The Texas Insurance Code (Chapter 1452, Subchapter C) allows a physician joining an established medical group that has a current contract with a health plan to be paid as if he or she were participating in the plan while it is processing the physician's application.
The physician will be treated for payment purposes only as if he or she were participating in the health plan’s network if the physician:
- Is licensed in Texas,
- Is in good standing with the Texas Medical Board,
- Has submitted all documentation and information required by the health plan to begin the credentialing process, and
- Agrees to the terms of the contract between the medical group and the health plan.
Also pending the approval of the physician's application during the credentialing process:
- The physician may collect in-network copayments from the patient.
- The health plan may exclude the physician from its directory and Web site listing of participating physicians.
- In the case of an HMO, a patient may not select the physician as a primary care physician.
What if the health plan eventually declines to credential the physician to participate in its network? In that case:
- The health plan may recover, from either the physician or the medical group, the difference between payments for in-network benefits and out-of-network benefits.
- The physician may keep any patient in-network copayments already collected or in the process of being collected as of the date of the health plan's determination.
- The patient is not responsible for the difference between in-network copayments paid during the credentialing process and out-of-network benefits.
Last Updated On
May 13, 2016
Originally Published On
March 23, 2010