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Texas Statutes (Last Updated: January 4, 2014) |
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INSURANCE CODE |
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Title 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES |
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Subtitle D. PROVIDER PLANS |
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Chapter 1301. PREFERRED PROVIDER BENEFIT PLANS |
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Subchapter B. RELATIONS WITH PHYSICIANS OR HEALTH CARE PROVIDERS |
Sec. 1301.057. TERMINATION OF PARTICIPATION; EXPEDITED REVIEW PROCESS
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(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 make an expedited review available to a practitioner whose participation in a preferred provider benefit plan is being terminated. The expedited review process must comply with rules established by the commissioner.