CHAPTER 1467. OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION

State Codes and Statutes

Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1467-out-of-network-claim-dispute-resolution

INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE F. PHYSICIANS AND HEALTH CARE PROVIDERS

CHAPTER 1467. OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION

SUBCHAPTER A. GENERAL PROVISIONS

Sec. 1467.001. DEFINITIONS. In this chapter:

(1) "Administrator" means:

(A) an administering firm for a health benefit plan providing

coverage under Chapter 1551; and

(B) if applicable, the claims administrator for the health

benefit plan.

(2) "Chief administrative law judge" means the chief

administrative law judge of the State Office of Administrative

Hearings.

(3) "Enrollee" means an individual who is eligible to receive

benefits through a preferred provider benefit plan or a health

benefit plan under Chapter 1551.

(4) "Facility-based physician" means a radiologist, an

anesthesiologist, a pathologist, an emergency department

physician, or a neonatologist:

(A) to whom the facility has granted clinical privileges; and

(B) who provides services to patients of the facility under

those clinical privileges.

(5) "Mediation" means a process in which an impartial mediator

facilitates and promotes agreement between the insurer offering a

preferred provider benefit plan or the administrator and a

facility-based physician or the physician's representative to

settle a health benefit claim of an enrollee.

(6) "Mediator" means an impartial person who is appointed to

conduct a mediation under this chapter.

(7) "Party" means an insurer offering a preferred provider

benefit plan, an administrator, or a facility-based physician or

the physician's representative who participates in a mediation

conducted under this chapter. The enrollee is also considered a

party to the mediation.

Added by Acts 2009, 81st Leg., R.S., Ch.

1290, Sec. 1, eff. June 19, 2009.

Sec. 1467.002. APPLICABILITY OF CHAPTER. This chapter applies

to:

(1) a preferred provider benefit plan offered by an insurer

under Chapter 1301; and

(2) an administrator of a health benefit plan, other than a

health maintenance organization plan, under Chapter 1551.

Added by Acts 2009, 81st Leg., R.S., Ch.

1290, Sec. 1, eff. June 19, 2009.

Sec. 1467.003. RULES. The commissioner, the Texas Medical

Board, and the chief administrative law judge shall adopt rules

as necessary to implement their respective powers and duties

under this chapter.

Added by Acts 2009, 81st Leg., R.S., Ch.

1290, Sec. 1, eff. June 19, 2009.

Sec. 1467.004. REMEDIES NOT EXCLUSIVE. The remedies provided by

this chapter are in addition to any other defense, remedy, or

procedure provided by law, including the common law.

Added by Acts 2009, 81st Leg., R.S., Ch.

1290, Sec. 1, eff. June 19, 2009.

Sec. 1467.005. REFORM. This chapter may not be construed to

prohibit:

(1) an insurer offering a preferred provider benefit plan or

administrator from, at any time, offering a reformed claim

settlement; or

(2) a facility-based physician from, at any time, offering a

reformed charge for medical services.

Added by Acts 2009, 81st Leg., R.S., Ch.

1290, Sec. 1, eff. June 19, 2009.

SUBCHAPTER B. MANDATORY MEDIATION

Sec. 1467.051. AVAILABILITY OF MANDATORY MEDIATION; EXCEPTION.

(a) An enrollee may request mediation of a settlement of an

out-of-network health benefit claim if:

(1) the amount for which the enrollee is responsible to a

facility-based physician, after copayments, deductibles, and

coinsurance, including the amount unpaid by the administrator or

insurer, is greater than $1,000; and

(2) the health benefit claim is for a medical service or supply

provided by a facility-based physician in a hospital that is a

preferred provider or that has a contract with the administrator.

(b) Except as provided by Subsections (c) and (d), if an

enrollee requests mediation under this subchapter, the

facility-based physician or the physician's representative and

the insurer or the administrator, as appropriate, shall

participate in the mediation.

enrollee, a facility-based physician shall, before providing a

medical service or supply, provide a complete disclosure to an

enrollee that:

(1) explains that the facility-based physician does not have a

contract with the enrollee's health benefit plan;

(2) discloses projected amounts for which the enrollee may be

responsible; and

(3) discloses the circumstances under which the enrollee would

be responsible for those amounts.

(d) A facility-based physician who makes a disclosure under

Subsection (c) and obtains the enrollee's written acknowledgment

of that disclosure may not be required to mediate a billed charge

under this subchapter if the amount billed is less than or equal

to the maximum amount projected in the disclosure.

Added by Acts 2009, 81st Leg., R.S., Ch.

1290, Sec. 1, eff. June 19, 2009.

Sec. 1467.052. MEDIATOR QUALIFICATIONS. (a) Except as provided

by Subsection (b), to qualify for an appointment as a mediator

under this chapter a person must have completed at least 40

classroom hours of training in dispute resolution techniques in a

course conducted by an alternative dispute resolution

organization or other dispute resolution organization approved by

the chief administrative law judge.

(b) A person not qualified under Subsection (a) may be appointed

as a mediator on agreement of the parties.

dispute if the person has been employed by, consulted for, or

otherwise had a business relationship with an insurer offering

the preferred provider benefit plan or a physician during the

three years immediately preceding the request for mediation.

Added by Acts 2009, 81st Leg., R.S., Ch.

1290, Sec. 1, eff. June 19, 2009.

Sec. 1467.053. APPOINTMENT OF MEDIATOR; FEES. (a) A mediation

shall be conducted by one mediator.

(b) The chief administrative law judge shall appoint the

mediator through a random assignment from a list of qualified

mediators maintained by the State Office of Administrative

Hearings.

mediator appointed by the chief administrative law judge may

conduct the mediation on agreement of all of the parties and

notice to the chief administrative law judge.

(d) The mediator's fees shall be split evenly and paid by the

insurer or administrator and the facility-based physician.

Added by Acts 2009, 81st Leg., R.S., Ch.

1290, Sec. 1, eff. June 19, 2009.

Sec. 1467.054. REQUEST AND PRELIMINARY PROCEDURES FOR MANDATORY

MEDIATION. (a) An enrollee may request mandatory mediation

under this chapter.

(b) A request for mandatory mediation must be provided to the

department on a form prescribed by the commissioner and must

include:

(1) the name of the enrollee requesting mediation;

(2) a brief description of the claim to be mediated;

(3) contact information, including a telephone number, for the

requesting enrollee and the enrollee's counsel, if the enrollee

retains counsel;

(4) the name of the facility-based physician and name of the

insurer or administrator; and

(5) any other information the commissioner may require by rule.

notify the facility-based physician and insurer or administrator

of the request.

(d) In an effort to settle the claim before mediation, all

parties must participate in an informal settlement teleconference

not later than the 30th day after the date on which the enrollee

submits a request for mediation under this section.

(e) A dispute to be mediated under this chapter that does not

settle as a result of a teleconference conducted under Subsection

(d) must be conducted in the county in which the medical services

were rendered.

(f) The enrollee may elect to participate in the mediation. A

mediation may not proceed without the consent of the enrollee.

An enrollee may withdraw the request for mediation at any time

before the mediation.

(g) Notwithstanding Subsection (f), mediation may proceed

without the participation of the enrollee or the enrollee's

representative if the enrollee or representative is not present

in person or through teleconference.

Added by Acts 2009, 81st Leg., R.S., Ch.

1290, Sec. 1, eff. June 19, 2009.

Sec. 1467.055. CONDUCT OF MEDIATION; CONFIDENTIALITY. (a) A

mediator may not impose the mediator's judgment on a party about

an issue that is a subject of the mediation.

(b) A mediation session is under the control of the mediator.

in strict confidence all information provided to the mediator by

a party and all communications of the mediator with a party.

(d) If the enrollee is participating in the mediation in person,

at the beginning of the mediation the mediator shall inform the

enrollee that if the enrollee is not satisfied with the mediated

agreement, the enrollee may file a complaint with:

(1) the Texas Medical Board against the facility-based physician

for improper billing; and

(2) the department for unfair claim settlement practices.

(e) A party must have an opportunity during the mediation to

speak and state the party's position.

(f) Except on the agreement of the participating parties, a

mediation may not last more than four hours.

(g) Except at the request of an enrollee, a mediation shall be

held not later than the 180th day after the date of the request

for mediation.

(h) On receipt of notice from the department that an enrollee

has made a request for mediation that meets the requirements of

this chapter, the facility-based physician may not pursue any

collection effort against the enrollee who has requested

mediation for amounts other than copayments, deductibles, and

coinsurance before the earlier of:

(1) the date the mediation is completed; or

(2) the date the request to mediate is withdrawn.

(i) A service provided by a facility-based physician may not be

summarily disallowed. This subsection does not require an

insurer or administrator to pay for an uncovered service.

(j) A mediator may not testify in a proceeding, other than a

proceeding to enforce this chapter, related to the mediation

agreement.

Added by Acts 2009, 81st Leg., R.S., Ch.

1290, Sec. 1, eff. June 19, 2009.

Sec. 1467.056. MATTERS CONSIDERED IN MEDIATION; AGREED

RESOLUTION. (a) In a mediation under this chapter, the parties

shall:

(1) evaluate whether:

(A) the amount charged by the facility-based physician for the

medical service or supply is excessive; and

(B) the amount paid by the insurer or administrator represents

the usual and customary rate for the medical service or supply or

is unreasonably low; and

(2) as a result of the amounts described by Subdivision (1),

determine the amount, after copayments, deductibles, and

coinsurance are applied, for which an enrollee is responsible to

the facility-based physician.

(b) The facility-based physician may present information

regarding the amount charged for the medical service or supply.

The insurer or administrator may present information regarding

the amount paid by the insurer.

claim between the parties during a mediation.

(d) The goal of the mediation is to reach an agreement among the

enrollee, the facility-based physician, and the insurer or

administrator, as applicable, as to the amount paid by the

insurer or administrator to the facility-based physician, the

amount charged by the facility-based physician, and the amount

paid to the facility-based physician by the enrollee.

Added by Acts 2009, 81st Leg., R.S., Ch.

1290, Sec. 1, eff. June 19, 2009.

Sec. 1467.057. NO AGREED RESOLUTION. (a) The mediator of an

unsuccessful mediation under this chapter shall report the

outcome of the mediation to the department, the Texas Medical

Board, and the chief administrative law judge.

(b) The chief administrative law judge shall enter an order of

referral of a matter reported under Subsection (a) to a special

judge under Chapter 151, Civil Practice and Remedies Code, that:

(1) names the special judge on whom the parties agreed or

appoints the special judge if the parties did not agree on a

judge;

(2) states the issues to be referred and the time and place on

which the parties agree for the trial;

(3) requires each party to pay the party's proportionate share

of the special judge's fee; and

(4) certifies that the parties have waived the right to trial by

jury.

described by Subsection (b) must proceed under Chapter 151, Civil

Practice and Remedies Code, except that the special judge's

verdict is not relevant or material to any other balance bill

dispute and has no precedential value.

(d) Notwithstanding any other provision of this section, Section

151.012, Civil Practice and Remedies Code, does not apply to a

mediation under this chapter.

Added by Acts 2009, 81st Leg., R.S., Ch.

1290, Sec. 1, eff. June 19, 2009.

Sec. 1467.058. CONTINUATION OF MEDIATION. After a referral is

made under Section 1467.057, the facility-based physician and the

insurer or administrator may elect to continue the mediation to

further determine their responsibilities. Continuation of

mediation under this section does not affect the amount of the

billed charge to the enrollee.

Added by Acts 2009, 81st Leg., R.S., Ch.

1290, Sec. 1, eff. June 19, 2009.

Sec. 1467.059. MEDIATION AGREEMENT. The mediator shall prepare

a confidential mediation agreement and order that states:

(1) the total amount for which the enrollee will be responsible

to the facility-based physician, after copayments, deductibles,

and coinsurance; and

(2) any agreement reached by the parties under Section 1467.058.

Added by Acts 2009, 81st Leg., R.S., Ch.

1290, Sec. 1, eff. June 19, 2009.

Sec. 1467.060. REPORT OF MEDIATOR. The mediator shall report to

the commissioner and the Texas Medical Board:

(1) the names of the parties to the mediation; and

(2) whether the parties reached an agreement or the mediator

made a referral under Section 1467.057.

Added by Acts 2009, 81st Leg., R.S., Ch.

1290, Sec. 1, eff. June 19, 2009.

SUBCHAPTER C. BAD FAITH MEDIATION

Sec. 1467.101. BAD FAITH. (a) The following conduct

constitutes bad faith mediation for purposes of this chapter:

(1) failing to participate in the mediation;

(2) failing to provide information the mediator believes is

necessary to facilitate an agreement; or

(3) failing to designate a representative participating in the

mediation with full authority to enter into any mediated

agreement.

(b) Failure to reach an agreement is not conclusive proof of bad

faith mediation.

commissioner or the Texas Medical Board, as appropriate,

following the conclusion of the mediation.

Added by Acts 2009, 81st Leg., R.S., Ch.

1290, Sec. 1, eff. June 19, 2009.

Sec. 1467.102. PENALTIES. (a) Bad faith mediation, by a party

other than the enrollee, is grounds for imposition of an

administrative penalty by the regulatory agency that issued a

license or certificate of authority to the party who committed

the violation.

(b) Except for good cause shown, on a report of a mediator and

appropriate proof of bad faith mediation, the regulatory agency

that issued the license or certificate of authority shall impose

an administrative penalty.

Added by Acts 2009, 81st Leg., R.S., Ch.

1290, Sec. 1, eff. June 19, 2009.

SUBCHAPTER D. COMPLAINTS; CONSUMER PROTECTION

Sec. 1467.151. CONSUMER PROTECTION; RULES. (a) The

commissioner and the Texas Medical Board, as appropriate, shall

adopt rules regulating the investigation and review of a

complaint filed that relates to the settlement of an

out-of-network health benefit claim that is subject to this

chapter. The rules adopted under this section must:

(1) distinguish among complaints for out-of-network coverage or

payment and give priority to investigating allegations of delayed

medical care;

(2) develop a form for filing a complaint and establish an

outreach effort to inform enrollees of the availability of the

claims dispute resolution process under this chapter;

(3) ensure that a complaint is not dismissed without appropriate

consideration;

(4) ensure that enrollees are informed of the availability of

mandatory mediation; and

(5) require the administrator to include a notice of the claims

dispute resolution process available under this chapter with the

explanation of benefits sent to an enrollee.

(b) The department and the Texas Medical Board shall maintain

information:

(1) on each complaint filed that concerns a claim or mediation

subject to this chapter; and

(2) related to a claim that is the basis of an enrollee

complaint, including:

(A) the type of services that gave rise to the dispute;

(B) the type and specialty of the facility-based physician who

provided the out-of-network service;

service or supply was provided;

(D) whether the medical service or supply was for emergency

care; and

(E) any other information about:

(i) the insurer or administrator that the commissioner by rule

requires; or

(ii) the physician that the Texas Medical Board by rule

requires.

and the Texas Medical Board under Subsection (b)(2) is public

information as defined by Section 552.002, Government Code, and

may not include personally identifiable information or medical

information.

(d) A facility-based physician who fails to provide a disclosure

under Section 1467.051 is not subject to discipline by the Texas

Medical Board for that failure and a cause of action is not

created by a failure to disclose as required by Section 1467.051.

Added by Acts 2009, 81st Leg., R.S., Ch.

1290, Sec. 1, eff. June 19, 2009.

State Codes and Statutes

State Codes and Statutes

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