CHAPTER 1274. ELECTRONIC TRANSMISSION OF ELIGIBILITY AND PAYMENT STATUS
INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE C. MANAGED CARE
CHAPTER 1274. ELECTRONIC TRANSMISSION OF ELIGIBILITY AND PAYMENT
STATUS
Sec. 1274.001. DEFINITIONS. In this chapter:
(1) "Enrollee" means an individual who is eligible for coverage
under a health benefit plan, including a covered dependent.
(2) "Health benefit plan" means a group, blanket, or franchise
insurance policy, a certificate issued under a group policy, a
group hospital service contract, or a group subscriber contract
or evidence of coverage issued by a health maintenance
organization that provides benefits for health care services.
The term does not include:
(A) accident-only or disability income insurance coverage or a
combination of accident-only and disability income insurance
coverage;
(B) credit-only insurance coverage;
(C) disability insurance coverage;
(D) coverage only for a specified disease or illness;
(E) Medicare services under a federal contract;
(F) Medicare supplement and Medicare Select policies regulated
in accordance with federal law;
(G) long-term care coverage or benefits, nursing home care
coverage or benefits, home health care coverage or benefits,
community-based care coverage or benefits, or any combination of
those coverages or benefits;
(H) coverage that provides limited-scope dental or vision
benefits;
(I) coverage provided by a single service health maintenance
organization;
(J) coverage issued as a supplement to liability insurance;
(K) workers' compensation insurance coverage or similar
insurance coverage;
(L) automobile medical payment insurance coverage;
(M) a jointly managed trust authorized under 29 U.S.C. Section
141 et seq. that contains a plan of benefits for employees that
is negotiated in a collective bargaining agreement governing
wages, hours, and working conditions of the employees that is
authorized under 29 U.S.C. Section 157;
(N) hospital indemnity or other fixed indemnity insurance
coverage;
(O) reinsurance contracts issued on a stop-loss, quota-share, or
similar basis;
(P) liability insurance coverage, including general liability
insurance and automobile liability insurance coverage; or
(Q) coverage that provides other limited benefits specified by
federal regulations.
(3) "Health benefit plan issuer" means a health maintenance
organization operating under Chapter 843, a preferred provider
organization operating under Chapter 1301, an approved nonprofit
health corporation that holds a certificate of authority under
Chapter 844, and any other entity that issues a health benefit
plan, including:
(A) an insurance company;
(B) a group hospital service corporation operating under Chapter
842;
(C) a fraternal benefit society operating under Chapter 885; or
(D) a stipulated premium company operating under Chapter 884.
(4) "Health care provider" means:
(A) a person, other than a physician, who is licensed or
otherwise authorized to provide a health care service in this
state, including:
(i) a pharmacist or dentist; or
(ii) a pharmacy, hospital, or other institution or organization;
(B) a person who is wholly owned or controlled by a provider or
by a group of providers who are licensed or otherwise authorized
to provide the same health care service; or
(C) a person who is wholly owned or controlled by one or more
hospitals and physicians, including a physician-hospital
organization.
(5) "Participating provider" means:
(A) a physician or health care provider who contracts with a
health benefit plan issuer to provide medical care or health care
to enrollees in a health benefit plan; or
(B) a physician or health care provider who accepts and treats a
patient on a referral from a physician or provider described by
Paragraph (A).
(6) "Physician" means:
(A) an individual licensed to practice medicine in this state
under Subtitle B, Title 3, Occupations Code;
(B) a professional association organized under the Texas
Professional Association Act (Article 1528f, Vernon's Texas Civil
Statutes);
(C) a nonprofit health corporation certified under Chapter 162,
Occupations Code;
(D) a medical school or medical and dental unit, as defined or
described by Section 61.003, 61.501, or 74.601, Education Code,
that employs or contracts with physicians to teach or provide
medical services or employs physicians and contracts with
physicians in a practice plan; or
(E) another entity wholly owned by physicians.
Added by Acts 2005, 79th Leg., Ch.
880, Sec. 1, eff. September 1, 2005.
Sec. 1274.0015. EXEMPTION. This chapter does not apply to a
single-service health maintenance organization that provides
coverage only for dental or vision benefits.
Added by Acts 2005, 79th Leg., Ch.
880, Sec. 1, eff. September 1, 2005.
Sec. 1274.002. TRANSMISSION OF ENROLLEE ELIGIBILITY AND PAYMENT
STATUS. (a) Each health benefit plan issuer shall, upon the
participating provider's submission of the patient's name,
relationship to the primary enrollee, and birth date, make
available telephonically, electronically, or by an Internet
website portal to each participating provider information
maintained in the ordinary course of business and sufficient for
the provider to determine at the time of the enrollee's visit
information concerning:
(1) the enrollee, including:
(A) the enrollee's identification number assigned by the health
benefit plan issuer;
(B) the name of the enrollee and all covered dependents, if
appropriate;
(C) the birth date of the enrollee and the birth dates of all
covered dependents, if appropriate;
(D) the gender of the enrollee and the gender of each covered
dependent, if appropriate; and
(E) the current enrollment and eligibility status of the
enrollee under the health benefit plan;
(2) the enrollee's benefits, including:
(A) whether a specific type or category of service is a covered
benefit; and
(B) excluded benefits or limitations, both group and individual;
and
(3) the enrollee's financial information, including:
(A) copayment requirements, if any; and
(B) the unmet amount of the enrollee's deductible or enrollee
financial responsibility.
(b) Information required to be made available under this section
may be made available only to a participating provider who is
authorized under state and federal law to receive personally
identifiable information on an enrollee or dependent.
Added by Acts 2005, 79th Leg., Ch.
880, Sec. 1, eff. September 1, 2005.
Sec. 1274.003. CERTAIN CHARGES PROHIBITED. A health benefit
plan issuer may not directly or indirectly charge or hold a
physician, health care provider, or enrollee responsible for a
fee for making available or accessing information under this
chapter.
Added by Acts 2005, 79th Leg., Ch.
880, Sec. 1, eff. September 1, 2005.
Sec. 1274.004. RULES. (a) The commissioner shall adopt rules
as necessary to implement this chapter.
(b) Before adopting rules under this section, the commissioner
shall consult and receive advice from the technical advisory
committee on claims processing established under Chapter 1212.
Added by Acts 2005, 79th Leg., Ch.
880, Sec. 1, eff. September 1, 2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch.
730, Sec. 2G.006, eff. April 1, 2009.
Sec. 1274.005. WAIVER OF CERTAIN PROVISIONS FOR CERTAIN FEDERAL
PLANS. If the commissioner, in consultation with the
commissioner of health and human services, determines that a
provision of Section 1274.002 will cause a negative fiscal impact
on the state with respect to providing benefits or services under
Subchapter XIX, Social Security Act (42 U.S.C. Section 1396 et
seq.), or Subchapter XXI, Social Security Act (42 U.S.C. Section
1397aa et seq.), the commissioner of insurance by rule shall
waive the application of that provision to the providing of those
benefits or services.
Added by Acts 2005, 79th Leg., Ch.
880, Sec. 1, eff. September 1, 2005.