INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE A. HEALTH COVERAGE IN GENERAL

CHAPTER 1213.  ELECTRONIC HEALTH CARE TRANSACTIONS

Sec. 1213.001.  DEFINITION OF HEALTH BENEFIT PLAN.  (a)  In this chapter, "health benefit plan" means a plan that provides benefits for medical, surgical, or other treatment expenses incurred as a result of a health condition, a mental health condition, an accident, sickness, or substance abuse, including an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage or similar coverage document that is offered by:
(1)  an insurance company;
(2)  a group hospital service corporation operating under Chapter 842;
(3)  a fraternal benefit society operating under Chapter 885;
(4)  a stipulated premium insurance company operating under Chapter 884;
(5)  a Lloyd's plan operating under Chapter 941;
(6)  an exchange operating under Chapter 942;
(7)  a health maintenance organization operating under Chapter 843;
(8)  a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846; or
(9)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844.
(b)  The term includes:
(1)  a small employer health benefit plan written under Chapter 1501; and
(2)  a health benefit plan offered under Chapter 1551, 1575, 1579, or 1601.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.029(a), eff. September 1, 2005.

Sec. 1213.002.  ELECTRONIC SUBMISSION OF CLAIMS.  (a)  The issuer of a health benefit plan by contract may require that a health care professional licensed or registered under the Occupations Code or a health care facility licensed under the Health and Safety Code electronically submit a health care claim or equivalent encounter information, a referral certification, or an authorization or eligibility transaction.  The health benefit plan issuer shall comply with the standards for electronic transactions required by this section and established by the commissioner by rule.
(b)  The issuer of a health benefit plan by contract shall establish a default method to submit claims in a nonelectronic format if there is a system failure or failures or a catastrophic event substantially interferes with the normal business operations of the physician, provider, or health benefit plan or its agents.  The health benefit plan issuer shall comply with the standards for nonelectronic transactions established by the commissioner by rule.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.029(a), eff. September 1, 2005.

Sec. 1213.003.  ELECTRONIC SUBMISSION OF CLAIMS: WAIVER.  (a)  A contract between the issuer of a health benefit plan and a health care professional or health care facility must provide for a waiver of any requirement for electronic submission established under this chapter.
(b)  The commissioner shall establish circumstances under which a waiver is required, including:
(1)  circumstances in which no method is available for the submission of claims in electronic form;
(2)  the operation of small physician practices;
(3)  the operation of other small health care provider practices;
(4)  undue hardship, including fiscal or operational hardship; or
(5)  any other special circumstance that would justify a waiver.
(c)  Any health care professional or health care facility that is denied a waiver by the issuer of a health benefit plan may appeal the denial to the commissioner.  The commissioner shall determine whether a waiver must be granted.
(d)  The issuer of a health benefit plan may not refuse to contract or renew a contract with a health care professional or health care facility based in whole or in part on the professional or facility requesting or receiving a waiver or appealing a waiver determination.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.029(a), eff. September 1, 2005.

Sec. 1213.004.  MODE OF TRANSMISSION.  The issuer of a health benefit plan may not by contract limit the mode of electronic transmission that a health care professional or health care facility may use to submit information under this chapter.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.029(a), eff. September 1, 2005.

Sec. 1213.005.  CERTAIN CHARGES PROHIBITED.  A health benefit plan may not directly or indirectly charge or hold a health care professional, health care facility, or person enrolled in a health benefit plan responsible for a fee for the adjudication of a claim.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.029(a), eff. September 1, 2005.

Sec. 1213.006.  RULES.  The commissioner may adopt rules as necessary to implement this chapter.  The commissioner may not require any data element for electronically filed claims that is not required to comply with federal law.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.029(a), eff. September 1, 2005.