Form HMO007 "Evidence of Coverage (Eoc) Checklist - Single Health Care Service Plan - Dental Care" - Texas

What Is Form HMO007?

This is a legal form that was released by the Texas Department of Insurance - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2020;
  • The latest edition provided by the Texas Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form HMO007 by clicking the link below or browse more documents and templates provided by the Texas Department of Insurance.

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Download Form HMO007 "Evidence of Coverage (Eoc) Checklist - Single Health Care Service Plan - Dental Care" - Texas

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HMO007 | 0120
EVIDENCE OF COVERAGE (EOC) CHECKLIST
Single Health Care Service Plan - Dental Care
Every effort has been made to ensure the accuracy of the information in this document. All
parties should consult the Texas Insurance Code, the Texas Administrative Code, and other
applicable laws.
FILING REQUIREMENTS
HMOs must file the evidence of coverage and related forms, including the
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member handbook for all plans other than CHIP plans, for approval prior to
issuance -
TIC
§1271.101, and
28 TAC §11.301(4)
and
§11.501
Chip member handbooks are filed for information -
28 TAC §11.301(5)
All variable material must be bracketed and include an explanation of variability -
Page
28 TAC §11.505(e)
Certification of plain language requirements (transmittal checklist) -
28 TAC §3.601
Page
and
§3.602
and
§11.505(f)
Insert Pages - replacement page; may be filed with or subsequent to approval or
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review of an evidence of coverage or written plan description, including a member
handbook -
28 TAC §11.2(b)(22)
and
§11.505(h) - (j)
Matrix Filings - must identify each provision with a unique form number that is
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sufficient to distinguish it as a matrix filing -
28 TAC §11.2(b)(27)
and
§11.505(g)
SINGLE SERVICE HMO EOC - GENERAL PROVISIONS
Description of covered dental services, applicable copayments and glossary -
28
Page
TAC §11.2201
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HMO007 | 0120
EVIDENCE OF COVERAGE (EOC) CHECKLIST
Single Health Care Service Plan - Dental Care
Every effort has been made to ensure the accuracy of the information in this document. All
parties should consult the Texas Insurance Code, the Texas Administrative Code, and other
applicable laws.
FILING REQUIREMENTS
HMOs must file the evidence of coverage and related forms, including the
Page
member handbook for all plans other than CHIP plans, for approval prior to
issuance -
TIC
§1271.101, and
28 TAC §11.301(4)
and
§11.501
Chip member handbooks are filed for information -
28 TAC §11.301(5)
All variable material must be bracketed and include an explanation of variability -
Page
28 TAC §11.505(e)
Certification of plain language requirements (transmittal checklist) -
28 TAC §3.601
Page
and
§3.602
and
§11.505(f)
Insert Pages - replacement page; may be filed with or subsequent to approval or
Page
review of an evidence of coverage or written plan description, including a member
handbook -
28 TAC §11.2(b)(22)
and
§11.505(h) - (j)
Matrix Filings - must identify each provision with a unique form number that is
Page
sufficient to distinguish it as a matrix filing -
28 TAC §11.2(b)(27)
and
§11.505(g)
SINGLE SERVICE HMO EOC - GENERAL PROVISIONS
Description of covered dental services, applicable copayments and glossary -
28
Page
TAC §11.2201
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HMO007 | 0120
MANDATORY EOC PROVISIONS
Complaint and Appeal Procedures:
Complaints and appeals -
TIC §§843.251 - 843.262
and §1271.054, and
Page
28 TAC §11.506(b)(5)
A statement that an HMO will not engage in retaliatory action against an enrollee
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filing a complaint -
TIC §843.281
Utilization Review:
The provisions below are not required if the dental HMO does not perform utilization review. Any
plan that does not perform utilization review should not include terms such as dental necessity,
medical necessity, dentally necessary, medically necessary, preauthorization, prior authorization, prior
approval, adverse determination, or other terms descriptive of utilization review.
Preauthorization - favorable determination of medical necessity -
TIC
§843.348,
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and
28 TAC
§19.1718(d):
Preauthorization Renewal - a plan that requires preauthorization must provide a
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preauthorization renewal process that permits a renewal request at least 60 days
before an existing preauthorization expires
TIC §§1222.003 -1222.004
and
§843.348
(definition of preauthorization)
Adverse determination - services provided or proposed are determined not
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medically necessary or experimental and investigational -
TIC §4201.002
Adverse determination - retrospective review -
TIC §4201.305
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Adverse determination - appeal -
TIC §4201.359
Page
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HMO007 | 0120
Adverse determination - expedited appeal for denial of emergency care -
TIC
Page
§4201.357
Adverse determination - immediate appeal to independent review organization
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(IRO) for a life threatening condition -
TIC §4201.360
and
§§4201.401 - 4201.457
Continuation of Coverage - group plans
only- TIC §§1271.301 -
1271.304, and
28 TAC
§21.5302, and
§§21.5310 -
21.5314:
Enrollee must send written notice of election to continue coverage no later than
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60 days
Enrollee shall make payment no later than 45 days after the initial election for
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coverage and on the due date of each month thereafter
Following the first payment made, payments considered timely if made by the
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30 th day after the date payment is due
Enrollees not eligible for COBRA are entitled to 9 months Continuation coverage
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Enrollees eligible for COBRA, entitled to continuation of coverage for an additional
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6 months
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HMO007 | 0120
Eligibility and Enrollment Standards:
Eligibility requirements -
28 TAC §11.506(b)(8)
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Adopted children -
28 TAC §11.506(b)(8)(A)(i)
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Court-ordered medical and dental child support -
TIC §§1504.001 - 1504.102
Page
Grandchildren - if children are eligible, limiting age for children and grandchildren
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must be stated in the EOC -
TIC
§1201.062,
§1271.005(e)
and §1271.006, and
28
TAC §11.506(b)(8)(E)
Handicapped child - a covered disabled child's attainment of limiting age does not
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operate to terminate the coverage of such child -
28 TAC §11.506(b)(17)
Limiting age - subscriber and dependents -
28 TAC §11.506(b)(8)(C)
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Newborns -
28 TAC §11.506(b)(8)(D)
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Newly acquired dependents -
28 TAC §11.506(b)(8)(B)
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Past denial of coverage - HMO may not consider a determination that the
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applicant has or has not previously been denied health benefit plan coverage in
underwriting the coverage for which the applicant has applied - individual plans
only -
TIC §544.502
Student coverage - termination due to change in student enrollment status -
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TIC §§1503.001 -
1503.003, and
28 TAC §11.506(b)(18)
Genetic Testing -
TIC §§546.001 -
546.152:
Notice to enrollee -
TIC §546.051(a)(1)
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Consent required (including consent from mother for testing in utero) -
TIC
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§546.051(a)(3), §546.051(b)
and
§546.053(b)(1)
Information to enrollee of test results -
TIC §546.051(b)(1)-(2)
and
§546.101
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Inducement prohibited (to buy insurance or to induce abortion) -
TIC §546.051(c)
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and
§546.053(b)(2)
Improper use of test results prohibited -
TIC §546.052
Page
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