Relating to vision care benefits, including participation of optometrists and therapeutic optometrists in vision care or managed care plans.

Contracts

• "All-or-Nothing" Clauses: You must amend Master Service Agreements (MSAs) to reflect that if a provider is credentialed for one plan, they must be allowed participation in all vision care plans you offer in Texas.
• Coding Standards: Contracts must mandate the use of HCPCS, AMA (Level I), and CMS (Level II) codes. Proprietary internal billing codes are now unenforceable and must be removed from provider manuals.
• Fee Schedules: You must provide an electronic fee schedule that identifies reimbursement for *each* covered service. Summary schedules are no longer compliant.

Hiring/Training

• Credentialing Staff: Teams must be retrained on the statutory "shot clock." Failure to send contract terms by Day 10 or render a decision by Day 30 constitutes a violation.
• Audit Teams: Staff must be retrained to stop using statistical extrapolation. Auditors must now verify 100% of claims where recovery is sought; training must emphasize specific claim verification over sampling methodologies.

Reporting & Record-Keeping

• Application Portal: You must host a direct application method on your website.
• Denial Documentation: Generic denial letters are prohibited. You must issue a written explanation within 10 business days of a denial decision, citing specific credentialing failures.
• Timestamping: Implement system logic to track:
• 1. Date of application receipt.
• 2. Date contract/manuals were sent (Deadline: Day 10).
• 3. Date of decision (Deadline: Day 30).
• 4. Date of system activation (Deadline: 20 days post-approval).

Fees & Costs

• Administrative Overhead: Expect increased costs in credentialing departments due to the inability to cap network size.
• Audit Recovery: Recovery revenue may decrease, and audit costs will rise, as the ban on extrapolation requires significantly more man-hours to prove overpayments.