Tex.
Ins. Code Section 1551.228
Emergency Care Payments
(a)
In this section, “emergency care” has the meaning assigned by Section 1301.155 (Emergency Care).(b)
The administrator of a managed care plan provided under the group benefits program shall pay for covered emergency care performed by or a covered supply related to that care provided by an out-of-network provider at the usual and customary rate or at an agreed rate. The administrator shall make a payment required by this subsection directly to the provider not later than, as applicable:(1)
the 30th day after the date the administrator receives an electronic claim for those services that includes all information necessary for the administrator to pay the claim; or(2)
the 45th day after the date the administrator receives a nonelectronic claim for those services that includes all information necessary for the administrator to pay the claim.(c)
For emergency care subject to this section or a supply related to that care, an out-of-network provider or a person asserting a claim as an agent or assignee of the provider may not bill a participant in, and the participant does not have financial responsibility for, an amount greater than an applicable copayment, coinsurance, and deductible under the participant’s managed care plan that:(1)
is based on:(A)
the amount initially determined payable by the administrator; or(B)
if applicable, a modified amount as determined under the administrator’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).
Source:
Section 1551.228 — Emergency Care Payments, https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1551.htm#1551.228 (accessed Jun. 5, 2024).
