Physicians and Health Providers
This page includes information related to the prompt payment of claims, the filing of complaints, and credentialing for fully insured health plans. In addition, this page will provide links to helpful information on workers' compensation insurance, medical malpractice, and professional liability insurance. Note that the prompt pay and credentialing resources on this page don't apply to workers' compensation insurance.
If you are a consumer, please see our consumer page for more information. If you are looking for a provider in your health plan network, call your insurance company or HMO for a list of participating providers.
- Guidelines for Filing Complaints from Providers about Health Claim Payments
- Online Complaint Portal for consumers
- Complain to the proper agency
- Avoid filing errors
- HMO patient’s right to file a complaint
- Justified complaints defined (PDF)
- Technical Advisory Committee on Claims Processing (TACCP)
- Prompt pay guidelines
- Enforcement actions
- Provider Joint Underwriting Association
- Shopping guide
- Admitted carriers
- Overview and discussion (PDF)
- Medicare Advantage tips
- SB 50 & SB 51 Provider Resource (PDF) | (MS Word)
- Finding Your Way To Prompt Pay (PDF) | (zip)
- Pharmacists Resource Page
- Consumer health publications
- Education resources
Rules Update for PPOs and EPOs
On January 30, 2013, the TDI commissioner adopted rule amendments relating to preferred provider plans (PPOs) and new rules relating to exclusive provider benefit plans (EPOs), including definitions of network adequacy.
28 TAC §§3.3701 - 3.3725 Preferred and Exclusive Provider Benefit Plan Requirements
Effective for plans issued or renewed beginning July 21, 2013. The rules establish:
- Filing, application, and exam requirements for EPOs;
- Criteria for adequate networks that are similar to those for health maintenance organization (HMO) networks and tailored to meet the needs of the insureds in a geographic area. Networks must now contain an adequate number of doctors, hospitals and other providers to provide the full array of plan benefits within prescribed distances;
- Provider contract requirements, requiring physicians and facilities to notify the insurer when surgery is being scheduled, to provide an opportunity to coordinate in-network care;
- "Approved Hospital Care Network" designations for compliant plans and "Limited Hospital Care Network" designations for others;
- Criteria for selection, credentialing, and retention of preferred providers based on national standards;
- A waiver process for carriers unable to meet network adequacy standards. If providers are available in the area, the waiver may be denied unless the providers' contracting requests are determined, after input from both sides, to be unreasonable;
- Basic reimbursement standards for certain out-of-network claims, also aimed at reducing balance billing. In cases of emergencies or inadequate networks, carriers must pay claims based on at least the usual and customary charge.
Under new transparency requirements in the rules, PPOs and EPOs must provide:
- Disclosure of payment related policy terms and conditions to current and prospective insureds;
- Network information and disclosures on the insurer's website, where applicable;
- Consumer information about network facilities, including the likelihood of balance billing occurring at such facilities;
- Disclosure of how out-of-network claim payments are calculated; and
- In most plans, real time estimates of payments to out-of-network providers.
The need for the network adequacy and cost transparency rules arose from the increasing popularity of PPOs over the last decade, an increase in complaints about balance billing in PPOs, and several bills passed by the Legislature during the 2007 and 2009 legislative sessions. The text of the latest adopted rules is available on the TAC website.
For more information, contact: