CHAPTER 1457. PROVISIONAL CREDENTIALING STATUS
INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE F. PHYSICIANS AND HEALTH CARE PROVIDERS
CHAPTER 1457. PROVISIONAL CREDENTIALING STATUS
Sec. 1457.001. DEFINITIONS. In this chapter:
(1) "Enrollee" means an individual who is eligible to receive
health care services through a health benefit plan.
(2) "Physician" means an individual licensed to practice
medicine in this state under the authority of Subtitle B, Title
3, Occupations Code.
(3) "Provider network" means a health benefit plan under which
health care services are provided to enrollees through contracts
with physicians and that requires those enrollees to use
physicians participating in the plan and procedures covered by
the plan. The term includes a network operated by:
(A) a health maintenance organization;
(B) a preferred provider organization; or
(C) another entity that issues a health benefit plan, including
an insurance company.
Added by Acts 2005, 79th Leg., Ch.
789, Sec. 2, eff. June 17, 2005.
Sec. 1457.002. PROVISIONAL CREDENTIALING STATUS. (a) A health
benefit plan shall have a process for provisional credentialing
status in compliance with the requirements of the National
Committee for Quality Assurance.
(b) A health benefit plan may grant provisional credentialing
status to a physician who:
(1) submits a completed standard credentialing application to
the health benefit plan;
(2) meets the health plan's requirements for provisional
credentialing; and
(3) joins as a partner, shareholder, or employee of another
physician who is contracted with a health benefit plan to provide
medical or health care services to enrollees.
(c) A health benefit plan must complete the credentialing
process within 60 calendar days of the date a physician is
granted provisional status. In the event the physician does not
meet the health plan's credentialing standards, the physician
must be provided the same appeal process as any other physician
applying for participation with the health benefit plan.
Added by Acts 2005, 79th Leg., Ch.
789, Sec. 2, eff. June 17, 2005.