|(a) Purpose. The purpose of this section is to implement
the requirements of the Insurance Code Chapter 1467 and notify licensees
of their responsibilities under that chapter.
(b) Definitions and Applicability of Section.
(1) Definitions. Terms defined in the Insurance Code §1467.001
have the same meanings when used in this section, unless the context
clearly indicates otherwise.
(2) Applicability. This section applies to any facility-based
provider or emergency care provider, as those terms are defined in
the Insurance Code §1467.001, who bills an enrollee covered by
a preferred provider benefit plan offered by an insurer under the
Insurance Code Chapter 1301 or a health benefit plan, other than a
health maintenance organization plan, under the Insurance Code Chapters
1551, 1575, or 1579, for out-of-network emergency care, health care,
or medical service or supply provided on or after January 1, 2018.
This section is limited to facility-based providers and emergency
care providers that are subject to the Board's jurisdiction.
(c) Responsibilities of Licensee.
(A) An enrollee, as that term is defined in the Insurance
Code §1467.001(3), may request mediation of a settlement of an
out-of-network health benefit claim if:
(i) the amount for which the enrollee is responsible
to a facility-based or emergency care provider, after co-payments,
deductibles, and co-insurance, including the amount unpaid by the
administrator or insurer, is greater than $500; and
(ii) the health benefit claim is for:
(I) emergency care; or
(II) a health care or medical service or supply provided
by a facility-based provider in a facility that is a preferred provider
or that has a contract with the administrator.
(B) If an enrollee requests mediation under the Insurance
Code Chapter 1467, the facility-based or emergency care provider or
their representative must participate in the mediation.
(C) Prior to participation in a mediation, all parties,
including the facility-based or emergency care provider, or their
representative, must participate in an informal settlement teleconference
not later than the 30th day after the date on which the enrollee submits
the request for mediation. If the informal settlement teleconference
is unsuccessful in resolving the matter, a mediation must be conducted
in the county in which the health care or medical services were rendered.
(D) In a mediation under the Insurance Code Chapter
1467, the parties must:
(i) evaluate whether:
(I) the amount charged by the facility-based or emergency
care provider for the health care or medical service or supply is
(II) whether the amount paid by the insurer or administrator
represents the usual and customary rate for the health care or medical
service or supply or is unreasonably low; and
(ii) as a result of the amounts described by clause
(i) of this subparagraph, determine the amount, after co-payments,
deductibles, and co-insurance are applied, for which the enrollee
is responsible to the facility-based or emergency care provider.
(E) The mediator's fees for a mediation under the Insurance
Code Chapter 1467 shall be split evenly and paid by the facility-based
or emergency care provider and the insurer or administrator.
(F) In the event a mediation is unsuccessful, the matter
must be referred to a special judge, as set forth in the Insurance
(G) A facility-based provider will not be required
to participate in mediation to mediate a billed charge if, prior to
providing a health care service or supply, the facility-based provider
makes a disclosure, as set forth in paragraph (2) of this subsection,
and obtains the enrollee's written acknowledgment of that disclosure,
so long as the billed amount is less than or equal to the maximum
amount projected in the disclosure.
(2) Billing Notices.
(A) Except in the case of an emergency, and if requested
by an enrollee, an out-of-network facility-based provider must provide
a complete disclosure to the enrollee, prior to providing the health
care or medical service or supply, that:
(i) explains that the facility-based provider does
not have a contract with the enrollee's health benefit plan;
(ii) discloses projected amounts for which the enrollee
may be responsible; and
(iii) discloses the circumstances under which the enrollee
would be responsible for those amounts.
(B) Each bill sent to an enrollee by a facility-based
or emergency care provider for an out-of-network health benefit claim
(balance bill) eligible for mediation under the Insurance Code Chapter
1467 must include a conspicuous, plain-language explanation of the
mediation process available under Chapter 1467, as well as the information
specified in §1467.0511.
(3) Collection Notices. On receipt of notice from the
Texas Department of Insurance that an enrollee has made a request
for mediation that meets the requirements of the Insurance Code Chapter
1467, the facility-based or emergency care provider may not pursue
any collection efforts against the enrollee for amounts other than
co-payments, deductibles, and co-insurance, before the earlier of
the date the mediation is completed or the date the request to mediate
(d) Complaint Investigation and Resolution.
(1) Bad faith.
(A) Except for good cause shown, on a report of a mediator
and appropriate proof of bad faith mediation, the Board shall impose
an administrative penalty.
(B) The following conduct constitutes bad faith mediation:
(i) failing to participate in the mediation, if participation
in the mediation was required;
(ii) failing to provide information the mediator believes
is necessary to facilitate an agreement; or
(iii) failing to designate a representative participating
in the mediation with full authority to enter into any mediated agreement.
(C) Failure to reach an agreement is not conclusive
proof of bad faith mediation.
(2) Complaint process. A complaint may be filed with
the Board by a mediator against a licensee for bad faith mediation
or by an enrollee who is not satisfied with a mediated agreement.
Complaints that do not involve delayed health care or medical care
shall be assigned a Priority 4 status, as described in §213.13
of this title (relating to Complaint Investigation and Disposition).
After investigation, if the Board determines that a licensee has engaged
in improper billing practices or has committed a violation of the
Nursing Practice Act, Chapter 1467, or other applicable law, the Board
will impose appropriate disciplinary action.