Texas Insurance Code 1301.0053 – Exclusive Provider Benefit Plans: Emergency Care
(a) If an out-of-network provider provides emergency care as defined by § 1301.155 or post-emergency stabilization care to an enrollee in an exclusive provider benefit plan, the issuer of the plan shall reimburse the out-of-network provider at the usual and customary rate or at a rate agreed to by the issuer and the out-of-network provider for the provision of the services and any supply related to those services. The insurer 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 insurer receives an electronic clean claim as defined by § 1301.101 for those services that includes all information necessary for the insurer to pay the claim; or
(2) the 45th day after the date the insurer receives a nonelectronic clean claim as defined by § 1301.101 for those services that includes all information necessary for the insurer to pay the claim.
(b) For emergency care or post-emergency stabilization 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 an insured in, and the insured does not have financial responsibility for, an amount greater than an applicable copayment, coinsurance, and deductible under the insured’s exclusive provider benefit plan that:
(1) is based on:
(A) the amount initially determined payable by the insurer; or
(B) if applicable, a modified amount as determined under the insurer’s internal appeal process; and
(2) is not based on any additional amount determined to be owed to the provider under Chapter 1467.
Terms Used In Texas Insurance Code 1301.0053
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Person: includes corporation, organization, government or governmental subdivision or agency, business trust, estate, trust, partnership, association, and any other legal entity. See Texas Government Code 311.005
(c) This section may not be construed to require the imposition of a penalty under § 1301.137.
(d) Post-emergency stabilization care that is subject to this section and a supply related to that care are subject to Chapter 1467 in the same manner as if the care and supply are emergency care, as defined by § 1301.155.
(e) This section does not apply to claims for post-emergency stabilization care if all of the conditions described by 42 U.S.C. § 300gg-111(a)(3)(C)(ii)(II) are met.