Physician and provider contracts and arrangements shall include the following provisions:

1. (1) regarding hold harmless clause as described in the Insurance Code Article 20A.18A(g) and §11.1102 of this title (relating to Hold Harmless Clause);
2. (2) regarding retaliation as described in the Insurance Code Article 20A.14(k);
3. (3) regarding continuity of treatment, if applicable, as described in the Insurance Code Article 20A.18(A)(c);
4. (4) regarding written notification of termination to a physician or provider at least 90 days prior to the effective date of the termination of the physician or provider, except in the case of imminent harm to patient health, action against license to practice, or fraud pursuant to Insurance Code Article 20A.18A(b), in which case termination may be immediate. Upon written notification of termination, a physician or provider may seek review of the termination within a period not to exceed 60 days, pursuant to the procedure set forth in the Insurance Code Article 20A.18A(b). The HMO must provide notification of the termination of a physician or provider to its enrollees receiving care from the provider being terminated at least 30 days before the effective date of the termination. Notification of termination of a physician or provider to enrollees for reasons related to imminent harm may be given to enrollees immediately;
5. (5) regarding posting of complaints notice in physician/provider offices as described in the Insurance Code Article 20A.18A(i). A representative notice that complies with this requirement may be obtained from the Texas Department of Insurance, HMO/UR/QA Group, P.O. Box 149104, Austin, Texas 78714-9104;
6. (6) regarding indemnification of the HMO as described in the Insurance Code Article 20A.18A(f);
7. (7) regarding prompt payment of claims as described in the Insurance Code Article 20A.09(j) and all applicable statutes and rules pertaining to prompt payment of clean claims, including Insurance Code Article 20A.18B (Prompt Payment of Physician and Providers) and §§21.2801-21.2820 of this title (relating to Submission of Clean Claims) with respect to the payment to the physician or provider for covered services that are rendered to enrollees;
8. (8) regarding capitation, if applicable, as described in the Insurance Code Article 20A.18A(e);
9. (9) regarding selection of a primary physician or provider, if applicable, as described in the Insurance Code Article 20A.18A(e); and

10. (10) entitling the physician or provider upon request to all information necessary to determine that the physician or provider is being compensated in accordance with the contract. A physician or provider may make the request for information by any reasonable and verifiable means. The information must include a level of detail sufficient to enable a reasonable person with sufficient training, experience and competence in claims processing to determine the payment to be made according to the terms of the contract for covered services that are rendered to enrollees. The HMO may provide the required information by any reasonable method through which the physician or provider can access the information, including e-mail, computer disks, paper or access to an electronic database. Amendments, revisions or substitutions of any information provided pursuant to this paragraph must be made in accordance with subparagraph (D) of this paragraph. The HMO shall provide the fee schedules and other required information by the later of the 90th day after the effective date of this paragraph or the 30th day after the date the HMO receives the physician's or provider's request.

    1. (A) This information must include a physician-specific or provider-specific summary and explanation of all payment and reimbursement methodologies that will be used to pay claims submitted by a physician or provider. At a minimum, the information must include:

       1. (i) a fee schedule, including, if applicable, CPT, HCPCS, ICD-9-CM codes and modifiers:

          1. (I) by which all claims for covered services submitted by or on behalf of the contracting physician or provider will be calculated and paid; or
          2. (II) that pertains to the range of health care services reasonably expected to be delivered under the contract by that contracting physician or provider on a routine basis along with a toll-free number or electronic address through which the contracting physician or provider may request the fee schedules applicable to any covered services that the physician or provider intends to provide to an enrollee and any other information required by this paragraph, that pertains to the service for which the fee schedule is being requested if that information has not previously been provided to the physician or provider;
       2. (ii) all applicable coding methodologies;
       3. (iii) all applicable bundling processes;
       4. (iv) all applicable downcoding policies;
       5. (v) a description of any other applicable policy or procedure the HMO may use that affects the payment of specific claims submitted by or on behalf of the contracting physician or provider, including recoupment; and
       6. (vi) any addenda, schedules, exhibits or policies used by the HMO in carrying out the payment of claims submitted by or on behalf of the contracting physician or provider that are necessary to provide a reasonable understanding of the information provided pursuant to this paragraph.
    2. (B) In the case of a reference to source information as the basis for fee computation that is outside the control of the HMO, such as state Medicaid or federal Medicare fee schedules, the information provided by the HMO shall clearly identify the source and explain the procedure by which the physician or provider may readily access the source electronically, telephonically, or as otherwise agreed to by the parties.
    3. (C) Nothing in this paragraph shall be construed to require an HMO to provide specific information that would violate any applicable copyright law or licensing agreement. However, the HMO must supply, in lieu of any information withheld on the basis of copyright law or licensing agreement, a summary of the information that will allow a reasonable person with sufficient training, experience and competence in claims processing to determine the payment to be made according to the terms of the contract for covered services that are rendered to enrollees as required by subparagraph (A) of this paragraph.
    4. (D) No amendment, revision, or substitution of any of the claims payment procedures or any of the information required to be provided by this paragraph shall be effective as to the contracting physician or provider, unless the HMO provides at least 60 calendar days written notice to the contracting physician or provider identifying with specificity the amendment, revision or substitution. Where a contract specifies mutual agreement of the parties as the sole mechanism for requiring amendment, revision or substitution of the information required by this paragraph, the written notice specified in this section does not supersede the requirement for mutual agreement.
    5. (E) Failure to comply with this paragraph constitutes a violation of Insurance Code Chapter 20A (Texas Health Maintenance Organization Act).

    6. (F) This paragraph applies to all contracts entered into or renewed on or after the effective date of this paragraph. Upon receipt of a request, the HMO must provide the information required by subparagraphs (A) - (D) of this paragraph:

       1. (i) for contracts entered into or renewed on or after the effective date of this paragraph, to the physician or provider by the later of the 90th day after the effective date of this paragraph or contemporaneously with other contractual materials; or
       2. (ii) for an existing contract that does not contain the terms set forth in this paragraph, to the contracting physician or provider by the later of the 90th day after the effective date of this paragraph or the 30th day after the date the insurer receives the contracting physician's or provider's request.

    7. (G) A physician or provider that receives information under this paragraph:

       1. (i) may not use or disclose the information for any purpose other than the physician's or provider's practice management and billing activities;
       2. (ii) may not use this information to knowingly submit a claim for payment that does not accurately represent the level, type or amount of services that were actually provided to an enrollee or to misrepresent any aspect of the services; and
       3. (iii) may not rely upon information provided pursuant to this paragraph about a service as a verification that an enrollee is covered for that service under the terms of the enrollee's evidence of coverage.

Source Note:The provisions of this §11.901 adopted to be effective November 2, 1998, 23 TexReg 11347; amended to be effective October 8, 2002, 27 TexReg 9339.