| (a) A complaint against an issuer filed with the Texas
Department of Insurance for alleged violations of Insurance Code §1454.051
must include:
(1) a description of the alleged violation under Insurance
Code §1454.051;
(2) the complainant's name, address, telephone number
and fax number;
(3) the physician's or provider's name, if different
from the complainant;
(4) the name of the issuer;
(5) a statement indicating the complaint applies to
a health benefit plan as set forth in §21.3303 of this subchapter
(relating to Applicability); and
(6) documentation from the physician or provider that:
(A) identifies the amount reimbursed by the issuer
for a covered reproductive health or reproductive oncology service
provided to a woman;
(B) identifies the amount of time and resources spent
in providing the covered reproductive health or reproductive oncology
service;
(C) using objective criteria, identifies the same or
comparable covered service provided exclusively to men or to the general
population offered by the issuer;
(D) identifies the difference, if any, in the amount
of time and resources spent in providing the covered reproductive
health or reproductive oncology service and the same or comparable
covered service using objective criteria;
(E) identifies the level of expertise needed to provide
the covered reproductive health or reproductive oncology service and
the same or comparable covered service; and
(F) compares the difference in reimbursements for the
covered reproductive health or reproductive oncology service and the
same or comparable service from the issuer within the same geographic
service area as the physician or the provider performing the service.
(b) Within 10 days of receipt of a complaint, the department
will determine whether all the information in subsection (a) of this
section has been received.
(c) If all the information identified in subsection
(a) of this section is included in the complaint:
(1) the complaint will be considered filed on the date
of receipt;
(2) the complainant will be notified in writing and
the issuer will be contacted for a response; and
(3) the 120-day time period in Insurance Code §1454.107
will commence.
(d) If all the information identified in subsection
(a) of this section is not included with the complaint, the complaint
will be returned to the complainant with a letter explaining the deficiencies.
(e) If the department believes that the information
received by the department under subsection (a) of this section substantiates
the alleged unfair discrimination in compensation as contemplated
in Insurance Code Chapter 1454 and this subchapter, action will be
taken in accordance with Insurance Code Chapter 1454, Subchapter C.
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