| (a) Mediation request and notice.
(1) An out-of-network provider that is a facility or
a health benefit plan issuer or administrator may request mediation.
To be eligible for mediation, the party requesting mediation must
complete the mediation request information required on the department's
website at www.tdi.texas.gov, as specified in subsection (b) of this
section.
(2) The party who requests the mediation must provide
written notice to each other party on the date the mediation is requested.
The notification must contain the information as specified on the
department's website, including the necessary claim information and
contact information of the parties. A health benefit plan issuer or
administrator requesting mediation must send the mediation notification
to the mailing address or email address specified in the claim submitted
by the provider. If a provider does not specify an address to receive
notice requesting mediation in the claim, a health benefit plan issuer
or administrator may provide notice to the provider at the provider's
last known address the issuer or administrator has on file for the
provider. A provider requesting mediation must send the mediation
notification to the email address specified in the explanation of
benefits by the health benefit plan issuer or administrator.
(b) Submission of request. The requesting party must
submit information necessary to complete the initial mediation request,
including:
(1) facility details, including identifying the facility
type, facility contact information, and facility representative information;
(2) claim information, including the claim number,
type of service or supply provided, date of service, billed amount,
amount paid, and balance; and
(3) relevant information from the enrollee's health
benefit plan identification card or other similar document, including
plan number and group number.
(c) Notice of teleconference outcome. Parties must
submit additional information on the department's website at the completion
of the informal settlement teleconference period, including the date
the teleconference request was received and the date of the teleconference.
(d) Mediator selection.
(1) The parties must notify the department through
the department's website on or before 30 days from the date the mediation
is requested if:
(A) the parties agree to a settlement;
(B) the parties agree to the selection of a mediator;
or
(C) the parties agree to extend the deadline to have
the department select a mediator and notify the department of new
deadlines.
(2) If the department is not given notification under
paragraph (1) of this subsection, the department will assign a mediator
after the 30th day from the date the mediation is requested. The parties
must pay the nonrefundable mediator's fee to the mediator when the
mediator is assigned. Failure to pay the mediator when the mediator
is assigned constitutes bad faith participation.
(e) Submission of information. Parties must submit
information, as specified on the department's website, to the department
at the completion of the mediation or informal settlement, including:
(1) the name of the mediator, the date when the mediator
was selected, the date when the mediation was held, the date of the
agreement, the date of the mediator report, and when payment was made;
and
(2) the agreement, including the original billed amount,
payment amount, and the total agreed amount.
(f) Mediator approval and removal.
(1) Mediators may apply to the department using a method
as determined by the Commissioner, including through an application
on the department's website or through the department's procurement
process. An individual or entities that employ mediators may apply
for approval.
(2) A list of qualified mediators will be maintained
on the department's website. A mediator must notify the department
immediately if the mediator wants to voluntarily withdraw from the
list.
(3) At the discretion of the department, a mediator
may be removed from the list of qualified mediators in certain circumstances,
including failure to comply with any requirement under Insurance Code
Chapter 1467, concerning Out-of-Network Claim Dispute Resolution,
or rules adopted under Insurance Code §1467.003, concerning Rules.
(g) Mediation process.
(1) A party may request mediation after 20 days from
the date an out-of-network provider receives the initial payment for
a health benefit claim, during which time the out-of-network provider
may attempt to resolve a claim payment dispute through the health
benefit plan issuer's or administrator's internal appeal process.
(2) The parties may submit written information to a
mediator concerning the amount charged by the out-of-network provider
for the health care or medical service or supply and the amount paid
by the health benefit plan issuer or administrator.
(3) The parties must evaluate the factors specified
in Insurance Code §1467.056, concerning Matters Considered in
Mediation; Agreed Resolution.
(4) Each party is responsible for reviewing the list
of mediators and notifying the department within 10 days of the request
for mediation whether there is a conflict of interest with any of
the mediators on the list to avoid the department assigning a mediator
with a conflict of interest.
(5) The parties may agree to aggregate claims between
the same facility and same health benefit plan issuer or administrator
for mediation.
(h) Assistance. Assistance with submitting a request
for mediation is available on the department's website at www.tdi.texas.gov.
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| Source Note: The provisions of this §21.5011 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 |
