Texas Insurance Code 1272.301 – Access to Out-of-Network Services
(a) A contract between a health maintenance organization and a limited provider network or delegated entity must provide that:
(1) if medically necessary covered services are not available through network physicians or providers, the limited provider network or delegated entity, on the request of a network physician or provider, shall:
(A) allow a referral to a non-network physician or provider; and
(B) fully reimburse the non-network physician or provider at the usual and customary rate or an agreed rate; and
(2) before the limited provider network or delegated entity may deny a referral to a non-network physician or provider, a specialist of the same or similar specialty as the type of physician or provider to whom the referral is requested must conduct a review of the request.
(b) The limited provider network or delegated entity shall allow the referral within the time appropriate to the circumstances relating to the delivery of the services and the condition of the enrollee who is a patient, but not later than the fifth business day after the date the network or entity receives any reasonably requested documentation.
Terms Used In Texas Insurance Code 1272.301
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Contract: A legal written agreement that becomes binding when signed.
(c) An enrollee may not be required to change the enrollee’s primary care physician or specialist providers to receive medically necessary covered services that are not available within the limited provider network or through the delegated entity.
(d) A denial of out-of-network services under this section is subject to appeal under Chapter 4201.