| (a) Required criteria. An out-of-network provider that
is a facility or a health benefit plan issuer or administrator may
request mandatory mediation of an out-of-network claim under §21.5011
of this title (relating to Mediation Request Procedure) if the claim
complies with the criteria specified in this subsection. An out-of-network
claim that complies with those criteria is referred to as a "qualified
mediation claim" in this subchapter.
(1) The out-of-network health benefit claim must be
for:
(A) emergency care;
(B) an out-of-network laboratory service provided in
connection with a health care or medical service or supply provided
by a participating provider; or
(C) an out-of-network diagnostic imaging service provided
in connection with a health care or medical service or supply provided
by a participating provider.
(2) There is an amount billed by the provider and unpaid
by the health benefit plan issuer or administrator after copayments,
deductibles, and coinsurance, for which an enrollee may not be billed.
(b) Submission of multiple claim forms. The use of
more than one form in the submission of a claim, as defined in §21.5003
of this title (relating to Definitions), does not prevent eligibility
of a claim for mandatory mediation under this subchapter if the claim
otherwise meets the requirements of this section.
(c) Ineligible claims. This division does not require
a health benefit plan issuer or administrator to pay for an uncovered
service or supply.
|
| Source Note: The provisions of this §21.5010 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 June 27, 2023, 48 TexReg 3409 |
