| (a) Arbitration request and notice.
(1) An out-of-network provider or a health benefit
plan issuer or administrator may request arbitration. To be eligible
for arbitration, the party requesting arbitration must complete the
arbitration 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 arbitration must provide
written notice to each other party on the date the arbitration 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 arbitration must send the arbitration
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 arbitration in the claim,
the 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
arbitration must send the arbitration 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 arbitration request,
including:
(1) provider details, including identifying the provider
type, provider contact information, and provider 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 a 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, the date of the teleconference,
and settlement offer amounts.
(d) Arbitrator selection.
(1) The parties must notify the department, through
the department's website, on or before 30 days from the date arbitration
was requested if:
(A) the parties agree to a settlement;
(B) the parties agree to the selection of an arbitrator;
or
(C) the parties agree to extend the deadline to have
the department select an arbitrator 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 an arbitrator
after the 30th day from the date the arbitration is requested. The
parties must pay the nonrefundable arbitrator's fee to the arbitrator
when the arbitrator is assigned. Failure to pay the arbitrator when
the arbitrator is assigned constitutes bad faith participation, and
the arbitrator may award the binding amount to the other party.
(e) Submission of information.
(1) The arbitrator must submit information, as specified
on the department's website, to the department at the completion of
the arbitration, including:
(A) the name of the arbitrator, the date when the arbitrator
was selected, the date of the decision, the date of the arbitrator
report, and when payment was made; and
(B) the written decision, including any final offers
made during the health benefit plan issuer's or administrator's internal
appeal process or informal settlement, reasonable amount for the services
or supplies, and the binding award amount.
(2) If the parties settle the dispute before the arbitrator's
decision, the parties must submit information, as specified on the
department's website, to the department, including:
(A) the date of the settlement; and
(B) the amount of the settlement.
(f) Arbitrator approval and removal.
(1) Arbitrators may apply to the department using a
method as determined by the Commissioner, including through an application
on the department's website or the department's procurement process.
An individual or entities that employ arbitrators may apply for approval.
(2) A list of qualified arbitrators will be maintained
on the department's website. An arbitrator must notify the department
immediately if the arbitrator wants to voluntarily withdraw from the
list.
(3) At the discretion of the department, an arbitrator
may be removed from the list of qualified arbitrators 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) Arbitration process.
(1) A party may request arbitration 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 must submit written information to
an arbitrator 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 arbitrator must evaluate only the factors specified
in Insurance Code §1467.083, concerning Issue to Be Addressed;
Basis for Determination.
(4) The arbitrator must provide the parties an opportunity
to review the written information submitted by the other party, submit
additional written information, and respond in writing to the arbitrator
on the time line set by the arbitrator.
(5) Each party is responsible for reviewing the list
of arbitrators and notifying the department within 10 days of the
request for arbitration if there is a conflict of interest with any
of the arbitrators on the list to avoid the department assigning an
arbitrator with a conflict of interest.
(6) If a party does not respond to the arbitrator's
request for information, the dispute will be decided based on the
available information received by the arbitrator without an opportunity
for reconsideration.
(7) The submission of multiple claims to arbitration
in one proceeding must be for the same provider and the same health
benefit plan issuer or administrator and the total amount in controversy
may not exceed $5,000.
(h) Assistance. Assistance with submitting a request
for arbitration is available on the department's website at www.tdi.texas.gov.
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