State Law

Texas Statutes-Insurance Code-Title 6-Subtitle C-Chapter 843-Subchapter J. Payment of Claims to Physicians and Providers

08/24/2023 Texas Section 843.341

Claims Processing Procedures

Payment Edits, Payment Rules

(a) A health maintenance organization shall provide a participating physician or provider with copies of all applicable utilization review policies and claim processing policies or procedures.

(b) A health maintenance organization’s claims payment processes shall:

(1) use nationally recognized, generally accepted Current Procedural Terminology codes, notes, and guidelines, including all relevant modifiers; and

(2) be consistent with nationally recognized, generally accepted bundling edits and logic.