes:
(1) a small employer health benefit plan written under Chapter
1501; and
(2) a health benefit plan offered under Chapter 1551, 1575,
1579, or 1601.
Added by Acts 2005, 79th Leg., Ch.
728, Sec. 11.029(a), eff. September 1, 2005.
Sec. 1213.002. ELECTRONIC SUBMISSION OF CLAIMS. (a) The issuer
of a health benefit plan by contract may require that a health
care professional licensed or registered under the Occupations
Code or a health care facility licensed under the Health and
Safety Code electronically submit a health care claim or
equivalent encounter information, a referral certification, or an
authorization or eligibility transaction. The health benefit
plan issuer shall comply with the standards for electronic
transactions required by this section and established by the
commissioner by rule.
(b) The issuer of a health benefit plan by contract shall
establish a default method to submit claims in a nonelectronic
format if there is a system failure or failures or a catastrophic
event substantially interferes with the normal business
operations of the physician, provider, or health benefit plan or
its agents. The health benefit plan issuer shall comply with the
standards for nonelectronic transactions established by the
commissioner by rule.
Added by Acts 2005, 79th Leg., Ch.
728, Sec. 11.029(a), eff. September 1, 2005.
Sec. 1213.003. ELECTRONIC SUBMISSION OF CLAIMS: WAIVER. (a) A
contract between the issuer of a health benefit plan and a health
care professional or health care facility must provide for a
waiver of any requirement for electronic submission established
under this chapter.
(b) The commissioner shall establish circumstances under which a
waiver is required, including:
(1) circumstances in which no method is available for the
submission of claims in electronic form;
(2) the operation of small physician practices;
(3) the operation of other small health care provider practices;
(4) undue hardship, including fiscal or operational hardship; or
(5) any other special circumstance that would justify a waiver.
(c) Any health care professional or health care facility that is
denied a waiver by the issuer of a health benefit plan may appeal
the denial to the commissioner. The commissioner shall determine
whether a waiver must be granted.
(d) The issuer of a health benefit plan may not refuse to
contract or renew a contract with a health care professional or
health care facility based in whole or in part on the
professional or facility requesting or receiving a waiver or
appealing a waiver determination.
Added by Acts 2005, 79th Leg., Ch.
728, Sec. 11.029(a), eff. September 1, 2005.
Sec. 1213.004. MODE OF TRANSMISSION. The issuer of a health
benefit plan may not by contract limit the mode of electronic
transmission that a health care professional or health care
facility may use to submit information under this chapter.
Added by Acts 2005, 79th Leg., Ch.
728, Sec. 11.029(a), eff. September 1, 2005.
Sec. 1213.005. CERTAIN CHARGES PROHIBITED. A health benefit
plan may not directly or indirectly charge or hold a health care
professional, health care facility, or person enrolled in a
health benefit plan responsible for a fee for the adjudication of
a claim.
Added by Acts 2005, 79th Leg., Ch.
728, Sec. 11.029(a), eff. September 1, 2005.
Sec. 1213.006. RULES. The commissioner may adopt rules as
necessary to implement this chapter. The commissioner may not
require any data element for electronically filed claims that is
not required to comply with federal law.
Added by Acts 2005, 79th Leg., Ch.
728, Sec. 11.029(a), eff. September 1, 2005.