State Law

Texas Statutes-Insurance Code-Title 8-Subtitle D-Chapter 1301- Subchapter C-1. Other Provisions Relating to Payment of Claims

08/24/2023 Texas Section 1301.136

Availability of Coding Guidelines

Amendments, Fee Schedules, Payment Edits, Termination

See bold sections below:

Fee Schedules; Payment Edits

(a) A contract between an insurer and a preferred provider must provide that:

(1) the preferred provider may request a description and copy of the coding guidelines, including any underlying bundling, recoding, or other payment process and fee schedules applicable to specific procedures that the preferred provider will receive under the contract;

(2) the insurer or the insurer’s agent will provide the coding guidelines and fee schedules not later than the 30th day after the date the insurer receives the request;

Fee Schedules; Payment Edits (continued); Amendments; Termination

(3) the insurer or the insurer’s agent will provide notice of changes to the coding guidelines and fee schedules that will result in a change of payment to the preferred provider not later than the 90th day before the date the changes take effect and will not make retroactive revisions to the coding guidelines and fee schedules; and

(4) the contract may be terminated by the preferred provider on or before the 30th day after the date the preferred provider receives information requested under this subsection without penalty or discrimination in participation in other health care products or plans.

(b) A preferred provider who receives information under Subsection (a) may only:

(1) use or disclose the information for the purpose of practice management, billing activities, and other business operations; and

(2) disclose the information to a governmental agency involved in the regulation of health care or insurance.

Payment Edits

(c) The insurer shall, on request of the preferred provider, provide the name, edition, and model version of the software that the insurer uses to determine bundling and unbundling of claims.

(d) The provisions of this section may not be waived, voided, or nullified by contract.