All codes › Insurance Code › Title 6

Chapter 843

Health Maintenance Organizations

Subchapter A. General Provisions

843.001 Short Title 843.002 Definitions 843.003 Powers of Insurers and Group Hospital Service Corporations 843.004 Governing Body of Health Maintenance Organization 843.005 Use of Insurance-Related Terms by Health Maintenance Organization 843.006 Public Documents 843.007 Confidentiality of Medical and Health Information 843.008 Costs of Administering Health Maintenance Organization Laws 843.009 Appeals; Judicial Review 843.010 Applicability of Certain Provisions to Governmental Health Benefit Plans

Subchapter B. Applicability of and Construction with Other Laws

843.051 Applicability of Insurance and Group Hospital Service Corporation Laws 843.052 Laws Relating to Solicitation or Advertising 843.053 Laws Relating to Restraint of Trade 843.054 Laws Requiring Certificate of Need for Health Care Facility or Service 843.055 Laws Relating to Practice of Medicine 843.056 Inapplicability of Bankruptcy Law

Subchapter C. Authority to Engage in Business

843.071 Certificate of Authority Required; Use of "health Maintenance Organization" or "hmo" 843.072 Authorization Required to Act as Health Maintenance Organization 843.073 Certificate of Authority Requirement: Applicability to Physicians and Providers 843.074 Certificate of Authority Requirement: Applicability to Medical School and Medical and Dental Unit 843.075 Certificate of Authority for Single Health Care Service Plan 843.076 Application 843.077 Eligibility of Foreign Corporation 843.078 Contents of Application 843.079 Contents of Application: Limited Health Care Service Plan 843.080 Modification or Amendment of Application Information 843.082 Requirements for Approval of Application 843.083 Denial of Certificate of Authority 843.084 Duration of Certificate of Authority 843.085 Change in Control: Commissioner Approval

Subchapter D. General Powers and Duties of Health Maintenance Organizations

843.101 Providing or Arranging for Care 843.102 Health Maintenance Organization Quality Assurance 843.103 Acquisition and Operation of Facilities; Certain Loans; Commissioner Approval of Affiliate Transactions 843.104 Contracts for Certain Administrative Functions 843.105 Management and Exclusive Agency Contracts 843.106 Insurance, Reinsurance, Indemnity, and Reimbursement 843.107 Indemnity Benefits; Point-of-Service Provisions 843.108 Point-of-Service Rider 843.109 Payment by Governmental or Private Entity 843.110 Corporation, Partnership, or Association Powers 843.111 Group Model Health Maintenance Organizations 843.112 Dental Point-of-Service Option 843.113 Specified Powers Not Exclusive

Subchapter E. Regulation of Health Maintenance Organizations

843.151 Rules 843.152 Subpoena Authority 843.153 Authority to Contract 843.154 Fees 843.155 Annual Report 843.156 Examinations 843.157 Rehabilitation, Liquidation, Supervision, or Conservation of Health Maintenance Organization

Subchapter F. Relations with Enrollees and Group Contract Holders

843.201 Disclosure of Information About Health Care Plan Terms 843.2015 Information Available Through Internet Site 843.202 Disclosure of Information to Medicare Recipients 843.203 Selection of Primary Care Physician or Provider 843.204 Untrue or Misleading Information 843.205 Member's Handbook; Information About Complaints and Appeals 843.206 Notice of Change in Payment Arrangements 843.207 Notice of Change in Operations 843.2071 Notice of Increase in Charge for Coverage 843.208 Cancellation or Nonrenewal of Coverage 843.209 Identification Card 843.210 Terms of Enrollee Eligibility 843.211 Applicability of Subchapter to Entities Contracting with Health Maintenance Organization

Subchapter G. Dispute Resolution

843.251 Complaint System Required; Commissioner Rules and Examination 843.252 Complaint Initiation and Initial Response; Deadlines for Response and Resolution 843.253 Complaint Investigation and Resolution 843.254 Appeal to Complaint Appeal Panel; Deadlines 843.255 Composition of Complaint Appeal Panel 843.256 Information Provided to Complainant Relating to Complaint Appeal Panel 843.257 Rights of Complainant at Complaint Appeal Panel Meeting 843.258 Appeal Involving Ongoing Emergency or Continued Hospitalization 843.259 Notice of Decision on Appeal 843.260 Record of Complaints 843.261 Special Provisions for Appeals of Adverse Determinations 843.262 Certain Decisions Binding

Subchapter H. General Provisions Regarding Complaints

843.281 Retaliatory Action Prohibited 843.282 Submitting Complaints to Department 843.283 Posting of Information on Complaint Process Required

Subchapter I. Relations with Physicians and Providers

843.301 Practice of Medicine Not Affected 843.302 Disclosure of Application Procedures and Qualification Requirements to Physician or Provider 843.303 Denial of Initial Contract to Physician or Provider 843.304 Exclusion of Provider Based on Type of License Prohibited 843.3041 Acupuncturist Services 843.3042 Chiropractic Services 843.3045 Nurse First Assistant 843.305 Annual Application Period for Physicians and Providers to Contract 843.306 Termination of Participation; Advisory Review Panel 843.307 Expedited Review Process on Termination or Deselection 843.308 Notification of Patients of Deselected Physician or Provider 843.309 Contracts with Physicians or Providers: Notice to Certain Enrollees of Termination of Physician or Provider Participation in Plan 843.310 Contracts with Physicians or Providers: Certain Indemnity Clauses Prohibited 843.311 Contracts with Podiatrists 843.3115 Contracts with Dentists 843.312 Physician Assistants and Advanced Practice Nurses 843.313 Economic Profiling 843.314 Inducement to Limit Medically Necessary Services Prohibited 843.315 Payment of Capitation; Assignment of Primary Care Physician or Provider 843.316 Alternative Capitation System 843.317 Exclusion of Physician or Provider Based on Affiliation with Health Maintenance Organization Prohibited 843.318 Certain Contracts of Participating Physician or Provider Not Prohibited 843.319 Certain Required Contracts 843.320 Use of Hospitalist 843.321 Availability of Coding Guidelines 843.322 Incentives to Use Certain Physicians or Providers 843.323 Contract Provisions Prohibiting Rejection of Batched Claims

Subchapter J. Payment of Claims to Physicians and Providers

843.336 Definition 843.337 Time for Submission of Claim; Duplicate Claims; Acknowledgment of Receipt of Claim 843.338 Deadline for Action on Clean Claims 843.3385 Additional Information 843.339 Deadline for Action on Prescription Claims; Payment 843.340 Audited Claims 843.3405 Investigation and Determination of Payment 843.341 Claims Processing Procedures 843.342 Violation of Certain Claims Payment Provisions; Penalties 843.343 Attorney's Fees 843.344 Applicability of Subchapter to Entities Contracting with Health Maintenance Organization 843.345 Exception 843.346 Payment of Claims 843.347 Verification 843.348 Preauthorization of Health Care Services 843.3481 Posting of Preauthorization Requirements 843.3482 Changes to Preauthorization Requirements 843.3483 Remedy for Noncompliance 843.349 Coordination of Payment 843.350 Overpayment 843.351 Services Provided by Certain Physicians and Providers 843.352 Conflict with Other Law 843.353 Waiver Prohibited 843.354 Legislative Declaration

Subchapter K. Relations Between Enrollee and Physician or Provider

843.361 Enrollees Held Harmless 843.362 Continuity of Care; Obligation of Health Maintenance Organization 843.363 Protected Physician or Provider Communications with Patients

Subchapter L. Financial Regulation of Health Maintenance Organizations

843.401 Fiduciary Responsibility 843.402 Officers' and Employees' Bond 843.403 Minimum Net Worth 843.404 Additional Net Worth Requirements 843.405 Deposit with Comptroller 843.406 Hazardous Financial Condition 843.407 Receivership and Delinquency Proceedings 843.408 Insolvency and Allocation to Other Health Maintenance Organizations 843.409 Examination Expenses 843.410 Assessments

Subchapter N. Enforcement

843.461 Enforcement Actions 843.462 Operations During Suspension or After Revocation of Certificate of Authority 843.463 Injunctions 843.464 Criminal Penalty