The plan administrator must pay certain out-of-network diagnostic imaging or lab providers, and those providers generally cannot bill the enrollee above the usual cost-sharing amount.
Sec. 1575.173. OUT-OF-NETWORK DIAGNOSTIC IMAGING PROVIDER OR LABORATORY SERVICE PROVIDER PAYMENTS. (a) In this section, "diagnostic imaging provider" and "laboratory service provider" have the meanings assigned by Section 1467.001. (b) Except as provided by Subsection (d), the administrator of a managed care plan provided under the group program shall pay for a covered health care or medical service performed for or a covered supply related to that service provided to an enrollee by an out-of-network provider who is a diagnostic imaging provider or laboratory service provider at the usual and customary rate or at an agreed rate if the provider performed the service in connection with a health care or medical service performed by a participating provider. The administrator shall make a payment required by this subsection directly to the provider not later than, as applicable: (1) the 30th day after the date the administrator receives an electronic claim for those services that includes all information necessary for the administrator to pay the claim; or (2) the 45th day after the date the administrator receives a nonelectronic claim for those services that includes all information necessary for the administrator to pay the claim. (c) Except as provided by Subsection (d), an out-of-network provider who is a diagnostic imaging provider or laboratory service provider or a person asserting a claim as an agent or assignee of the provider may not bill an enrollee receiving a health care or medical service or supply described by Subsection (b) in, and the enrollee does not have financial responsibility for, an amount greater than an applicable copayment, coinsurance, and deductible under the enrollee's managed care plan that: (1) is based on: (A) the amount initially determined payable by the administrator; or (B) if applicable, the modified amount as determined under the administrator's internal appeal process; and (2) is not based on any additional amount determined to be owed to the provider under Chapter 1467. (d) This section does not apply to a nonemergency health care or medical service: (1) that an enrollee elects to receive in writing in advance of the service with respect to each out-of-network provider providing the service; and (2) for which an out-of-network provider, before providing the service, provides a complete written disclosure to the enrollee that: (A) explains that the provider does not have a contract with the enrollee's managed care plan; (B) discloses projected amounts for which the enrollee may be responsible; and (C) discloses the circumstances under which the enrollee would be responsible for those amounts. Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 1.15, eff. September 1, 2019.