|(a) Notice at Time of Presentation.
(1) Except in the case of an emergency and if requested
by an enrollee, a facility-based physician shall, before providing
a medical service or supply, provide a complete disclosure to an enrollee
consistent with the notice requirements of §1467.051 of the Texas
Insurance Code, that:
(A) explains that the facility-based physician does
not have a contract with the enrollee's health benefit plan;
(B) discloses projected amounts for which the enrollee
may be responsible; and
(C) discloses the circumstances under which the enrollee
would be responsible for those amounts.
(2) Failure to provide notice under this section shall
not subject a licensee to disciplinary action.
(b) Notice in Billing Statement.
(1) A facility-based physician who bills a patient
covered by a preferred provider plan or a health benefit plan under
Chapter 1551 of the Insurance Code that does not have a contract with
the facility-based physician shall send a billing statement to the
patient that contains a conspicuous, plain-language explanation of
the mandatory mediation process under Chapter 1467 of the Insurance
Code if the amount for which the enrollee is responsible to the physician,
after copayments, deductibles, and coinsurance, including the amount
unpaid by the administrator or insurer, is greater than $500.
(2) The written notice shall include a reference to
TDI's website about the mediation process - http://www.tdi.state.tx.us/consumer/cpmmediation.html.