CHAPTER 1457. PROVISIONAL CREDENTIALING STATUS - Texas Statutes

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, 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, Sec. 2, eff. June 17, 2005.