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HMO Provider Contract Provisions

The purpose of this webpage is to direct you to the HMO Provider Contract Checklist and the related statutes and rules.

A HMO may contract with a physician or provider (provider) to arrange to provide health care services to an enrollee under a health benefit plan. These arrangements are established through written agreements, contracts between the HMO and the provider. Texas Insurance Code (TIC) Chapter 843 and Texas Administrative Code §11.901 contains in full detail all required contract provisions; however, below are a few provisions an HMO physician or provider contract must include:

  • A "Prompt Payment of Claims" provision which provides claim processing requirements that a HMO must adhere to when processing clean claims in compliance with TIC §843.336.
  • A "Capitation" provision (where applicable) related to payment arranged in compliance with TIC §§843.315-843.316
  • A "Termination" provision which provides the protocol and circumstances, including notice to enrollees, regarding termination in compliance with TIC §§843.306-843.309.
  • A "Continuity of Treatment" provision as it relates to continued health care past termination of a contract with compensation, for an enrollee with an acute or life-threatening condition in compliance with TIC §843.262.
  • A "Complaints" provision as it relates to a physician or provider posting a notice to enrollees regarding their right to file a complaint with TDI in compliance with TIC §843.283. A contract must also include a complaint provision which states that a HMO is prohibited from taking retaliatory action against the enrollee or provider for filing a complaint with the Department in accordance with TIC §843.281.

A HMO and a physician or provider may agree to additional contract provisions so long as they are not in conflict with Texas law. Physicians and Providers should take time to read and understand their contracts terms in its entirety.

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Last updated: 3/3/2015