Tex. Ins. Code Section 1301.0051
Exclusive Provider Benefit Plans: Quality Improvement and Utilization Management

(a)

An insurer that offers an exclusive provider benefit plan shall establish procedures to ensure that health care services are provided to insureds under reasonable standards of quality of care that are consistent with prevailing professionally recognized standards of care or practice. The procedures must include:

(1)

mechanisms to ensure availability, accessibility, quality, and continuity of care;

(2)

subject to Section 1301.059 (Quality Assessment), a continuing quality improvement program to monitor and evaluate services provided under the plan, including primary and specialist physician services and ancillary and preventive health care services, provided in institutional or noninstitutional settings;

(3)

a method of recording formal proceedings of quality improvement program activities and maintaining quality improvement program documentation in a confidential manner;

(4)

subject to Section 1301.059 (Quality Assessment), a physician review panel to assist the insurer in reviewing medical guidelines or criteria;

(5)

a patient record system that facilitates documentation and retrieval of clinical information for the insurer’s evaluation of continuity and coordination of services and assessment of the quality of services provided to insureds under the plan;

(6)

a mechanism for making available to the commissioner the clinical records of insureds for examination and review by the commissioner on request of the commissioner; and

(7)

a specific procedure for the periodic reporting of quality improvement program activities to:

(A)

the governing body and appropriate staff of the insurer; and

(B)

physicians and health care providers that provide health care services under the plan.

(b)

Minutes of a formal proceeding of the quality improvement program established under Subsection (a) shall be made available to the commissioner on request of the commissioner.

(c)

Insured records made available to the commissioner under Subsection (a)(6) are confidential and privileged, and are not subject to Chapter 552 (Public Information), Government Code, or to subpoena, except to the extent necessary for the commissioner to enforce this chapter.
Added by Acts 2011, 82nd Leg., R.S., Ch. 288 (H.B. 1772), Sec. 9, eff. September 1, 2011.

Source: Section 1301.0051 — Exclusive Provider Benefit Plans: Quality Improvement and Utilization Management, https://statutes.­capitol.­texas.­gov/Docs/IN/htm/IN.­1301.­htm#1301.­0051 (accessed Jun. 5, 2024).

1301.001
Definitions 1301.002
Nonapplicability to Dental Care Benefits 1301.003
Preferred Provider Benefit Plans and Exclusive Provider Benefit Plans Permitted 1301.005
Availability of Preferred Providers 1301.006
Availability of and Accessibility to Health Care Services 1301.007
Rules 1301.008
Conflict with Other Law 1301.009
Annual Report 1301.010
Balance Billing Prohibition Notice 1301.0041
Applicability 1301.0042
Applicability of Insurance Law 1301.0045
Construction of Chapter 1301.0046
Coinsurance Requirements for Services of Nonpreferred Providers 1301.0051
Exclusive Provider Benefit Plans: Quality Improvement and Utilization Management 1301.051
Designation as Preferred Provider 1301.052
Designation of Advanced Practice Nurse or Physician Assistant as Preferred Provider 1301.0052
Exclusive Provider Benefit Plans: Referrals for Medically Necessary Services 1301.053
Appeal Relating to Designation as Preferred Provider 1301.0053
Exclusive Provider Benefit Plans: Emergency Care 1301.054
Notice to Practitioners of Preferred Provider Benefit Plan 1301.0055
Network Adequacy Standards 1301.055
Complaint Resolution 1301.0056
Examinations and Fees 1301.056
Restrictions on Payment and Reimbursement 1301.0057
Access to Out-of-network Providers 1301.057
Termination of Participation 1301.0058
Protected Communications by Preferred Providers 1301.058
Economic Profiling 1301.059
Quality Assessment 1301.060
Compensation on Discounted Fee Basis 1301.0061
Terms of Enrollee Eligibility 1301.061
Preferred Provider Networks 1301.062
Preferred Provider Contracts Between Insurers and Podiatrists 1301.063
Contract Provisions Relating to Use of Hospitalist 1301.064
Contract Provisions Relating to Payment of Claims 1301.065
Shifting of Insurer’s Tort Liability Prohibited 1301.066
Retaliation Against Preferred Provider Prohibited 1301.067
Interference with Relationship Between Patient and Physician or Health Care Provider Prohibited 1301.068
Inducement to Limit Medically Necessary Services Prohibited 1301.069
Services Provided by Certain Physicians and Health Care Providers 1301.101
Definition 1301.102
Submission of Claim 1301.103
Deadline for Action on Clean Claims 1301.104
Deadline for Action on Pharmacy Claims 1301.105
Audited Claims 1301.106
Claims Processing Procedures and Claims Payment Processes 1301.107
Contractual Waiver and Other Actions Prohibited 1301.108
Attorney’s Fees 1301.109
Applicability to Entities Contracting with Insurer 1301.131
Elements of Clean Claim 1301.132
Overpayment 1301.133
Verification 1301.134
Coordination of Payment 1301.135
Preauthorization of Medical and Health Care Services 1301.136
Availability of Coding Guidelines 1301.137
Violation of Claims Payment Requirements 1301.138
Applicability to Entities Contracting with Insurer 1301.139
Legislative Declaration 1301.140
Out-of-pocket Expense Credit 1301.151
Insured’s Right to Treatment 1301.152
Continuing Care in General 1301.153
Continuity of Care 1301.154
Obligation for Continuity of Care of Insurer 1301.155
Emergency Care 1301.156
Payment of Claims to Insured 1301.157
Plain Language Requirements 1301.158
Information Concerning Preferred Provider Benefit Plans 1301.159
Annual List of Preferred Providers 1301.160
Notification of Termination of Participation of Preferred Provider 1301.161
Retaliation Against Insured Prohibited 1301.162
Identification Card 1301.163
Applicability of Subchapter to Entities Contracting with Insurer 1301.164
Out-of-network Facility-based Providers 1301.165
Out-of-network Diagnostic Imaging Provider or Laboratory Service Provider 1301.166
Out-of-network Emergency Medical Services Provider 1301.201
Contracts with and Reimbursement for Nurse First Assistants 1301.202
Contracts with Hospitals 1301.0515
Acupuncturist Services 1301.0516
Chiropractic Services 1301.0521
Designation of Certain Podiatrists as Preferred Providers 1301.0522
Designation of Certain Optometrists, Therapeutic Optometrists, and Ophthalmologists as Preferred Providers 1301.00553
Maximum Travel Time and Distance Standards by Preferred Provider Type 1301.00554
Other Maximum Distance Standard Requirements 1301.00555
Maximum Appointment Wait Time Standards 1301.00565
Public Hearing on Network Adequacy Standards Waivers 1301.00566
Effect of Network Adequacy Standards Waiver on Balance Billing Prohibitions 1301.0625
Health Care Collaboratives 1301.0641
Contract Provisions Prohibiting Rejection of Batched Claims 1301.0642
Contract Provisions Allowing Certain Adverse Material Changes Prohibited 1301.1021
Receipt of Claim 1301.1051
Completion of Audit 1301.1052
Preferred Provider Appeal After Audit 1301.1053
Deadlines Not Extended 1301.1054
Requests for Additional Information 1301.1351
Posting of Preauthorization Requirements 1301.1352
Changes to Preauthorization Requirements 1301.1353
Remedy for Noncompliance 1301.1581
Information Concerning Exclusive Provider Benefit Plans 1301.1591
Preferred Provider Information on Internet
Green check means up to date. Up to date

Accessed:
Jun. 5, 2024

§ 1301.0051’s source at texas​.gov