| (a) This subchapter applies to a qualified mediation
claim or qualified arbitration claim filed under health benefit plan
coverage:
(1) issued by an insurer as a preferred provider benefit
plan under Insurance Code Chapter 1301, concerning Preferred Provider
Benefit Plans, including an exclusive provider benefit plan;
(2) administered by an administrator of a health benefit
plan, other than a health maintenance organization (HMO) plan, under
Insurance Code Chapters 1551, concerning Texas Employees Group Benefits
Act; 1575, concerning Texas Public School Employees Group Benefits
Program; 1579, concerning Texas School Employees Uniform Group Health
Coverage; or 1682, concerning Health Benefits Provided by Certain
Nonprofit Agricultural Organizations;
(3) offered by an HMO operating under Insurance Code
Chapter 843, concerning Health Maintenance Organizations; or
(4) offered by a self-insured or self-funded plan established
by an employer under ERISA if the plan sponsor submitted election
according to §21.5060 of this title (relating to Election Submission
Requirements).
(b) This subchapter does not apply to a claim for health
benefits that is not a covered claim under the terms of the health
benefit plan coverage.
(c) Except as provided in §21.5050 of this title
(relating to Submission of Information), this subchapter applies to
a claim for emergency care or health care or medical services or supplies,
provided on or after January 1, 2020. A claim for health care or medical
services or supplies provided before January 1, 2020, is governed
by the rules in effect immediately before the effective date of this
subsection, and those rules are continued in effect for that purpose.
This subchapter applies to a claim filed for emergency care or health
care or medical services or supplies by the administrator of a health
benefit plan under Insurance Code Chapter 1682.
|
| Source Note: The provisions of this §21.5002 adopted to be effective October 19, 2010, 35 TexReg 9300; amended to be effective November 3, 2016, 41 TexReg 8612; amended to be effective April 26, 2018, 43 TexReg 2423; amended to be effective December 23, 2019, 44 TexReg 7988; amended to be effective February 20, 2022, 47 TexReg 792; amended to be effective June 27, 2023, 48 TexReg 3409; amended to be effective January 3, 2024, 48 TexReg 8372 |
