| (a) Required criteria. An out-of-network provider that
is not a facility or a health benefit plan issuer or administrator
may request mandatory binding arbitration of an out-of-network claim
under §21.5021 of this title (relating to Arbitration Request
Procedure) if the claim complies with the criteria specified in this
section. An out-of-network claim that complies with those criteria
is referred to as a "qualified arbitration claim" in this subchapter.
(1) The health benefit claim must be for:
(A) emergency care;
(B) a health care or medical service or supply provided
by a facility-based provider in a facility that is a participating
provider;
(C) an out-of-network laboratory service provided in
connection with a health care or medical service or supply provided
by a participating provider; or
(D) an out-of-network diagnostic imaging service provided
in connection with a health care or medical service or supply provided
by a participating provider; and
(2) The health benefit claim must be for a charge billed
by the provider and unpaid by the health benefit plan issuer or administrator
after copayments, coinsurance, and deductibles for which an enrollee
may not be billed.
(b) Availability. Not later than the 90th day after
the date an out-of-network provider receives the initial payment for
a health care or medical service or supply, the out-of-network provider
or the health benefit plan issuer or administrator may request arbitration
of a settlement of an out-of-network health benefit claim. The initial
payment could be zero dollars if the allowable amount was applied
to an enrollee's deductible.
(c) Ineligible claims. Unless otherwise agreed to by
the parties, an arbitrator may not determine whether a health benefit
plan covers a particular health care or medical service or supply.
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