Tex. Ins. Code Section 1271.158
Non-network Diagnostic Imaging Provider or Laboratory Service Provider


(a)

In this section, “diagnostic imaging provider” and “laboratory service provider” have the meanings assigned by Section 1467.001 (Definitions).

(b)

Except as provided by Subsection (d), a health maintenance organization shall pay for a covered health care service performed by or a covered supply related to that service provided to an enrollee by a non-network diagnostic imaging provider or laboratory service provider at the usual and customary rate or at an agreed rate if the provider performed the service in connection with a health care service performed by a network physician or provider. The health maintenance organization shall make a payment required by this subsection directly to the physician or provider not later than, as applicable:

(1)

the 30th day after the date the health maintenance organization receives an electronic clean claim as defined by Section 843.336 (Definition) for those services that includes all information necessary for the health maintenance organization to pay the claim; or

(2)

the 45th day after the date the health maintenance organization receives a nonelectronic clean claim as defined by Section 843.336 (Definition) for those services that includes all information necessary for the health maintenance organization to pay the claim.

(c)

Except as provided by Subsection (d), a non-network diagnostic imaging provider or laboratory service provider or a person asserting a claim as an agent or assignee of the provider may not bill an enrollee receiving a health care service or supply described by Subsection (b) in, and the enrollee does not have financial responsibility for, an amount greater than an applicable copayment, coinsurance, and deductible under the enrollee’s health care plan that:

(1)

is based on:

(A)

the amount initially determined payable by the health maintenance organization; or

(B)

if applicable, a modified amount as determined under the health maintenance organization’s internal appeal process; and

(2)

is not based on any additional amount determined to be owed to the provider under Chapter 1467 (Out-of-network Claim Dispute Resolution).

(d)

This section does not apply to a nonemergency health care or medical service:

(1)

that an enrollee elects to receive in writing in advance of the service with respect to each non-network physician or provider providing the service; and

(2)

for which a non-network physician or provider, before providing the service, provides a complete written disclosure to the enrollee that:

(A)

explains that the physician or provider does not have a contract with the enrollee’s health benefit plan;

(B)

discloses projected amounts for which the enrollee may be responsible; and

(C)

discloses the circumstances under which the enrollee would be responsible for those amounts.

(e)

This section may not be construed to require the imposition of a penalty under Section 843.342 (Violation of Certain Claims Payment Provisions; Penalties).
Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 1.04, eff. September 1, 2019.

Source: Section 1271.158 — Non-network Diagnostic Imaging Provider or Laboratory Service Provider, https://statutes.­capitol.­texas.­gov/Docs/IN/htm/IN.­1271.­htm#1271.­158 (accessed May 18, 2024).

1271.001
Applicability of Definitions
1271.002
Right to Evidence of Coverage
1271.003
Evidence of Coverage Not Health Insurance Policy
1271.004
Individual Health Care Plan
1271.005
Applicability of Other Law
1271.006
Benefits to Dependent Child and Grandchild
1271.007
Religious Convictions
1271.008
Balance Billing Prohibition Notice
1271.051
Evidence of Coverage: Contract and Certificate Requirements
1271.052
Information About Benefits and Limitations
1271.053
Information About Obtaining Services
1271.054
Information About Complaints and Appeals
1271.055
Out-of-network Services
1271.056
Unfair or Deceptive Provisions and Statements Prohibited
1271.057
Discretionary Clauses Prohibited
1271.101
Approval of Form of Evidence of Coverage or Group Contract
1271.102
Procedures for Approval of Form of Evidence of Coverage or Group Contract
1271.103
Withdrawal of Approval of Form
1271.104
Information Required by Commissioner
1271.151
Provision of Basic Health Care Services
1271.152
Standards for Basic Health Care Services
1271.153
Periodic Health Evaluations
1271.154
Well-child Care from Birth
1271.155
Emergency Care
1271.156
Benefits for Rehabilitation Services and Therapies
1271.157
Non-network Facility-based Providers
1271.158
Non-network Diagnostic Imaging Provider or Laboratory Service Provider
1271.159
Non-network Emergency Medical Services Provider
1271.201
Designation of Specialist as Primary Care Physician
1271.202
Appeal
1271.203
Effective Date of Designation
1271.251
Approval of Formula or Method for Computing Schedule of Charges
1271.252
Consideration of Individual Health Status Prohibited
1271.253
Information Required by Commissioner
1271.301
Entitlement to Continuation of Group Coverage
1271.302
Request for Continued Coverage
1271.303
Payment for Continued Coverage
1271.304
Termination of Continued Coverage
1271.306
Conversion Contracts
1271.307
Renewability of Coverage: Individual Health Care Plans and Conversion Contracts

Accessed:
May 18, 2024

§ 1271.158’s source at texas​.gov