|
SECTION 1. Chapter 1452,
Insurance Code, is amended by adding Subchapter D to read as follows:
SUBCHAPTER D. EXPEDITED
CREDENTIALING PROCESS
FOR CERTAIN PODIATRISTS
Sec. 1452.151.
DEFINITIONS. In this subchapter:
(1) "Applicant
podiatrist" means a podiatrist applying for expedited credentialing
under this subchapter.
(2) "Enrollee"
means an individual who is eligible to receive health care services under a
managed care plan.
(3) "Health care
provider" means:
(A) an individual who is
licensed, certified, or otherwise authorized to provide health care
services in this state; or
(B) a hospital, emergency
clinic, outpatient clinic, or other facility providing health care
services.
(4) "Managed care
plan" means a health benefit plan under which health care services are
provided to enrollees through contracts with health care providers and that
requires enrollees to use participating providers or that provides a
different level of coverage for enrollees who use participating providers.
The term includes a health benefit plan issued by:
(A) a health maintenance
organization;
(B) a preferred provider
benefit plan issuer; or
(C) any other entity that
issues a health benefit plan, including an insurance company.
(5) "Participating
provider" means a health care provider who has contracted with a
health benefit plan issuer to provide services to enrollees.
(6) "Professional
practice" means a business entity that is owned by one or more
podiatrists or physicians.
Sec. 1452.152.
APPLICABILITY. This subchapter applies only to a podiatrist who joins an
established professional practice that has a current contract in force with
a managed care plan.
Sec. 1452.153.
ELIGIBILITY REQUIREMENTS. To qualify for expedited credentialing under
this subchapter and payment under Section 1452.154, an applicant podiatrist
must:
(1) be licensed in this
state by, and in good standing with, the Texas State Board of Podiatric
Medical Examiners;
(2) submit all
documentation and other information required by the issuer of the managed
care plan as necessary to enable the issuer to begin the credentialing
process required by the issuer to include a podiatrist in the issuer's
health benefit plan network; and
(3) agree to comply with
the terms of the managed care plan's participating provider contract
currently in force with the applicant podiatrist's established professional
practice.
Sec. 1452.154. PAYMENT OF
APPLICANT PODIATRIST DURING CREDENTIALING PROCESS. On submission by the
applicant podiatrist of the information required by the managed care plan
issuer under Section 1452.153(2), and for payment purposes only, the issuer
shall treat the applicant podiatrist as if the podiatrist were a
participating provider in the health benefit plan network when the
applicant podiatrist provides services to the managed care plan's
enrollees, including:
(1) authorizing the
applicant podiatrist to collect copayments from the enrollees; and
(2) making payments to
the applicant podiatrist.
Sec. 1452.155. DIRECTORY
ENTRIES. Pending the approval of an application submitted under Section
1452.154, the managed care plan may exclude the applicant podiatrist from
the managed care plan's directory of participating podiatrists, the managed
care plan's website listing of participating podiatrists, or any other
listing of participating podiatrists.
Sec. 1452.156. EFFECT OF
FAILURE TO MEET CREDENTIALING REQUIREMENTS. If, on completion of the
credentialing process, the managed care plan issuer determines that the
applicant podiatrist does not meet the issuer's credentialing requirements:
(1) the managed care plan
issuer may recover from the applicant podiatrist or the podiatrist's
professional practice an amount equal to the difference between payments
for in-network benefits and out-of-network benefits; and
(2) the applicant
podiatrist or the podiatrist's professional practice may retain any
copayments collected or in the process of being collected as of the date of
the issuer's determination.
Sec. 1452.157. ENROLLEE
HELD HARMLESS. An enrollee in the managed care plan is not responsible and
shall be held harmless for the difference between in-network copayments
paid by the enrollee to a podiatrist who is determined to be ineligible
under Section 1452.156 and the managed care plan's charges for
out-of-network services. The podiatrist and the podiatrist's professional
practice may not charge the enrollee for any portion of the podiatrist's
fee that is not paid or reimbursed by the enrollee's managed care plan.
Sec. 1452.158.
LIMITATION ON MANAGED CARE ISSUER LIABILITY. A managed care plan issuer
that complies with this subchapter is not subject to liability for damages
arising out of or in connection with, directly or indirectly, the payment
by the issuer of an applicant podiatrist as if the podiatrist were a
participating provider in the health benefit plan network.
No equivalent provision.
No equivalent provision.
No equivalent provision.
No equivalent provision.
No equivalent provision.
No equivalent provision.
No equivalent provision.
No equivalent provision.
|
SECTION 1. Chapter 1452,
Insurance Code, is amended by adding Subchapters D and E to read as
follows:
SUBCHAPTER D. EXPEDITED
CREDENTIALING PROCESS
FOR CERTAIN PODIATRISTS
Sec. 1452.151. DEFINITIONS.
In this subchapter:
(1) "Applicant
podiatrist" means a podiatrist applying for expedited credentialing
under this subchapter.
(2) "Enrollee"
means an individual who is eligible to receive health care services under a
managed care plan.
(3) "Health care
provider" means:
(A) an individual who is
licensed, certified, or otherwise authorized to provide health care
services in this state; or
(B) a hospital, emergency
clinic, outpatient clinic, or other facility providing health care
services.
(4) "Managed care
plan" means a health benefit plan under which health care services are
provided to enrollees through contracts with health care providers and that
requires enrollees to use participating providers or that provides a
different level of coverage for enrollees who use participating providers.
The term includes a health benefit plan issued by:
(A) a health maintenance
organization;
(B) a preferred provider
benefit plan issuer; or
(C) any other entity that
issues a health benefit plan, including an insurance company.
(5) "Participating
provider" means a health care provider who has contracted with a
health benefit plan issuer to provide services to enrollees.
(6) "Professional
practice" means a business entity that is owned by one or more podiatrists
or physicians.
Sec. 1452.152.
APPLICABILITY. This subchapter applies only to a podiatrist who joins an
established professional practice that has a current contract in force with
a managed care plan.
Sec. 1452.153.
ELIGIBILITY REQUIREMENTS. To qualify for expedited credentialing under
this subchapter and payment under Section 1452.154, an applicant podiatrist
must:
(1) be licensed in this
state by, and in good standing with, the Texas State Board of Podiatric
Medical Examiners;
(2) submit all
documentation and other information required by the issuer of the managed
care plan as necessary to enable the issuer to begin the credentialing
process required by the issuer to include a podiatrist in the issuer's
health benefit plan network; and
(3) agree to comply with
the terms of the managed care plan's participating provider contract
currently in force with the applicant podiatrist's established professional
practice.
Sec. 1452.154. PAYMENT OF
APPLICANT PODIATRIST DURING CREDENTIALING PROCESS. On submission by the
applicant podiatrist of the information required by the managed care plan
issuer under Section 1452.153(2), and for payment purposes only, the issuer
shall treat the applicant podiatrist as if the podiatrist were a
participating provider in the health benefit plan network when the
applicant podiatrist provides services to the managed care plan's
enrollees, including:
(1) authorizing the
applicant podiatrist to collect copayments from the enrollees; and
(2) making payments to
the applicant podiatrist.
Sec. 1452.155. DIRECTORY
ENTRIES. Pending the approval of an application submitted under Section
1452.154, the managed care plan may exclude the applicant podiatrist from
the managed care plan's directory of participating podiatrists, the managed
care plan's website listing of participating podiatrists, or any other
listing of participating podiatrists.
Sec. 1452.156. EFFECT OF
FAILURE TO MEET CREDENTIALING REQUIREMENTS. If, on completion of the
credentialing process, the managed care plan issuer determines that the
applicant podiatrist does not meet the issuer's credentialing requirements:
(1) the managed care plan
issuer may recover from the applicant podiatrist or the podiatrist's
professional practice an amount equal to the difference between payments
for in-network benefits and out-of-network benefits; and
(2) the applicant
podiatrist or the podiatrist's professional practice may retain any
copayments collected or in the process of being collected as of the date of
the issuer's determination.
Sec. 1452.157. ENROLLEE
HELD HARMLESS. An enrollee in the managed care plan is not responsible and
shall be held harmless for the difference between in-network copayments
paid by the enrollee to a podiatrist who is determined to be ineligible under
Section 1452.156 and the managed care plan's charges for out-of-network
services. The podiatrist and the podiatrist's professional practice may
not charge the enrollee for any portion of the podiatrist's fee that is not
paid or reimbursed by the enrollee's managed care plan.
Sec. 1452.158.
LIMITATION ON MANAGED CARE ISSUER LIABILITY. A managed care plan issuer
that complies with this subchapter is not subject to liability for damages
arising out of or in connection with, directly or indirectly, the payment
by the issuer of an applicant podiatrist as if the podiatrist were a
participating provider in the health benefit plan network.
SUBCHAPTER E. EXPEDITED
CREDENTIALING PROCESS
FOR CERTAIN THERAPEUTIC
OPTOMETRISTS
Sec. 1452.201.
DEFINITIONS. In this subchapter:
(1) "Applicant
therapeutic optometrist" means a therapeutic optometrist applying for
expedited credentialing under this subchapter.
(2) "Enrollee"
means an individual who is eligible to receive health care services under a
managed care plan.
(3) "Health care
provider" has the meaning assigned by Section 1452.151.
(4) "Managed care
plan" has the meaning assigned by Section 1452.151.
(5) "Participating
provider" means a health care provider who has contracted with a
health benefit plan issuer to provide services to enrollees.
(6) "Professional
practice" means a business entity that is owned by one or more
therapeutic optometrists or physicians.
Sec. 1452.202.
APPLICABILITY. This subchapter applies only to a therapeutic optometrist
who joins an established professional practice that has a current contract
in force with a managed care plan.
Sec. 1452.203.
ELIGIBILITY REQUIREMENTS. To qualify for expedited credentialing under
this subchapter and payment under Section 1452.204, an applicant
therapeutic optometrist must:
(1) be licensed in this
state by, and in good standing with, the Texas Optometry Board;
(2) submit all
documentation and other information required by the issuer of the managed
care plan as necessary to enable the issuer to begin the credentialing
process required by the issuer to include a therapeutic optometrist in the
issuer's health benefit plan network; and
(3) agree to comply with
the terms of the managed care plan's participating provider contract
currently in force with the applicant therapeutic optometrist's established
professional practice.
Sec. 1452.204. PAYMENT OF
APPLICANT THERAPEUTIC OPTOMETRIST DURING CREDENTIALING PROCESS. On
submission by the applicant therapeutic optometrist of the information
required by the managed care plan issuer under Section 1452.203(2), and for
payment purposes only, the issuer shall treat the applicant therapeutic
optometrist as if the therapeutic optometrist were a participating provider
in the health benefit plan network when the applicant therapeutic
optometrist provides services to the managed care plan's enrollees,
including:
(1) authorizing the
applicant therapeutic optometrist to collect copayments from the enrollees;
and
(2) making payments to
the applicant therapeutic optometrist.
Sec. 1452.205. DIRECTORY
ENTRIES. Pending the approval of an application submitted under Section
1452.204, the managed care plan may exclude the applicant therapeutic
optometrist from the managed care plan's directory of participating therapeutic
optometrists, the managed care plan's website listing of participating
therapeutic optometrists, or any other listing of participating therapeutic
optometrists.
Sec. 1452.206. EFFECT OF
FAILURE TO MEET CREDENTIALING REQUIREMENTS. If, on completion of the
credentialing process, the managed care plan issuer determines that the
applicant therapeutic optometrist does not meet the issuer's credentialing
requirements:
(1) the managed care plan
issuer may recover from the applicant therapeutic optometrist or the
therapeutic optometrist's professional practice an amount equal to the
difference between payments for in-network benefits and out-of-network
benefits; and
(2) the applicant
therapeutic optometrist or the therapeutic optometrist's professional practice
may retain any copayments collected or in the process of being collected as
of the date of the issuer's determination.
Sec. 1452.207. ENROLLEE
HELD HARMLESS. An enrollee in the managed care plan is not responsible and
shall be held harmless for the difference between in-network copayments
paid by the enrollee to a therapeutic optometrist who is determined to be
ineligible under Section 1452.206 and the managed care plan's charges for
out-of-network services. The therapeutic optometrist and the therapeutic
optometrist's professional practice may not charge the enrollee for any
portion of the therapeutic optometrist's fee that is not paid or reimbursed
by the enrollee's managed care plan.
Sec. 1452.208.
LIMITATION ON MANAGED CARE ISSUER LIABILITY. A managed care plan issuer
that complies with this subchapter is not subject to liability for damages
arising out of or in connection with, directly or indirectly, the payment
by the issuer of an applicant therapeutic optometrist as if the therapeutic
optometrist were a participating provider in the health benefit plan
network.
|