NATIONAL PROVIDER IDENTIFIER (NPI)
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires the adoption of a standard unique identifier for health care providers.  The National Provider Identifier (NPI) was adopted as this standard.  For more information, please refer to the HIPAA section of this site.

NEW PRACTICE INFORMATION
Whether embarking on a new practice, expanding an existing one, or relocating to the Houston area, HCMS member physicians will find the New Practice Checklist an invaluable resource in the creation and maintenance of a successful enterprise.
If you are new to Texas or have recruited a physician from out of state, be sure to check out Texas Medical Association'sNew to Texas Resource Page.  Also, HCMS can help you to grow your practice and increase your patient base!  Please refer to the above marketing info.

NOTICES FOR POSTING IN OFFICE
The Texas Medical Association provides guidance on notices (for employees and patients) that should be posted in the medical office.
For your Employees:
The Texas Workforce Commission (TWC) requires any Texas and Federal Labor Law postings to be visible to the staff.  The TWC's "Posters at the Workplace" section of their Web site is located athttp://www.twc.state.tx.us/ui/lablaw/posters.html. The US Department of Labor (DOL) provides an overview to help determine which of their posters are required for small business and other employers.  This "elaws Poster Advisor" and the needed posters can be found on the DOL Web page at http://www.dol.gov/compliance/topics/posters.htm.
For your Patients:
Both the Texas Medical Board (TMB) and the Texas Department of Insurance (TDI) have notices that must be posted in your office where patients can easily read them.  (Both notices are in English and Spanish.)
The TMB's Notice Concerning Complaints advises patients who have a complaint against a physician of the TMB's address and telephone number.  The current notice can be found athttp://www.tmb.state.tx.us/professionals/hcpres/compost.php.
The TDI's Notice to HMO Patients advises HMO patients of the steps they should take if they have a complaint against their HMO plan.  The current notice can be found athttp://www.tdi.texas.gov/hmo/documents/hmonote.pdf.
With the 'transparency laws' in effect, a medical practice is required to reveal specific billing information to patients, such as advising that the practice's billing and charity policies are available for their review.  Please refer to New Billing Disclosures Requiredfrom the TMA. You could post the simple sign "Billing and Charity Care Policies are available for review" in an area where patients would see it.  Also, a summary of your office's HIPAANotice of Privacy Practices (Primary Care Physicians)(from the TMA) should be posted. Copies of your complete privacy policy then could be made available in the waiting area.  The above notice must be customized for your practice.  For more HIPAA compliance help, please see theTMA HIPAA Resource Centerand the HCMS HIPAA Web section. 

PHYSICIAN RATINGS BY HEALTH PLANS
For information about the rules health plans must follow when rating physicians as well as a TMA guide to assist in reviewing and disputing a ranking, please refer to the Managed Care section of our site.

PRE-EXISTING CONDITIONS   
Physicians now have the opportunity to help patients with pre-existing conditions obtain affordable and comprehensive health coverage.  The Pre-Existing Condition Health Plan (PCIP) has changed its guidelines to allow adults and children to submit a letter from a doctor as proof of a pre-existing condition to enroll in PCIP. PCIP is a federal program and is administered by the Government Employees Health Association.  To qualify, an applicant must: be a U.S. citizen or reside in the U.S. legally; have not been insured in the past six months; have a pre-existing condition or have been denied coverage because of a health condition.
ThePre-Existing Condition Insurance Plan (PCIP)rates are lower than the rates in the Texas Health Insurance Pool (THIP), which also is for patients with pre-existing conditions.  Patients may apply for PCIP online atwww.pcip.gov.  Forplan info and options...
For more information, call 1-855-TEX-CHAP or go towww.TexasHealthOptions.com.
For information from the Texas Department of Insurance (TDI)about Federal Health Reform, the Affordable Care Act, FAQs, and federal and state resources...
Requirements under other individual policies and insurance plans
Federal and state requirements affect how pre-existing conditions are to be considered under other individual policies and insurance plans. Information can be found at the federal Dept of Labor HIPAA site under FAQs, in the Texas Insurance Code and in the Texas Administrative Code.
From the Federal Dept of Labor -HIPAA FAQ:
How does HIPAA apply when changing from group health coverage to an individual insurance policy?
HIPAA also protects those who are otherwise unable to get group health insurance.
The law guarantees access to individual insurance policies and state high-risk pools for eligible individuals. They must meet all of the following criteria:
* Had coverage for at least 18 months, most recently in a group health plan, without a significant break;
* Lost group coverage but not because of fraud or nonpayment of premiums;
* Are not eligible for COBRA coverage; or if COBRA coverage was offered under Federal or state law, elected and exhausted it; and
* Are not eligible for coverage under another group health plan, Medicare, or Medicaid; or have any other health insurance coverage.
The opportunity to buy an individual policy is the same whether a person quits a job, was fired, or was laid off.
From the Texas Insurance Code -TIC 1201.151 - 1201.154:
SUBCHAPTER D. PREEXISTING CONDITIONS:
Sec. 1201.151. COMPLIANCE WITH SUBCHAPTER; PROHIBITION OF DEFENSE. Except as provided by this subchapter, an individual accident and health insurance policy may not include a provision that permits a defense based on a preexisting condition.
Sec. 1201.154. COVERAGE FOR CERTAIN PREVIOUSLY COVERED PERSONS.
(a)  In this section, "creditable coverage" has the meaning assigned by Sec. 1205.004(a).
(b)  A preexisting condition provision in an individual accident and health insurance policy may not apply to an individual who was continuously covered for an aggregate period of 18 months by creditable coverage that was in effect up to a date not more than 63 days before the effective date of the individual coverage, excluding any waiting period.
(c)  In determining whether a preexisting condition provision of an individual accident and health insurance policy applies to an individual, an insurer shall credit the time the individual previously was covered under creditable coverage if the previous coverage was in effect at any time during the 18 months preceding the effective date of the individual coverage.
The Texas Administrative Code provides even more detailed information atTAC 3.3018 under the Policy Definition of a Preexisting Condition (TAC Title 28, Part 1, Chaper 3, Subchapter D, Rule 3.3018). 

PRESCRIBING DATA / PHYSICIAN DATA RESTRICTION PROGRAM (PDRP)
The American Medical Association (AMA) created the Physician Data Restriction Program (PDRP) in 2006 to offer physicians the option to restrict their prescribing data from pharmaceutical sales representatives.  The PDRP also allows physicians to register complaints against sales representatives or pharmaceutical companies who they believe are using their prescribing data inappropriately.  Below are materials about this program and how physicians can make an individual choice about the accessibility of their prescribing data.  For more information and to register for the PDRP, please see the AMA's PDRP Web page.  (Note: This program is available to all physicians, both AMA members and nonmembers.)
--An overview of the Physician Data Restriction Program (PDRP) also discusses enforcement 
-- Physicians discuss use of prescribing data the pros and cons of restricting data 
-- Q&A on the Physician Data Restriction Program
-- Physician prescribing data - The choice is yours - How to register
-- AMA Therapeutic Insights program offers quarterly online newsletters with current treatment guidelines 

PRESCRIPTIONS (RX) / PHARMACEUTICAL SAMPLES   
For some information and requirements involving prescription medications and providing free pharmaceutical samples to patients, please click on the links below:
--Drugs - TMA Board of Councilors Current Opinion
--To register for FDA alerts as soon as they are issued (through HCNN).
--TMF Health Quality Institute has a project to promote Part D drug safety.
--TDPS requirements for Schedule II-V controlled substances; and DPS notification of July 7, 2008.
--Q&A from the TSBP concerning substitution laws and rules.
--Health insurance plan requests for DEA numbers; and TDI bulletins on appropriate use.
--Drug registration info: TX Dept of Public Safety; DEA Office of Diversion Control.
--Prescription pad requirements for controlled substances (schedules II through V) (info from the TX Controlled Substances Act, TX Dangerous Drugs Act, and the rules of the Texas Board of Pharmacy).
--For Medicaid requirements on prescription pad and drug claims, please refer to the Medicaid Section under Prescription/Drug Claims and Medicaid.
--Writing valid prescriptions - what makes a "valid" prescription? (info from the Texas Secretary of State Web site).
--Over-the-counter drugs/items that require a prescription for a patient to be reimbursed under a tax-deferred health benefit plan.
--For electronic prescribing resources, please see our E-Prescribing Web page...
Pharmaceutical samples to patients:  
Below are statutes/rules from the Texas Medical Board about providing free pharmaceutical samples to patients and record keeping:
Statute Sec. 158.002. PROVISION OF FREE SAMPLES:
(a)  This chapter does not prohibit a physician from supplying a pharmaceutical sample to a patient free of charge if, in the physician's opinion, it is advantageous to the patient, in adhering to a course of treatment prescribed by the physician, to receive the sample.
(b)  A pharmaceutical sample provided under this section must be: (1) provided to the physician from the manufacturer free of charge and delivered to a patient free of any direct or indirect charge; (2) prepackaged by the original manufacturer and not repackaged; and (3)  marked on the immediate container to indicate that it is a sample or recorded in records that indicate it is a sample.
(c)  Each state and federal labeling and recordkeeping requirement must be followed and documented.  A record maintained under Subsection (b)(3) must be accessible as provided under state and federal law.
Rule 169.7 RECORD KEEPING:
(a) The following provisions relate to dangerous drugs: 
(1) A licensee shall be presumed to have complied with record keeping requirements for dangerous drugs (the Texas Health and Safety Code, Chapter 483) received as pharmaceutical samples if: (A) the licensee maintains a copy of each signed request form for samples required by the Prescription Drug Marketing Act of 1987, Public Law Number 100-293, 102 Statute 95 (21 United States Code 503(D) for a period of two years from the date of acquisition; and (B) the licensee makes appropriate entries in patients' medical records when a pharmaceutical sample is supplied to a patient.
(b) The following provisions relate to controlled substances:
(1) A licensee shall be presumed to have complied with record keeping requirements for controlled substances (the Texas Health and Safety Code, Chapter 481) received as pharmaceutical samples if: (A) the licensee maintains a copy of each signed request form for samples required by the Prescription Drug Marketing Act of 1987, Public Law Number 100-293, 102 Statute 95 (21 United States Code 503(D) for a period of two years from the date of acquisition; and (B) the licensee maintains records of pharmaceutical samples as required by the Texas Department of Public Safety under 37 TAC §§13.201 - 13.209 (Controlled Substances - Record Keeping).     

PROMPT PAY / CLEAN CLAIMS / SB418
Please refer to our TDI Prompt Pay Rules & Proceduressection.