| (a) Any person may submit a complaint to the division
for alleged administrative violations, except as provided in subsection
(b) of this section.
(b) A health care provider cannot submit a complaint
about a medical billing issue if the date of service for the medical
billing issue was more than 12 months before the date of the complaint,
unless the issue qualifies for an exception to the filing deadline
under §133.307(c)(1)(B) of this title, concerning medical fee
dispute resolution. If the issue qualifies for an exception to the
medical fee dispute resolution filing deadline under §133.307(c)(1)(B),
then a health care provider cannot submit a complaint about that issue
if the medical fee dispute resolution filing deadline in §133.307(c)(1)(B)
has passed. This subsection does not apply to a health care provider
submitting a complaint under Insurance Code Chapter 1305.
(c) A person may submit a complaint to the division:
(1) through the division's website;
(2) by email;
(3) through written correspondence;
(4) by fax; or
(5) in person. The division will help a person submitting
an in-person complaint reduce the complaint to writing.
(d) A complaint submitted on the form provided by the
division or in any other written format must contain the following
information as applicable:
(1) complainant's name and contact information;
(2) name and contact information of the subject or
parties of the complaint, if known;
(3) name and contact information of witnesses, if known;
(4) claim file information, including, but not limited
to, the name, address, and date of injury of the injured employee,
if known;
(5) the statement of the facts about the alleged violation,
including the dates or time period the alleged violation occurred;
(6) the nature of the alleged violation, including
the specific sections of the Act and division rules alleged to have
been violated, if known;
(7) supporting documentation relevant to the allegation
that may include, but is not limited to, medical bills, Explanation
of Benefits statements, copies of payment invoices or checks, and
medical reports, as applicable;
(8) supporting documentation for alleged fraud that
may include photographs, video, audio, and surveillance recordings,
and reports; and
(9) other sources of pertinent information, if known.
(e) Contact information may include, but is not limited
to, name, address, telephone number, fax number, email address, business
name, business address, business telephone number, and websites.
(f) A complaint must contain sufficient information
for the division to investigate the complaint.
(g) On receipt of a complaint, the division will review,
monitor, and may investigate the allegation against a person or entity
who may have violated the Act or division rules.
(h) The division will assign priorities to complaints
being investigated based on a risk-based complaint investigation system
that considers:
(1) the severity of the alleged violation;
(2) whether the noncompliance or alleged violation
is ongoing;
(3) whether a commissioner order has been violated;
or
(4) other risk-based criteria the division determines
necessary.
(i) A person commits an administrative violation if
the person submits a complaint to the division that is:
(1) frivolous, as defined in §180.1 of this title
(relating to Definitions);
(2) groundless or made in bad faith; or
(3) done specifically for competitive or economic advantage.
|
| Source Note: The provisions of this §180.2 adopted to be effective March 14, 2002, 27 TexReg 1817; amended to be effective January 9, 2011, 35 TexReg 11873; amended to be effective May 27, 2024, 49 TexReg 3805 |
