Source: https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=11&ch=217&rl=23
Timestamp: 2019-03-20 01:37:52
Document Index: 414830779

Matched Legal Cases: ['§217', '§1467', '§1467', '§1467', '§1467', '§1467', '§213', '§217']

RULE §217.23 Balance Billing Dispute Resolution
(a) Purpose. The purpose of this section is to implement the requirements of the Insurance Code Chapter 1467 and notify licensees of their responsibilities under that chapter.
(b) Definitions and Applicability of Section.
(1) Definitions. Terms defined in the Insurance Code §1467.001 have the same meanings when used in this section, unless the context clearly indicates otherwise.
(2) Applicability. This section applies to any facility-based provider or emergency care provider, as those terms are defined in the Insurance Code §1467.001, who bills an enrollee covered by a preferred provider benefit plan offered by an insurer under the Insurance Code Chapter 1301 or a health benefit plan, other than a health maintenance organization plan, under the Insurance Code Chapters 1551, 1575, or 1579, for out-of-network emergency care, health care, or medical service or supply provided on or after January 1, 2018. This section is limited to facility-based providers and emergency care providers that are subject to the Board's jurisdiction.
(c) Responsibilities of Licensee.
(A) An enrollee, as that term is defined in the Insurance Code §1467.001(3), may request mediation of a settlement of an out-of-network health benefit claim if:
(i) the amount for which the enrollee is responsible to a facility-based or emergency care provider, after co-payments, deductibles, and co-insurance, including the amount unpaid by the administrator or insurer, is greater than $500; and
(ii) the health benefit claim is for:
(I) emergency care; or
(II) a health care or medical service or supply provided by a facility-based provider in a facility that is a preferred provider or that has a contract with the administrator.
(B) If an enrollee requests mediation under the Insurance Code Chapter 1467, the facility-based or emergency care provider or their representative must participate in the mediation.
(C) Prior to participation in a mediation, all parties, including the facility-based or emergency care provider, or their representative, must participate in an informal settlement teleconference not later than the 30th day after the date on which the enrollee submits the request for mediation. If the informal settlement teleconference is unsuccessful in resolving the matter, a mediation must be conducted in the county in which the health care or medical services were rendered.
(D) In a mediation under the Insurance Code Chapter 1467, the parties must:
(i) evaluate whether:
(I) the amount charged by the facility-based or emergency care provider for the health care or medical service or supply is excessive; and
(II) whether the amount paid by the insurer or administrator represents the usual and customary rate for the health care or medical service or supply or is unreasonably low; and
(ii) as a result of the amounts described by clause (i) of this subparagraph, determine the amount, after co-payments, deductibles, and co-insurance are applied, for which the enrollee is responsible to the facility-based or emergency care provider.
(E) The mediator's fees for a mediation under the Insurance Code Chapter 1467 shall be split evenly and paid by the facility-based or emergency care provider and the insurer or administrator.
(F) In the event a mediation is unsuccessful, the matter must be referred to a special judge, as set forth in the Insurance Code §1467.057.
(G) A facility-based provider will not be required to participate in mediation to mediate a billed charge if, prior to providing a health care service or supply, the facility-based provider makes a disclosure, as set forth in paragraph (2) of this subsection, and obtains the enrollee's written acknowledgment of that disclosure, so long as the billed amount is less than or equal to the maximum amount projected in the disclosure.
(2) Billing Notices.
(A) Except in the case of an emergency, and if requested by an enrollee, an out-of-network facility-based provider must provide a complete disclosure to the enrollee, prior to providing the health care or medical service or supply, that:
(i) explains that the facility-based provider does not have a contract with the enrollee's health benefit plan;
(ii) discloses projected amounts for which the enrollee may be responsible; and
(iii) discloses the circumstances under which the enrollee would be responsible for those amounts.
(B) Each bill sent to an enrollee by a facility-based or emergency care provider for an out-of-network health benefit claim (balance bill) eligible for mediation under the Insurance Code Chapter 1467 must include a conspicuous, plain-language explanation of the mediation process available under Chapter 1467, as well as the information specified in §1467.0511.
(3) Collection Notices. On receipt of notice from the Texas Department of Insurance that an enrollee has made a request for mediation that meets the requirements of the Insurance Code Chapter 1467, the facility-based or emergency care provider may not pursue any collection efforts against the enrollee for amounts other than co-payments, deductibles, and co-insurance, before the earlier of the date the mediation is completed or the date the request to mediate is withdrawn.
(d) Complaint Investigation and Resolution.
(A) Except for good cause shown, on a report of a mediator and appropriate proof of bad faith mediation, the Board shall impose an administrative penalty.
(B) The following conduct constitutes bad faith mediation:
(i) failing to participate in the mediation, if participation in the mediation was required;
(ii) failing to provide information the mediator believes is necessary to facilitate an agreement; or
(iii) failing to designate a representative participating in the mediation with full authority to enter into any mediated agreement.
(C) Failure to reach an agreement is not conclusive proof of bad faith mediation.
(2) Complaint process. A complaint may be filed with the Board by a mediator against a licensee for bad faith mediation or by an enrollee who is not satisfied with a mediated agreement. Complaints that do not involve delayed health care or medical care shall be assigned a Priority 4 status, as described in §213.13 of this title (relating to Complaint Investigation and Disposition). After investigation, if the Board determines that a licensee has engaged in improper billing practices or has committed a violation of the Nursing Practice Act, Chapter 1467, or other applicable law, the Board will impose appropriate disciplinary action.
Source Note: The provisions of this §217.23 adopted to be effective August 9, 2018, 43 TexReg 5086