On September 18, 2002, the Texas Department of Insurance (TDI) adopted rules that require insurers that issue preferred provider plans and health maintenance organizations (collectively "carriers") to disclose certain information, including fee schedules, to contracted physicians and providers who request such information. See 28 TAC §3.3703 http://www.tdi.state.tx.us/rules/0915A-059.html and §11.901 http://www.tdi.state.tx.us/rules/0915B-059.html. The rules also required carriers to provide 60 days notice of any changes to the information by identifying with specificity the particular change. On September 15, 2003, TDI amended these rules pursuant to SB 418 to require, among other things, that carriers give 90 days notice prior to making these changes.
It has recently come to TDI's attention that some carriers are notifying their contracted physicians and providers of fee schedule changes by providing a representative sample of the new fees. While specific codes and fees listed in a representative sample would comply with the notice requirement if applicable to the notice recipient, the sample would not satisfy the requirements of the rules regarding those fee changes not illustrated in the sample because the rules state that the carrier must provide "... at least 90 calendar days written notice ... identifying with specificity the amendment, revision or substitution" (emphasis added). A carrier must send to the provider the specific changes to all claims payment policies, procedures and information that will affect the payment to be made under the contract. A carrier may meet its obligation under the rule by giving notice and providing a source, such as a link to a web page, where each provider can obtain information concerning each applicable change, so long as the provider has the ability to access the information without any additional request to the payor. In addition, while a carrier may provide the required information via such means as a website, it is not sufficient to merely direct a physician or provider to a general website absent specific directions about how to access the information.
TDI expects all carriers subject to the above requirements to review their procedures to ensure that they are acting in full compliance with this and all other applicable rules. Any questions concerning this bulletin may be addressed to Ryan Tredway, Director of Project Development for Life, Health & Licensing, via phone at 512-305-6746 or via e-mail at LifeHealth@tdi.state.tx.us.
Senior Associate Commissioner
Life, Health & Licensing
Texas Department of Insurance