INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE F. PHYSICIANS AND HEALTH CARE PROVIDERS

CHAPTER 1457.  PROVISIONAL CREDENTIALING STATUS

Sec. 1457.001.  DEFINITIONS.  In this chapter:
(1)  "Enrollee" means an individual who is eligible to receive health care services through a health benefit plan.
(2)  "Physician" means an individual licensed to practice medicine in this state under the authority of Subtitle B, Title 3, Occupations Code.
(3)  "Provider network" means a health benefit plan under which health care services are provided to enrollees through contracts with physicians and that requires those enrollees to use physicians participating in the plan and procedures covered by the plan.  The term includes a network operated by:
(A)  a health maintenance organization;
(B)  a preferred provider organization; or
(C)  another entity that issues a health benefit plan, including an insurance company.
Added by Acts 2005, 79th Leg., Ch. 789 (S.B. 155), Sec. 2, eff. June 17, 2005.

Sec. 1457.002.  PROVISIONAL CREDENTIALING STATUS.  (a)  A health benefit plan shall have a process for provisional credentialing status in compliance with the requirements of the National Committee for Quality Assurance.
(b)  A health benefit plan may grant provisional credentialing status to a physician who:
(1)  submits a completed standard credentialing application to the health benefit plan;
(2)  meets the health plan's requirements for provisional credentialing; and
(3)  joins as a partner, shareholder, or employee of another physician who is contracted with a health benefit plan to provide medical or health care services to enrollees.
(c)  A health benefit plan must complete the credentialing process within 60 calendar days of the date a physician is granted provisional status.  In the event the physician does not meet the health plan's credentialing standards, the physician must be provided the same appeal process as any other physician applying for participation with the health benefit plan.
Added by Acts 2005, 79th Leg., Ch. 789 (S.B. 155), Sec. 2, eff. June 17, 2005.