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RULE §510.45Facility Billing

(a) Itemized statements. A facility shall adopt, implement, and enforce a policy to ensure that the facility complies with the Health and Safety Code (HSC), §311.002 (relating to Itemized Statement of Billed Services).

(b) Audits of billing. A facility shall adopt, implement, and enforce a policy to ensure that the facility complies with HSC, §311.0025(a) (relating to Audits of Billing).

(c) Complaint investigation procedures.

  (1) A complaint submitted to HHSC's Complaint and Incident Intake relating to billing must specify the patient for whom the bill was submitted.

  (2) Upon receiving a complaint warranting an investigation, HHSC shall send the complaint to the facility requesting the facility to conduct an internal investigation. Within 30 days of the facility's receipt of the complaint, the facility shall submit to HHSC:

    (A) a report outlining the facility's investigative process;

    (B) the resolution or conclusions reached by the facility with the patient, third party payor or complainant; and

    (C) corrections, if any, in the policies or protocols which were made as a result of its investigative findings.

  (3) In addition to the facility's internal investigation, HHSC may also conduct an investigation to audit any billing and patient records of the facility.

  (4) HHSC may inform in writing a complainant who identifies themselves by name and address in writing of the receipt and disposition of the complaint.

  (5) HHSC shall refer investigative reports of billing by health care professionals who have provided improper, unreasonable, or medically or clinically unnecessary treatments or billed for treatments which were not provided to the appropriate licensing agency.

(d) Balance Billing.

  (1) A facility may not violate a law that prohibits the facility from billing a patient who is an insured, participant, or enrollee in a managed care plan an amount greater than an applicable copayment, coinsurance, and deductible under the insured's, participant's, or enrollee's managed care plan or that imposes a requirement related to that prohibition.

  (2) A facility shall comply with Senate Bill 1264, 86th Legislature, Regular Session, 2019, and with related Texas Department of Insurance rules at 28 TAC Chapter 21, Subchapter OO, §§21.4901 - 21.4904 (relating to Disclosures by Out-of-Network Providers) to the extent this subchapter applies to the facility.

Source Note: The provisions of this §510.45 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469; amended to be effective April 15, 2021, 46 TexReg 2427

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