1. (a) An HMO shall allow enrollees with chronic, disabling, or life threatening illnesses to apply to the HMO's medical director to utilize a nonprimary care physician specialist as a primary care physician, provided that:

   1. (1) the request includes the following information:

      1. (A) certification by the nonprimary care physician specialist of the medical need for the enrollee to utilize the nonprimary care physician specialist as a primary care physician;
      2. (B) a statement signed by the nonprimary care physician specialist that he or she is willing to accept responsibility for the coordination of all of the enrollee's health care needs; and
      3. (C) signature of the enrollee;
   2. (2) the nonprimary care physician specialist meets the HMO's requirements for primary care physician participation, including credentialing;
   3. (3) the HMO has ensured that the contractual obligations of the nonprimary care physician specialist are consistent with the contractual obligations of the HMO's primary care physicians; and
   4. (4) the HMO provides the nonprimary care physician specialist with a current directory of participating specialist physicians and providers.
2. (b) HMO Action on Nonprimary Care Physician Specialist as Primary Care Physician. An HMO must approve or deny the request for special consideration as specified in subsection (a) of this section and provide written notification of the decision to the enrollee not later than 30 days after receiving the request. If the request is denied, the HMO must provide in the written notification to the enrollee the reasons for the denial of the request. An HMO must establish written criteria for determining medical need for an enrollee to utilize a non-primary care physician specialist as a primary care provider, and must include such criteria in the provider manual.
3. (c) Appeal of HMO Denial of Nonprimary Care Physician Specialist as Primary Care Physician. If the request for consideration specified in subsection (a) of this section is denied by the HMO, an enrollee may appeal the decision through the HMO's established complaint and appeal process.

Source Note:The provisions of this §11.900 adopted to be effective November 2, 1998, 23 TexReg 11347.