CHAPTER 1452. PHYSICIAN AND PROVIDER CREDENTIALS
INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE F. PHYSICIANS AND HEALTH CARE PROVIDERS
CHAPTER 1452. PHYSICIAN AND PROVIDER CREDENTIALS
SUBCHAPTER A. CREDENTIALING OF PHYSICIANS AND PROVIDERS BY HEALTH
MAINTENANCE ORGANIZATION
Sec. 1452.001. APPLICABILITY OF CERTAIN DEFINITIONS. In this
subchapter, a term defined by Section 843.002 has the meaning
assigned by that section.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1452.002. VERIFICATION OF PHYSICIAN'S LICENSE OR
CERTIFICATE. The commissioner shall require a health maintenance
organization to verify that a physician's license to practice
medicine and any other certificate the physician is required to
hold, including a certificate issued by the Department of Public
Safety or the federal Drug Enforcement Administration or a
certificate issued under the Medicare program, is valid as of the
date of:
(1) initial credentialing of the physician; and
(2) each recredentialing.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1452.003. SITE VISIT FOR INITIAL CREDENTIALING. (a) The
commissioner shall require a health maintenance organization that
conducts a site visit for the purpose of initial credentialing of
a physician or provider to evaluate during the visit a site's
accessibility, appearance, space, medical or dental recordkeeping
practices, availability of appointments, and confidentiality
procedures.
(b) The commissioner may not require the health maintenance
organization to evaluate the appropriateness of equipment during
the site visit.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1452.004. LIMITATION ON COMMISSIONER'S AUTHORITY. The
commissioner may not require a health maintenance organization
to:
(1) formally recredential a physician or provider more
frequently than once in any three-year period;
(2) verify the validity of a license or certificate held by a
physician as of a date other than the date of initial
credentialing or recredentialing of the physician;
(3) use clinical personnel to perform a site visit for initial
credentialing of a physician or provider unless clinical review
is needed during the site visit; or
(4) require a site visit be performed for the purpose of
recredentialing of a physician or provider.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1452.005. SITE VISIT FOR CAUSE NOT PRECLUDED. This
subchapter does not preclude a health maintenance organization
from conducting a site visit of a physician or provider at any
time for cause, including a complaint made by a member or another
external complaint made to the health maintenance organization.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1452.006. RULES RELATED TO SELECTION OF PHYSICIANS AND
PROVIDERS BY HEALTH MAINTENANCE ORGANIZATION. A rule adopted by
the commissioner under Section 843.102 that relates to
implementation and maintenance by a health maintenance
organization of a process for selecting and retaining affiliated
physicians and providers must comply with:
(1) this subchapter; and
(2) standards adopted by the National Committee for Quality
Assurance, to the extent those standards do not conflict with
other laws of this state.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER B. STANDARDIZED FORMS
Sec. 1452.051. DEFINITIONS. In this subchapter:
(1) "Advanced practice nurse" has the meaning assigned by
Section 301.152, Occupations Code.
(2) "Physician" means an individual licensed to practice
medicine in this state.
(3) "Physician assistant" means an individual who holds a
license issued under Chapter 204, Occupations Code.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2005, 79th Leg., Ch.
728, Sec. 11.045(a), eff. September 1, 2005.
Sec. 1452.052. STANDARDIZED FORM FOR VERIFICATION OF
CREDENTIALS. (a) The commissioner by rule shall:
(1) prescribe a standardized form for the verification of the
credentials of a physician, advanced practice nurse, or physician
assistant; and
(2) require a public or private hospital, a health maintenance
organization operating under Chapter 843, or the issuer of a
preferred provider benefit plan under Chapter 1301 to use the
form for verification of credentials.
(b) In prescribing a form under this section, the commissioner
shall consider any credentialing application form that is widely
used in this state or any form currently used by the department.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2005, 79th Leg., Ch.
728, Sec. 11.045(a), eff. September 1, 2005.
SUBCHAPTER C. EXPEDITED CREDENTIALING PROCESS
FOR CERTAIN PHYSICIANS
Sec. 1452.101. DEFINITIONS. In this subchapter:
(1) "Applicant physician" means a physician applying for
expedited credentialing under this subchapter.
(2) "Enrollee" means an individual who is eligible to receive
health care services under a managed care plan.
(3) "Health care provider" means:
(A) an individual who is licensed, certified, or otherwise
authorized to provide health care services in this state; or
(B) a hospital, emergency clinic, outpatient clinic, or other
facility providing health care services.
(4) "Managed care plan" means a health benefit plan under which
health care services are provided to enrollees through contracts
with health care providers and that requires enrollees to use
participating providers or that provides a different level of
coverage for enrollees who use participating providers. The term
includes a health benefit plan issued by:
(A) a health maintenance organization;
(B) a preferred provider benefit plan issuer; or
(C) any other entity that issues a health benefit plan,
including an insurance company.
(5) "Medical group" means:
(A) a single legal entity owned by two or more physicians;
(B) a professional association composed of licensed physicians;
or
(C) any other business entity composed of licensed physicians as
permitted under Subchapter B, Chapter 162, Occupations Code.
(6) "Participating provider" means a health care provider who
has contracted with a health benefit plan issuer to provide
services to enrollees.
Added by Acts 2007, 80th Leg., R.S., Ch.
1203, Sec. 1, eff. September 1, 2007.
Amended by:
Acts 2009, 81st Leg., R.S., Ch.
296, Sec. 1, eff. September 1, 2009.
Sec. 1452.102. APPLICABILITY. This subchapter applies only to a
physician who joins an established medical group that has a
current contract in force with a managed care plan.
Added by Acts 2007, 80th Leg., R.S., Ch.
1203, Sec. 1, eff. September 1, 2007.
Sec. 1452.103. ELIGIBILITY REQUIREMENTS. To qualify for
expedited credentialing under this subchapter and payment under
Section 1452.104, an applicant physician must:
(1) be licensed in this state by, and in good standing with, the
Texas Medical Board;
(2) submit all documentation and other information required by
the issuer of the managed care plan as necessary to enable the
issuer to begin the credentialing process required by the issuer
to include a physician in the issuer's health benefit plan
network; and
(3) agree to comply with the terms of the managed care plan's
participating provider contract currently in force with the
applicant physician's established medical group.
Added by Acts 2007, 80th Leg., R.S., Ch.
1203, Sec. 1, eff. September 1, 2007.
Sec. 1452.104. PAYMENT OF APPLICANT PHYSICIAN DURING
CREDENTIALING PROCESS. On submission by the applicant physician
of the information required by the managed care plan issuer under
Section 1452.103(2), and for payment purposes only, the issuer
shall treat the applicant physician as if the physician were a
participating provider in the health benefit plan network when
the applicant physician provides services to the managed care
plan's enrollees, including:
(1) authorizing the applicant physician to collect copayments
from the enrollees; and
(2) making payments to the applicant physician.
Added by Acts 2007, 80th Leg., R.S., Ch.
1203, Sec. 1, eff. September 1, 2007.
Sec. 1452.105. DIRECTORY ENTRIES. Pending the approval of an
application submitted under Section 1452.104, the managed care
plan may exclude the applicant physician from the managed care
plan's directory of participating physicians, the managed care
plan's website listing of participating physicians, or any other
listing of participating physicians.
Added by Acts 2007, 80th Leg., R.S., Ch.
1203, Sec. 1, eff. September 1, 2007.
Sec. 1452.106. EFFECT OF FAILURE TO MEET CREDENTIALING
REQUIREMENTS. If, on completion of the credentialing process,
the managed care plan issuer determines that the applicant
physician does not meet the issuer's credentialing requirements:
(1) the managed care plan issuer may recover from the applicant
physician or the physician's medical group an amount equal to the
difference between payments for in-network benefits and
out-of-network benefits; and
(2) the applicant physician or the physician's medical group may
retain any copayments collected or in the process of being
collected as of the date of the issuer's determination.
Added by Acts 2007, 80th Leg., R.S., Ch.
1203, Sec. 1, eff. September 1, 2007.
Sec. 1452.107. ENROLLEE HELD HARMLESS. An enrollee in the
managed care plan is not responsible and shall be held harmless
for the difference between in-network copayments paid by the
enrollee to a physician who is determined to be ineligible under
Section 1452.106 and the managed care plan's charges for
out-of-network services. The physician and the physician's
medical group may not charge the enrollee for any portion of the
physician's fee that is not paid or reimbursed by the enrollee's
managed care plan.
Added by Acts 2007, 80th Leg., R.S., Ch.
1203, Sec. 1, eff. September 1, 2007.
Sec. 1452.108. LIMITATION ON MANAGED CARE ISSUER LIABILITY. A
managed care plan issuer that complies with this subchapter is
not subject to liability for damages arising out of or in
connection with, directly or indirectly, the payment by the
issuer of an applicant physician as if the physician were a
participating provider in the health benefit plan network.
Added by Acts 2007, 80th Leg., R.S., Ch.
1203, Sec. 1, eff. September 1, 2007.