Texas Insurance Code 1551.229 – Out-of-Network Facility-Based Provider Payments
(a) In this section, “facility-based provider” means a physician or health care provider who provides health care or medical services to patients of a health care facility.
(b) Except as provided by Subsection (d), the administrator of a managed care plan provided under the group benefits program shall pay for a covered health care or medical service performed for or a covered supply related to that service provided to a participant by an out-of-network provider who is a facility-based provider at the usual and customary rate or at an agreed rate if the provider performed the service at a health care facility that is a participating provider. 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.
Terms Used In Texas Insurance Code 1551.229
- 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.
- Contract: A legal written agreement that becomes binding when signed.
- in writing: includes any representation of words, letters, or figures, whether by writing, printing, or other means. See Texas Government Code 312.011
- 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
- Written: includes any representation of words, letters, symbols, or figures. See Texas Government Code 311.005
(c) Except as provided by Subsection (d), an out-of-network provider who is a facility-based provider or a person asserting a claim as an agent or assignee of the provider may not bill a participant receiving a health care or medical service or supply described by Subsection (b) 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.
(d) This section does not apply to a nonemergency health care or medical service:
(1) that a participant elects to receive in writing in advance of the service with respect to each out-of-network provider providing the service; and
(2) for which an out-of-network provider, before providing the service, provides a complete written disclosure to the participant that:
(A) explains that the provider does not have a contract with the participant’s managed care plan;
(B) discloses projected amounts for which the participant may be responsible; and
(C) discloses the circumstances under which the participant would be responsible for those amounts.