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Chapter 1301

Preferred Provider Benefit Plans

Subchapter A. General Provisions

1301.001 Definitions 1301.002 Nonapplicability to Dental Care Benefits 1301.003 Preferred Provider Benefit Plans and Exclusive Provider Benefit Plans Permitted 1301.0041 Applicability 1301.0042 Applicability of Insurance Law 1301.0045 Construction of Chapter 1301.0046 Coinsurance Requirements for Services of Nonpreferred Providers 1301.0047 Incentives to Use Certain Physicians or Health Care Providers 1301.005 Availability of Preferred Providers; Service Area Limitations 1301.0051 Exclusive Provider Benefit Plans: Quality Improvement and Utilization Management 1301.0052 Exclusive Provider Benefit Plans: Referrals for Medically Necessary Services 1301.0053 Exclusive Provider Benefit Plans: Emergency Care 1301.0055 Network Adequacy Standards 1301.00553 Maximum Travel Time and Distance Standards by Preferred Provider Type 1301.00554 Other Maximum Distance Standard Requirements; Commissioner Authority 1301.00555 Maximum Appointment Wait Time Standards 1301.0056 Examinations and Fees 1301.00565 Public Hearing on Network Adequacy Standards Waivers 1301.00566 Effect of Network Adequacy Standards Waiver on Balance Billing Prohibitions 1301.0057 Access to Out-of-Network Providers 1301.0058 Protected Communications by Preferred Providers 1301.006 Availability of and Accessibility to Health Care Services 1301.0061 Terms of Enrollee Eligibility 1301.0065 Value-Based and Capitated Payment Arrangements with Primary Care Physicians or Primary Care Physician Groups Not Prohibited 1301.007 Rules 1301.008 Conflict with Other Law 1301.009 Annual Report 1301.010 Balance Billing Prohibition Notice

Subchapter B. Relations with Physicians or Health Care Providers

1301.051 Designation as Preferred Provider 1301.0515 Acupuncturist Services 1301.0516 Chiropractic Services 1301.052 Designation of Advanced Practice Nurse or Physician Assistant as Preferred Provider 1301.0521 Designation of Certain Podiatrists as Preferred Providers 1301.0522 Designation of Certain Optometrists, Therapeutic Optometrists, and Ophthalmologists as Preferred Providers 1301.053 Appeal Relating to Designation as Preferred Provider 1301.054 Notice to Practitioners of Preferred Provider Benefit Plan 1301.055 Complaint Resolution 1301.056 Restrictions on Payment and Reimbursement 1301.057 Termination of Participation; Expedited Review Process 1301.058 Economic Profiling 1301.059 Quality Assessment 1301.060 Compensation on Discounted Fee Basis 1301.061 Preferred Provider Networks 1301.062 Preferred Provider Contracts Between Insurers and Podiatrists 1301.0625 Health Care Collaboratives 1301.063 Contract Provisions Relating to Use of Hospitalist 1301.064 Contract Provisions Relating to Payment of Claims 1301.0641 Contract Provisions Prohibiting Rejection of Batched Claims 1301.0642 Contract Provisions Allowing Certain Adverse Material Changes Prohibited 1301.065 Shifting of Insurer's Tort Liability Prohibited 1301.066 Retaliation Against Preferred Provider Prohibited 1301.067 Interference with Relationship Between Patient and Physician or Health Care Provider Prohibited 1301.068 Inducement to Limit Medically Necessary Services Prohibited 1301.069 Services Provided by Certain Physicians and Health Care Providers

Subchapter C. Prompt Payment of Claims

1301.101 Definition 1301.102 Submission of Claim 1301.1021 Receipt of Claim 1301.103 Deadline for Action on Clean Claims 1301.104 Deadline for Action on Pharmacy Claims; Payment 1301.105 Audited Claims 1301.1051 Completion of Audit 1301.1052 Preferred Provider Appeal After Audit 1301.1053 Deadlines Not Extended 1301.1054 Requests for Additional Information 1301.106 Claims Processing Procedures and Claims Payment Processes 1301.107 Contractual Waiver and Other Actions Prohibited 1301.108 Attorney's Fees 1301.109 Applicability to Entities Contracting with Insurer

Subchapter C-1. Other Provisions Relating to Payment of Claims

1301.131 Elements of Clean Claim 1301.132 Overpayment 1301.133 Verification 1301.134 Coordination of Payment 1301.135 Preauthorization of Medical and Health Care Services 1301.1351 Posting of Preauthorization Requirements 1301.1352 Changes to Preauthorization Requirements 1301.1353 Remedy for Noncompliance 1301.136 Availability of Coding Guidelines 1301.137 Violation of Claims Payment Requirements; Penalty 1301.138 Applicability to Entities Contracting with Insurer 1301.139 Legislative Declaration 1301.140 Out-of-Pocket Expense Credit

Subchapter D. Relations Between Insureds and Preferred Providers

1301.151 Insured's Right to Treatment 1301.152 Continuing Care in General 1301.153 Continuity of Care 1301.154 Obligation for Continuity of Care of Insurer 1301.155 Emergency Care 1301.156 Payment of Claims to Insured 1301.157 Plain Language Requirements 1301.158 Information Concerning Preferred Provider Benefit Plans 1301.1581 Information Concerning Exclusive Provider Benefit Plans 1301.159 Annual List of Preferred Providers 1301.1591 Preferred Provider Information on Internet 1301.160 Notification of Termination of Participation of Preferred Provider 1301.161 Retaliation Against Insured Prohibited 1301.162 Identification Card 1301.163 Applicability of Subchapter to Entities Contracting with Insurer 1301.164 Out-of-Network Facility-Based Providers 1301.165 Out-of-Network Diagnostic Imaging Provider or Laboratory Service Provider 1301.166 Out-of-Network Emergency Medical Services Provider

Subchapter E. Certain Health Care Providers

1301.201 Contracts with and Reimbursement for Nurse First Assistants 1301.202 Contracts with Hospitals