Texas § IN.1301.0052 - EXCLUSIVE PROVIDER BENEFIT PLANS

§ IN.1301.0052. EXCLUSIVE PROVIDER BENEFIT PLANS

EXCLUSIVE PROVIDER BENEFIT PLANS: REFERRALS FOR MEDICALLY NECESSARY SERVICES. (a) If a covered service is medically necessary and is not available through a preferred provider, the issuer of an exclusive provider benefit plan, on the request of a preferred provider, shall: (1) approve the referral of an insured to a nonpreferred provider within a reasonable period; and (2) fully reimburse the nonpreferred provider at the usual and customary rate or at a rate agreed to by the issuer and the nonpreferred provider. (b) An exclusive provider benefit plan must provide for a review by a health care provider with expertise in the same specialty as or a specialty similar to the type of health care provider to whom a referral is requested under Subsection (a) before the issuer of the plan may deny the referral. Added by Acts 2011, 82nd Leg., R.S., Ch. 288 (H.B. 1772 ), Sec. 9, eff. September 1, 2011.