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Physicians & Health Providers

Highlights

Prompt Pay

Credentialing Application

Professional Liability


NEW Preferred Provider Plan Rules | Provider Quick Links

This is the Physician/Provider webpage on the TDI website. This page is designed to assist physicians and other health care providers find information related to the prompt payment of claims, the filing of complaints, and credentialing for fully insured health plans. In addition, this page will provide links to helpful information on workers’ compensation insurance, medical malpractice, and professional liability insurance. Note that the prompt pay and credentialing resources on this page do not apply to workers’ compensation insurance.

If you are a consumer, please see our consumer page for more information. If you are looking for a particular provider in your health plan network, please consult your insurance carrier for a list of participating providers.

   

Rules Update for Preferred Provider Plans in Texas

On May 15, 2011, the Commissioner of Insurance adopted rules relating to preferred provider plans (PPPs) including definitions of network adequacy and new requirements for cost transparency. 

Following is a brief summary of these rules:
28 TAC §§3.3701 - 3.3711 and 3.3713 Preferred Provider Plans
Adopted May 15, 2011; effective May 19, 2012. The rules establish:

  • Criteria for adequate networks that are similar to those for health maintenance organization (HMO) networks and tailored to meet the needs of the insureds in a geographic area. Networks must now contain enough doctors, hospitals and other providers to provide the full array of plan benefits within a prescribed drive time;
  • “Approved Hospital Care Network” designations for compliant plans and “Limited Hospital Care Network” designations for others;
  • Criteria for selection, credentialing, and retention of preferred providers based on national standards;
  • Basic reimbursement standards for out-of-network claims, also aimed at reducing balance billing.

Under new transparency requirements in the rules, PPPs must provide:

  • Consumer notices when out of network referrals are made;
  • Consumer information about network facilities, including the likelihood of balance billing occurring at such facilities;
  • Disclosure of how out of network claim payments are calculated and the carrier’s average negotiated rates; and
  • Real time estimates of payments to out of network providers.

The need for the network adequacy and cost transparency rules arose from the increasing popularity of PPPs over the last decade, an increase in complaints about balance billing in PPPs, and several bills passed by the Legislature during the 2007 and 2009 legislative sessions.

The text of the latest adopted rules is available at: http://www.tdi.texas.gov/rules/2011/documents/3-3701-3-3713fi.pdf

The Commissioner previously adopted rules relating to transparency of PPP health care reimbursement rate information. The text of these rules is available at: http://www.tdi.texas.gov/rules/2010/documents/21.4501-21.4507.pdf

   

Provider Quick Links

Chiropractors Resource · Pharmacists Resource · Consumer Health Publications 

Provider Resources

Complaints - includes links to information about avoiding filing errors, reporting to the proper agency and filing justified complaints.


Prompt Pay - includes links to frequently asked questions, TACCP meeting notes, and guidelines.
Professional Liability - includes links to JUA, professional liability admitted carriers and medical malpractice information.


Rules - includes links to Rules and Proposed Rules.







Enforcement - includes links to enforcement actions and unauthorized insurance plans.


Education Resources - includes links to workshop handouts, as well as SB 418, HB 610, "clean claims" and "prompt pay" materials.


Credentialing - includes links to the credentialing application and information on how to complete.





Helpful Information - includes links to news releases, provider news, HMO patient notice, forms and reports.

Workers' Compensation - includes Workers' Compensation related links.


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Injured Workers 800-252-7031
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Last updated: 03/26/2014

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