Commercial Plans
Incident-to Billing Guide - Provides the incident-to billing guidelines for various payors. See our Advanced Practice Providers web page for additional information.
Texas Prompt Pay Law (fully insured plans) - On June 17, 2003, Governor Perry signed into law SB 418 also known as Texas Prompt Pay to help physicians receive payment for services promptly. Plans that are regulated by this law will have "TDI" or "DOI" printed on the front or back of the member's insurance card.The Texas Department of Insurance (TDI) provider website has Tips and FAQ's on prompt pay laws and instructions for filing complaints via paper or online for providers and consumers to file complaints against payors who violate provisions of SB 418.
Texas Expedited Credentialing (applies to fully-insured plans and Medicaid Managed Care plans only) - If you have an established group contract with a commercial or Medicaid Managed Care plan and you have a new physician joining the group contract, upon submission of all the appropriate credentialing information to the plan, for payment purposes only until credentialing is approved, the fully-insured commercial plan shall treat the applicant physician as if the physician were a participating provider in the health plan's network when the applicant physician provides services to the managed care plan's enrollees. Be sure to request the that the plan apply the Texas Expedited Credentialing provisions to the physician. Also be aware that some plans may be unable to pay claims until the physician is fully contracted. If so, continue to file claims timely and seek reimbursement once contracting is complete. In addition, if the plan is using a third party entity for credentialing purposes, the third party is also subject to the same requirements that the plan is subject to for claims payment purposes. It is recommended that confirmation be obtained from the plan that the credentialing application and all required documents needed to credential have been received and credentialing can begin. The date of this confirmation should be the date that the physician can begin seeing the plan's enrollees as an in-network provider while their application is in process. It is advisable to confirm this understanding with the plan. If the physician is ultimately not credentialed, all claims paid as in-network will be reprocessed as out-of-network and refunds of any overpayments will be required.
Retroactive Termination (fully insured plans) - Senate Bill 51 prohibits retro-terminations and requires that an employer is required to provide coverage under the policy until the end of the month in which the employer notifies the insurer of termination of the employee's benefits. However, if the termination of employment occurs in the last seven days of the month, the employer has three business days into the next month to notify the carrier of the termination and thus avoid paying the additional premium for that month. An exception to this law applies to any former employee already enrolled in some form of continuation of coverage, such as Texas State Continuation, COBRA, or USERRA.
* Texas HB 574 - An act regarding out-of-network disclosures that took effect Sept. 1, 2015. This act provides information regarding access to out of network physicians/providers/facilities disclosure forms.