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A BILL TO BE ENTITLED
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AN ACT
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relating to expedited credentialing for certain physicians |
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providing services under a managed care plan. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Chapter 1452, Insurance Code, is amended by |
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adding Subchapter C to read as follows: |
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SUBCHAPTER C. EXPEDITED CREDENTIALING PROCESS |
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FOR CERTAIN PHYSICIANS |
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Sec. 1452.101. DEFINITIONS. In this subchapter: |
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(1) "Applicant physician" means a physician applying |
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for expedited credentialing under this subchapter. |
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(2) "Enrollee" means an individual who is eligible to |
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receive health care services under a managed care plan. |
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(3) "Health care provider" means: |
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(A) an individual who is licensed, certified, or |
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otherwise authorized to provide health care services in this state; |
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or |
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(B) a hospital, emergency clinic, outpatient |
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clinic, or other facility providing health care services. |
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(4) "Managed care plan" means a health benefit plan |
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under which health care services are provided to enrollees through |
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contracts with health care providers and that requires enrollees to |
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use participating providers or that provides a different level of |
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coverage for enrollees who use participating providers. The term |
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includes a health benefit plan issued by: |
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(A) a health maintenance organization; |
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(B) a preferred provider benefit plan issuer; or |
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(C) any other entity that issues a health benefit |
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plan, including an insurance company. |
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(5) "Medical group" means a professional corporation |
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or other business entity composed of licensed physicians as |
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permitted under Subchapter B, Chapter 162, Occupations Code. |
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(6) "Participating provider" means a health care |
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provider who has contracted with a health benefit plan issuer to |
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provide services to enrollees. |
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Sec. 1452.102. APPLICABILITY. This subchapter applies only |
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to a physician who joins an established medical group that has a |
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current contract in force with a managed care plan. |
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Sec. 1452.103. ELIGIBILITY REQUIREMENTS. To qualify for |
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expedited credentialing under this subchapter, an applicant |
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physician must: |
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(1) be licensed in this state by, and in good standing |
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with, the Texas Medical Board; and |
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(2) submit all documentation and other information |
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required by the issuer of the managed care plan as necessary to |
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enable the issuer to begin the credentialing process required by |
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the issuer to include a physician in the issuer's health benefit |
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plan network. |
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Sec. 1452.104. PAYMENT OF APPLICANT PHYSICIAN DURING |
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CREDENTIALING PROCESS. On submission by the applicant physician of |
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the information required by the managed care plan issuer under |
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Section 1452.103(2), the issuer shall treat the applicant physician |
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as if the physician were a participating provider in the health |
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benefit plan network when the applicant physician provides services |
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to the managed care plan's enrollees, including: |
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(1) authorizing the applicant physician to collect |
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copayments from the enrollees; and |
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(2) making payments to the applicant physician. |
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Sec. 1452.105. DIRECTORY ENTRIES. Pending the approval of |
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the application, the managed care plan may exclude the applicant |
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physician from the managed care plan's directory of participating |
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physicians, the managed care plan's website listing of |
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participating physicians, or any other listing of participating |
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physicians. |
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Sec. 1452.106. EFFECT OF FAILURE TO MEET CREDENTIALING |
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REQUIREMENTS. If, on completion of the credentialing process, the |
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managed care plan issuer determines that the applicant physician |
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does not meet the issuer's credentialing requirements: |
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(1) the managed care plan issuer may recover from the |
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applicant physician or the physician's medical group an amount |
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equal to the difference between payments for in-network benefits |
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and out-of-network benefits; and |
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(2) the applicant physician or the physician's medical |
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group may retain any copayments collected or in the process of being |
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collected as of the date of the issuer's determination. |
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Sec. 1452.107. ENROLLEE HELD HARMLESS. An enrollee in the |
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managed care plan is not responsible and shall be held harmless for |
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the difference between in-network copayments paid by the enrollee |
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to a physician who is determined to be ineligible under Section |
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1452.106 and the managed care plan's total payments for |
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out-of-network services. The physician and the physician's medical |
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group may not charge the enrollee for any portion of the physician's |
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fee that is not paid or reimbursed by the enrollee's managed care |
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plan. |
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SECTION 2. The change in law made by this Act applies only |
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to credentialing of a physician under a contract entered into or |
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renewed by a medical group and an issuer of a managed care plan on or |
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after the effective date of this Act. A contract entered into or |
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renewed before the effective date of this Act is governed by the law |
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in effect immediately before that date, and that law is continued in |
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effect for that purpose. |
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SECTION 3. This Act takes effect September 1, 2007. |