Section 1301.0052 - Exclusive Provider Benefit Plans: Referrals for Medically Necessary Services(a) If a covered service is medically necessary and is not available through a preferred provider, the issuer of an exclusive provider benefit plan, on the request of a preferred provider, shall:(1) approve the referral of an insured to a nonpreferred provider within a reasonable period; and(2) fully reimburse the nonpreferred provider at the usual and customary rate or at a rate agreed to by the issuer and the nonpreferred provider.(b) An exclusive provider benefit plan must provide for a review by a health care provider with expertise in the same specialty as or a specialty similar to the type of health care provider to whom a referral is requested under Subsection (a) before the issuer of the plan may deny the referral.Tex. Ins. Code § 1301.0052
Added by Acts 2011, 82nd Leg., R.S., Ch. 288, Sec. 9, eff. 9/1/2011.