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RULE §133.46Hospital Billing

(a) Itemized statements. A hospital shall adopt, implement, and enforce a policy to ensure that the hospital complies with the Health and Safety Code (HSC), §311.002 (Itemized Statement of Billed Services).

(b) Audits of billing. A hospital shall adopt, implement, and enforce a policy to ensure that the hospital complies with HSC, §311.0025(a) (relating to Audits of Billing).

(c) Balance Billing.

  (1) A hospital may not violate a law that prohibits the hospital from billing a patient who is an insured, participant, or enrollee in a managed care plan an amount greater than an applicable copayment, coinsurance, and deductible under the insured's, participant's, or enrollee's managed care plan or that imposes a requirement related to that prohibition.

  (2) A hospital shall comply with Senate Bill 1264, 86th Legislature, Regular Session, 2019, and with related Texas Department of Insurance rules at 28 TAC Chapter 21, Subchapter OO, §§21.4901 - 21.4904 (relating to Disclosures by Out-of-Network Providers) to the extent this subchapter applies to the hospital.

(d) Complaint investigation procedures.

  (1) A complaint submitted to HHSC's Complaint and Incident Intake relating to billing must specify the patient for whom the bill was submitted.

  (2) Upon receiving a complaint warranting an investigation, HHSC shall send the complaint to the hospital requesting the hospital to conduct an internal investigation. Within 30 days of the hospital's receipt of the complaint, the hospital shall submit to HHSC:

    (A) a report outlining the hospital's investigative process;

    (B) the resolution or conclusions reached by the hospital with the patient, third party payor or complainant; and

    (C) corrections, if any, in the hospital's policies or protocols which were made as a result of its investigative findings.

  (3) In addition to the hospital's internal investigation, HHSC may also conduct an investigation to audit any billing and patient records of the hospital.

  (4) HHSC shall inform in writing a complainant who identifies himself by name and address:

    (A) of the receipt of the complaint;

    (B) if the complainant's allegations are potential violations of the Act or this chapter warranting an investigation;

    (C) whether the complaint will be investigated by HHSC;

    (D) if the complaint was referred to the hospital for internal investigation;

    (E) whether and to whom the complaint will be referred;

    (F) of the results of the hospital's investigation and the hospital's resolution with the complainant; and

    (G) of HHSC's findings if an on-site audit investigation was conducted.

  (5) HHSC shall refer investigative reports of billing by health care professionals who have provided improper, unreasonable, or medically or clinically unnecessary treatments or billed for treatments which were not provided to the appropriate licensing agency.

Source Note: The provisions of this §133.46 adopted to be effective June 21, 2007, 32 TexReg 3587; amended to be effective April 15, 2021, 46 TexReg 2421

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