(a) An insurer must submit network configuration information as specified in this section in connection with a request for a waiver under §3.3707 of this title (relating to Waiver Due to Failure to Contract in Local Markets), an annual network adequacy report required under §3.3709 of this title (relating to Annual Network Adequacy Report), or an application for a network modification under §3.3722 of this title (relating to Application for Preferred and Exclusive Provider Benefit Plan Approval; Qualifying Examination; Network Modifications).
(b) A network configuration filing must be submitted to the department using SERFF or another electronic method that is acceptable to the department.
(c) A network configuration filing must contain the following items.
  (1) Provider listing data. The insurer must use the provider listings form available at www.tdi.texas.gov to provide a comprehensive searchable and sortable listing of physicians and health care providers in the plan's network that includes:
    (A) information about the insurer, including the insurer's name, National Association of Insurance Commissioners number, network name, and network ID;
    (B) information about each preferred provider, including:
      (i) the preferred provider's name, address of practice location, county, and telephone number;
      (ii) the preferred provider's national provider identifier (NPI) number and Texas license number;
      (iii) the preferred provider's specialty type, license, or facility type, as applicable, using the categories specified in the form; and
      (iv) whether the preferred provider offers telemedicine or telehealth; and
    (C) information about a preferred provider that is not a facility, including information on the preferred provider's facility privileges.
  (2) Network compliance analysis. The insurer must use the network compliance and waiver request form available at www.tdi.texas.gov to provide a listing of each county in the insurer's service area and data regarding network compliance for each county, including:
    (A) the number of each type of preferred provider in the plan's network, using the provider specialty types specified in the form;
    (B) information indicating whether the network adequacy standards specified in §3.3704 of this title (relating to Freedom of Choice; Availability of Preferred Providers) are met with respect to each type of physician or provider, including specifying the nature of the deficiency (such as insufficient providers, insufficient choice, or deficient appointment wait times);
    (C) if the network adequacy standards are not met for a given type of physician or provider, a waiver request and an access plan consistent with §3.3707 of this title (relating to Waiver Due to Failure to Contract in Local Markets), including an explanation of:
      (i) the reason the waiver is needed, including whether the waiver is needed because there are no physicians or providers available with whom a contract would allow the insurer to meet the network adequacy standards, or because of a failure to contract with available providers;
      (ii) if the waiver is needed because of a failure to contract with available providers, each year for which the waiver has previously been approved, beginning with 2024;
      (iii) the total number of currently practicing physicians or providers that are located within each county and the source of this information; and
      (iv) the access plan procedures the insurer will use to assist insureds in obtaining medically necessary services when no preferred provider is available within the network adequacy standards, including procedures to coordinate care to limit the likelihood of balance billing, consistent with the procedures established in §3.3707(j) of this title; and
    (D) except for a network offered in connection with an exclusive provider benefit plan, an insurer must include a description of how the insurer provides access to different types of facilities, as required by Insurance Code §1301.0055(b)(6), concerning Network Adequacy Standards.
  (3) Online provider listing. The insurer must include a link to the online provider listing made available to insureds and a pdf copy of the provider listing that is made available to insureds that request a nonelectronic version.
  (4) Access plan for unforeseen network gaps. The insurer must include a copy of the access plan required in §3.3707(m) of this title, which applies to any unforeseen circumstance in which an insured is unable to access covered health care services within the network adequacy standards provided in §3.3704 of this title.
(d) The information submitted as required under this section is considered public information under Government Code Chapter 552, concerning Public Information, and the insurer may not submit the provider listings form or network compliance and waiver request form in a manner that precludes the public release of the information. The department will use the data submitted under this section to publish network data consistent with Insurance Code §§1301.0055(a)(3), concerning Network Adequacy Standards, 1301.00565(g), concerning Public Hearing on Network Adequacy Standards Waivers, and 1301.009, concerning Annual Report.
(e) Upon request by TDI, an insurer must provide access to any information necessary for the commissioner to evaluate and make a determination of compliance with quality of care and network adequacy standards, including the information set forth in Insurance Code §1301.0056(e), concerning Examinations and Fees.

Source Note: The provisions of this §3.3712 adopted to be effective April 25, 2024, 49 TexReg 2497