Texas § IN.1301.057 - TERMINATION OF PARTICIPATION

§ IN.1301.057. TERMINATION OF PARTICIPATION

TERMINATION OF PARTICIPATION; EXPEDITED REVIEW PROCESS. (a) Before terminating a contract with a preferred provider, an insurer shall: (1) provide written reasons for the termination; and (2) if the affected provider is a practitioner, provide, on request, a reasonable review mechanism, except in a case involving: (A) imminent harm to a patient's health; (B) an action by a state medical or other physician licensing board or other government agency that effectively impairs the practitioner's ability to practice medicine; or (C) fraud or malfeasance. (b) The review mechanism described by Subsection (a)(2) must incorporate, in an advisory role only, a review panel selected in the manner described by Section 1301.053 (b) and must be completed within a period not to exceed 60 days. (c) The insurer shall provide to the affected practitioner: (1) the panel's recommendation, if any; and (2) on request, a written explanation of the insurer's determination, if that determination is contrary to the panel's recommendation. (d) On request, an insurer shall provide to a practitioner whose participation in a preferred provider benefit plan is being terminated: (1) an expedited review conducted in accordance with a process that complies with rules established by the commissioner; and (2) all information on which the insurer wholly or partly based the termination, including the economic profile of the preferred provider, the standards by which the provider is measured, and the statistics underlying the profile and standards. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005. Amended by: Acts 2015, 84th Leg., R.S., Ch. 275 (H.B. 574 ), Sec. 6, eff. September 1, 2015.