Texas § IN.1301.056 - RESTRICTIONS ON PAYMENT AND REIMBURSEMENT

§ IN.1301.056. RESTRICTIONS ON PAYMENT AND REIMBURSEMENT

RESTRICTIONS ON PAYMENT AND REIMBURSEMENT. (a) An insurer or third-party administrator may not reimburse a physician or other practitioner, institutional provider, or organization of physicians and health care providers on a discounted fee basis for covered services that are provided to an insured unless: (1) the insurer or third-party administrator has contracted with either: (A) the physician or other practitioner, institutional provider, or organization of physicians and health care providers; or (B) a preferred provider organization that has a network of preferred providers and that has contracted with the physician or other practitioner, institutional provider, or organization of physicians and health care providers; (2) the physician or other practitioner, institutional provider, or organization of physicians and health care providers has agreed to the contract and has agreed to provide health care services under the terms of the contract; and (3) the insurer or third-party administrator has agreed to provide coverage for those health care services under the health insurance policy. (b) A party to a preferred provider contract, including a contract with a preferred provider organization, may not sell, lease, or otherwise transfer information regarding the payment or reimbursement terms of the contract without the express authority of and prior adequate notification to the other contracting parties. This subsection does not affect the authority of the commissioner of insurance or the commissioner of workers' compensation under this code or Title 5, Labor Code, to request and obtain information. (c) An insurer or third-party administrator who violates this section: (1) commits an unfair claim settlement practice in violation of Subchapter A , Chapter 542 ; and (2) is subject to administrative penalties under Chapters 82 and 84 . Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005. Amended by: Acts 2005, 79th Leg., Ch. 265 (H.B. 7 ), Sec. 6.061, eff. September 1, 2005.