Tex. Ins. Code Section 1272.301
Access to Out-of-network Services


(a)

A contract between a health maintenance organization and a limited provider network or delegated entity must provide that:

(1)

if medically necessary covered services are not available through network physicians or providers, the limited provider network or delegated entity, on the request of a network physician or provider, shall:

(A)

allow a referral to a non-network physician or provider; and

(B)

fully reimburse the non-network physician or provider at the usual and customary rate or an agreed rate; and

(2)

before the limited provider network or delegated entity may deny a referral to a non-network physician or provider, a specialist of the same or similar specialty as the type of physician or provider to whom the referral is requested must conduct a review of the request.

(b)

The limited provider network or delegated entity shall allow the referral within the time appropriate to the circumstances relating to the delivery of the services and the condition of the enrollee who is a patient, but not later than the fifth business day after the date the network or entity receives any reasonably requested documentation.

(c)

An enrollee may not be required to change the enrollee’s primary care physician or specialist providers to receive medically necessary covered services that are not available within the limited provider network or through the delegated entity.

(d)

A denial of out-of-network services under this section is subject to appeal under Chapter 4201 (Utilization Review Agents).
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2G.005, eff. April 1, 2009.

Source: Section 1272.301 — Access to Out-of-network Services, https://statutes.­capitol.­texas.­gov/Docs/IN/htm/IN.­1272.­htm#1272.­301 (accessed Dec. 2, 2023).

1272.001
Definitions
1272.002
Compliance of Limited Provider Network or Delegated Entity with Certain Legal Requirements
1272.051
Applicability of Subchapter
1272.052
Delegation Agreement Required
1272.053
Monitoring Plan
1272.054
Requirements for Termination Without Cause
1272.055
Collection of Payments
1272.056
Compliance with Statutory and Regulatory Requirements
1272.057
Examination by Commissioner
1272.058
Information Relating to Delegated Third Party
1272.059
Contracts with Delegated Third Party
1272.060
Utilization Review
1272.061
Rights and Duties of Delegated Entity and Health Maintenance Organization
1272.062
Information to Be Provided by Delegated Entity to Health Maintenance Organization
1272.063
Enrollee Complaints
1272.064
Rules
1272.101
Applicability of Subchapter
1272.102
Reporting Required
1272.103
Rules
1272.151
Applicability of Subchapter
1272.152
General Reserve Requirements
1272.153
Reserve Requirements for Medical Care and Hospital or Institutional Services
1272.154
Reserve Requirements for Prescription Drugs
1272.155
Form of Reserves
1272.156
Escrow Account
1272.201
Applicability of Subchapter
1272.202
Notice of Noncompliance or Hazardous Operating Condition
1272.203
Response to Notice
1272.204
Cooperation of Health Maintenance Organization
1272.205
Examination by Department
1272.206
Response to Department Report
1272.207
Request for Corrective Action
1272.208
Authority of Commissioner to Issue Order
1272.209
Public Documents
1272.210
Record of Complaints
1272.211
Rules
1272.251
Applicability of Subchapter
1272.252
Suspension or Revocation of License of Third-party Administrator or Utilization Review Agent
1272.253
Sanctions and Penalties Against Health Maintenance Organization
1272.254
Contractual Penalties Required
1272.255
Rules
1272.301
Access to Out-of-network Services
1272.302
Continuity of Care

Accessed:
Dec. 2, 2023

§ 1272.301’s source at texas​.gov