By:
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Thompson H.B.
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No.
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1631A BILL TO BE ENTITLEDAN ACTrelating to expedited credentialing for certain podiatristsproviding services under a managed care plan.BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:SECTION
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1.
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Chapter 1452, Insurance Code, is amended byadding Subchapter D to read as follows:SUBCHAPTER D. EXPEDITED CREDENTIALING PROCESSFOR CERTAIN PODIATRISTSSec.
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1452.151.
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DEFINITIONS. In this subchapter:(1)
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"Applicant podiatrist" means a podiatristapplying for expedited credentialing under this subchapter.(2)
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"Enrollee" means an individual who is eligible toreceive health care services under a managed care plan.(3)
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"Health care provider" means:(A)
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an individual who is licensed, certified, orotherwise authorized to provide health care services in this state;or(B)
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a hospital, emergency clinic, outpatientclinic, or other facility providing health care services.(4)
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"Managed care plan" means a health benefit planunder which health care services are provided to enrollees throughcontracts with health care providers and that requires enrollees touse participating providers or that provides a different level ofcoverage for enrollees who use participating providers. The term123456789101112131415161718192021222324
82R8884 TRH-F
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includes a health benefit plan issued by:(A)
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a health maintenance organization;(B)
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a preferred provider benefit plan issuer; or(C)
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any other entity that issues a health benefitplan, including an insurance company.(5)
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"Participating provider" means a health careprovider who has contracted with a health benefit plan issuer toprovide services to enrollees.(6)
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"Professional practice" means a business entitythat is owned by one or more podiatrists or physicians.Sec.
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1452.152.
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APPLICABILITY. This subchapter applies onlyto a podiatrist who joins an established professional practice thathas a current contract in force with a managed care plan.Sec.
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1452.153.
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ELIGIBILITY REQUIREMENTS. To qualify forexpedited credentialing under this subchapter and payment underSection 1452.154, an applicant podiatrist must:(1)
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be licensed in this state by, and in good standingwith, the Texas State Board of Podiatric Medical Examiners;(2)
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submit all documentation and other informationrequired by the issuer of the managed care plan as necessary toenable the issuer to begin the credentialing process required bythe issuer to include a podiatrist in the issuer
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s health benefitplan network; and(3)
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agree to comply with the terms of the managed careplan
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s participating provider contract currently in force with theapplicant podiatrist
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s established professional practice.Sec.
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1452.154.
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PAYMENT OF APPLICANT PODIATRIST DURING123456789101112131415161718192021222324252627H.B.
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CREDENTIALING PROCESS. On submission by the applicant podiatristof the information required by the managed care plan issuer underSection 1452.153(2), and for payment purposes only, the issuershall treat the applicant podiatrist as if the podiatrist were aparticipating provider in the health benefit plan network when theapplicant podiatrist provides services to the managed care plan
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senrollees, including:(1)
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authorizing the applicant podiatrist to collectcopayments from the enrollees; and(2)
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making payments to the applicant podiatrist.Sec.
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1452.155.
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DIRECTORY ENTRIES. Pending the approval ofan application submitted under Section 1452.154, the managed careplan may exclude the applicant podiatrist from the managed careplan
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s directory of participating podiatrists, the managed careplan
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s website listing of participating podiatrists, or any otherlisting of participating podiatrists.Sec.
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1452.156.
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EFFECT OF FAILURE TO MEET CREDENTIALINGREQUIREMENTS. If, on completion of the credentialing process, themanaged care plan issuer determines that the applicant podiatristdoes not meet the issuer
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s credentialing requirements:(1)
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the managed care plan issuer may recover from theapplicant podiatrist or the podiatrist
’
s professional practice anamount equal to the difference between payments for in-networkbenefits and out-of-network benefits; and(2)
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the applicant podiatrist or the podiatrist
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sprofessional practice may retain any copayments collected or in theprocess of being collected as of the date of the issuer
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