| (a) Written complaint. A party may submit a written
complaint on the department's website regarding the settlement of
an out-of-network health benefit claim that is subject to Insurance
Code Chapter 1467.
(b) Complaint information. The recommended information
for filing a complaint under subsection (a) of this section includes:
(1) whether the complaint is within the scope of Insurance
Code Chapter 1467 (concerning Out-of-Network Claim Dispute Resolution);
(2) whether emergency care, health care, or a medical
service has been delayed or has not been given;
(3) whether the health care, medical service, or supply,
or a combination of health care, medical service, or supply, that
is the subject of the complaint was for emergency care; and
(4) specific information about the qualified mediation
claim or qualified arbitration claim, including:
(A) the name, type, and specialty of the provider;
(B) the type of service performed or supplies provided;
(C) the city and county where the service or supply
was performed; and
(D) the dollar amount of the disputed claim.
(c) Department processing. The department will maintain
procedures to ensure that a written complaint made through the department's
website under this section is not dismissed without appropriate consideration,
including:
(1) review of all of the information submitted in the
written complaint;
(2) contact with the parties that are the subject of
the complaint; and
(3) review of the responses received from the subjects
of the complaint to determine if and what further action is required,
as appropriate.
|
| Source Note: The provisions of this §21.5030 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 |
