chiropractors get in-network pay before credentialing is done

The text as introduced · 708 words

89R3998 SCF-F

By: Parker
S.B. No. 832

A BILL TO BE ENTITLED

AN ACT

relating to expedited credentialing of certain chiropractors by

managed care plan issuers.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Chapter 1452, Insurance Code, is amended by

adding Subchapter F to read as follows:

SUBCHAPTER F. EXPEDITED CREDENTIALING PROCESS FOR CERTAIN

CHIROPRACTORS

Sec. 1452.251. DEFINITIONS. In this subchapter:

(1) "Applicant" means a chiropractor applying for

expedited credentialing under this subchapter.

(2) "Enrollee" means an individual who is eligible to

receive health care services under a managed care plan.

(3) "Health care provider" means:

(A) an individual who is licensed, certified, or

otherwise authorized to provide health care services in this state;

or

(B) a hospital, emergency clinic, outpatient

clinic, or other facility providing health care services.

(4) "Managed care plan" means a health benefit plan

under which health care services are provided to enrollees through

contracts with health care providers and that requires enrollees to

use participating providers or that provides a different level of

coverage for enrollees who use participating providers. The term

includes a health benefit plan issued by:

(A) a health maintenance organization;

(B) a preferred provider benefit plan issuer; or

(C) any other entity that issues a health benefit

plan, including an insurance company.

(5) "Participating provider" means a health care

provider who has contracted with a health benefit plan issuer to

provide services to enrollees.

(6) "Professional practice" means a business entity

owned by one or more chiropractors or physicians.

Sec. 1452.252. APPLICABILITY. This subchapter applies only

to a chiropractor who joins an established professional practice

that has a contract with a managed care plan.

Sec. 1452.253. ELIGIBILITY REQUIREMENTS. To qualify for

expedited credentialing under this subchapter and payment under

Section 1452.254, a chiropractor must:

(1) be licensed in this state by, and in good standing

with, the Texas Board of Chiropractic Examiners;

(2) submit all documentation and other information

required by the managed care plan issuer to begin the credentialing

process required for the issuer to include the chiropractor in the

plan's network; and

(3) agree to comply with the terms of the managed care

plan's participating provider contract with the chiropractor's

established professional practice.

Sec. 1452.254. PAYMENT OF CHIROPRACTOR DURING

CREDENTIALING PROCESS. After an applicant has submitted the

information required by the managed care plan issuer under Section

1452.253, the issuer shall, for payment purposes only, treat the

applicant as if the applicant is a participating provider in the

plan's network when the applicant provides services to the plan's

enrollees, including:

(1) authorizing the applicant to collect copayments

from the enrollees; and

(2) making payments to the applicant.

Sec. 1452.255. DIRECTORY ENTRIES. Pending the approval of

an application submitted under Section 1452.253, the managed care

plan issuer may exclude the applicant from the plan's directory,

Internet website listing, or other listing of participating

providers.

Sec. 1452.256. EFFECT OF FAILURE TO MEET CREDENTIALING

REQUIREMENTS. If, on completion of the credentialing process, the

managed care plan issuer determines that the applicant does not

meet the issuer's credentialing requirements:

(1) the issuer may recover from the applicant or the

applicant's professional practice an amount equal to the difference

between payments for in-network benefits and out-of-network

benefits; and

(2) the applicant or the applicant's professional

practice may retain any copayments collected or in the process of

being collected as of the date of the issuer's determination.

Sec. 1452.257. ENROLLEE HELD HARMLESS. An enrollee is not

responsible and shall be held harmless for the difference between

in-network copayments paid by the enrollee to a chiropractor who is

determined to be ineligible under Section 1452.256 and the

enrollee's managed care plan's charges for out-of-network services.

The chiropractor and the chiropractor's professional practice may

not charge the enrollee for any portion of the chiropractor's fee

that is not paid or reimbursed by the plan.

Sec. 1452.258. LIMITATION ON MANAGED CARE ISSUER LIABILITY.

A managed care plan issuer that complies with this subchapter is not

subject to liability for damages arising out of or in connection

with, directly or indirectly, the payment by the issuer of a

chiropractor treated as if the chiropractor is a participating

provider in the plan's network.

SECTION 2. This Act takes effect September 1, 2025.