Texas Insurance Code - INS § 4201.659. Effect of Preauthorization Exemption

(1) knowingly and materially misrepresented the health care service in a request for payment submitted to the health maintenance organization or insurer with the specific intent to deceive and obtain an unlawful payment from the health maintenance organization or insurer;  or

(2) failed to substantially perform the health care service.

(1) to determine if the physician or provider still qualifies for an exemption under this subchapter;  or

(2) if the health maintenance organization or insurer has a reasonable cause to suspect a basis for denial exists under Subsection (a).

(1) the requirements under or application of Section 4201.305, including any timeframes specified by that section;  or

(2) any other applicable law, except to prescribe the only circumstances under which:

(1) a statement that the physician or provider qualifies for an exemption from preauthorization requirements under Section 4201.653;

(2) a list of the health care services and health benefit plans to which the exemption applies;  and

(3) a statement of the duration of the exemption.

(1) the information described by Subsection (d);  and

(2) a notification of the health maintenance organization's or insurer's payment requirements.

(1) authorize a physician or provider to provide a health care service outside the scope of the provider's applicable license issued under Title 3, Occupations Code;  or

(2) require a health maintenance organization or insurer to pay for a health care service described by Subdivision (1) that is performed in violation of the laws of this state.