Tex. Insurance Code § 1301.0052
This is the official text of Tex. Insurance Code § 1301.0052, part of Texas’s Insurance Code — regulates insurance companies and the policies they sell.
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§ 1301.0052.
Official statutory text
Sec. 1301.0052. EXCLUSIVE PROVIDER BENEFIT PLANS: REFERRALS FOR MEDICALLY NECESSARY SERVICES. (a) If a covered service is medically necessary and is not available through a preferred provider, the issuer of an exclusive provider benefit plan, on the request of a preferred provider, shall:
(1) approve the referral of an insured to a nonpreferred provider within a reasonable period; and
(2) fully reimburse the nonpreferred provider at the usual and customary rate or at a rate agreed to by the issuer and the nonpreferred provider.
(b) An exclusive provider benefit plan must provide for a review by a health care provider with expertise in the same specialty as or a specialty similar to the type of health care provider to whom a referral is requested under Subsection (a) before the issuer of the plan may deny the referral.
(1) approve the referral of an insured to a nonpreferred provider within a reasonable period; and
(2) fully reimburse the nonpreferred provider at the usual and customary rate or at a rate agreed to by the issuer and the nonpreferred provider.
(b) An exclusive provider benefit plan must provide for a review by a health care provider with expertise in the same specialty as or a specialty similar to the type of health care provider to whom a referral is requested under Subsection (a) before the issuer of the plan may deny the referral.
Status: in_force · Read it on the official government site
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