Texas § IN.1551.228 - EMERGENCY CARE PAYMENTS

§ IN.1551.228. EMERGENCY CARE PAYMENTS

EMERGENCY CARE PAYMENTS. (a) In this section, "emergency care" has the meaning assigned by Section 1301.155 . (b) The administrator of a managed care plan provided under the group benefits program shall pay for covered emergency care performed by or a covered supply related to that care provided by an out-of-network provider at the usual and customary rate or at an agreed rate. 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. (c) For emergency 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 a participant 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 . Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264 ), Sec. 1.12, eff. September 1, 2019.