Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS
Subchapter J - PHYSICIAN AND PROVIDER CONTRACTS AND ARRANGEMENTS
Section 11.900 - Nonprimary Care Physician Specialist as Primary Care Physician
Current through Reg. 50, No. 13; March 28, 2025
(a) An HMO must allow an enrollee with chronic, disabling, or life threatening illnesses to apply to the HMO's medical director to use a nonprimary care physician specialist as a primary care physician, provided that:
(b) An HMO must approve or deny the request for special consideration and provide written notification of the decision to the enrollee not later than 30 days after receiving the request. If the HMO denies the request, the HMO must provide the reasons for denial in the written notification. An HMO must establish written criteria for determining medical need for an enrollee to use a nonprimary care physician specialist as a primary care provider, and must include the criteria in the provider manual.
(c) If the HMO denies a request for special consideration, an enrollee may appeal the decision through the HMO's established complaint and appeal process.
