reglab/statecodes huggingface dataset:
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1460 - Standards Required Regarding Certain Physician Rankings by Health Benefit Plans › Section 1460.002. Exemption

Text of section effective until April 01, 2025
Sec. 1460.002.  EXEMPTION.  This chapter does not apply to:
(1)  a Medicaid managed care program operated under Chapter 533, Government Code;
(2)  a Medicaid program operated under Chapter 32, Human Resources Code;
(3)  the child health plan program under Chapter 62, Health and Safety Code, or the health benefits plan for children under Chapter 63, Health and Safety Code; or
(4)  a Medicare supplement benefit plan, as defined by Chapter 1652.
Added by Acts 2009, 81st Leg., R.S., Ch. 652 (H.B. 1888), Sec. 1, eff. September 1, 2009.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 2.135, eff. April 1, 2025.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1460 - Standards Required Regarding Certain Physician Rankings by Health Benefit Plans › Section 1460.002. Exemption

Text of section effective on April 01, 2025
Sec. 1460.002.  EXEMPTION.  This chapter does not apply to:
(1)  a Medicaid managed care program operated under Chapter 540 or 540A, Government Code, as applicable;
(2)  a Medicaid program operated under Chapter 32, Human Resources Code;
(3)  the child health plan program under Chapter 62, Health and Safety Code, or the health benefits plan for children under Chapter 63, Health and Safety Code; or
(4)  a Medicare supplement benefit plan, as defined by Chapter 1652.
Added by Acts 2009, 81st Leg., R.S., Ch. 652 (H.B. 1888), Sec. 1, eff. September 1, 2009.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 2.135, eff. April 1, 2025.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1460 - Standards Required Regarding Certain Physician Rankings by Health Benefit Plans › Section 1460.003. Physician Ranking Requirements

Sec. 1460.003.  PHYSICIAN RANKING REQUIREMENTS.  (a)  A  health benefit plan issuer, including a subsidiary or affiliate, may not rank physicians, classify physicians into tiers based on performance, or publish physician-specific information that includes rankings, tiers, ratings, or other comparisons of a physician's performance against standards, measures, or other physicians, unless:
(1)  the standards used by the health benefit plan issuer conform to nationally recognized standards and guidelines as required by rules adopted under Section 1460.005;
(2)  the standards and measurements to be used by the health benefit plan issuer are disclosed to each affected physician before any evaluation period used by the health benefit plan issuer; and
(3)  each affected physician is afforded, before any publication or other public dissemination, an opportunity to dispute the ranking or classification through a process that, at a minimum, includes due process protections that conform to the following protections:
(A)  the health benefit plan issuer provides at least 45 days' written notice to the physician of the proposed rating, ranking, tiering, or comparison, including the methodologies, data, and all other information utilized by the health benefit plan issuer in its rating, tiering, ranking, or comparison decision;
(B)  in addition to any written fair reconsideration process, the health benefit plan issuer, upon a request for review that is made within 30 days of receiving the notice under Paragraph (A), provides a fair reconsideration proceeding, at the physician's option:
(i)  by teleconference, at an agreed upon time; or
(ii)  in person, at an agreed upon time or between the hours of 8:00 a.m. and 5:00 p.m. Monday through Friday;
(C)  the physician has the right to provide information at a requested fair reconsideration proceeding for determination by a decision-maker, have a representative participate in the fair reconsideration proceeding, and submit a written statement at the conclusion of the fair reconsideration proceeding; and
(D)  the health benefit plan issuer provides a written communication of the outcome of a fair reconsideration proceeding prior to any publication or dissemination of the rating, ranking, tiering, or comparison.  The written communication must include the specific reasons for the final decision.
(b)  This section does not apply to the publication of a list of network physicians and providers if ratings or comparisons are not made and the list is not a product of nor reflects the tiering or classification of physicians or providers.
Added by Acts 2009, 81st Leg., R.S., Ch. 652 (H.B. 1888), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1460 - Standards Required Regarding Certain Physician Rankings by Health Benefit Plans › Section 1460.004. Duties of Physicians

Sec. 1460.004.  DUTIES OF PHYSICIANS.  A physician may not require or request that a patient of the physician enter into an agreement under which the patient agrees not to:
(1)  rank or otherwise evaluate the physician;
(2)  participate in surveys regarding the physician; or
(3)  in any way comment on the patient's opinion of the physician.
Added by Acts 2009, 81st Leg., R.S., Ch. 652 (H.B. 1888), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1460 - Standards Required Regarding Certain Physician Rankings by Health Benefit Plans › Section 1460.005. Rules; Standards

Sec. 1460.005.  RULES; STANDARDS.  (a)  The commissioner shall adopt rules as necessary to implement this chapter.
(b)  The commissioner shall adopt rules as necessary to ensure that a health benefit plan issuer that uses a physician ranking system complies with the standards and guidelines described by Subsection (c).
(c)  In adopting rules under this section, the commissioner shall consider the standards, guidelines, and measures prescribed by nationally recognized organizations that establish or promote guidelines and performance measures emphasizing quality of health care, including the National Quality Forum and the AQA Alliance. If neither the National Quality Forum nor the AQA Alliance has established standards or guidelines regarding an issue, the commissioner shall consider the standards, guidelines, and measures prescribed by the National Committee on Quality Assurance and other similar national organizations.  If neither the National Quality Forum, nor the AQA Alliance, nor other national organizations have established standards or guidelines regarding an issue, the commissioner shall consider standards, guidelines, and measures based on other bona fide nationally recognized guidelines, expert-based physician consensus quality standards, or leading objective clinical evidence and scholarship.
Added by Acts 2009, 81st Leg., R.S., Ch. 652 (H.B. 1888), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1460 - Standards Required Regarding Certain Physician Rankings by Health Benefit Plans › Section 1460.006. Duties of Health Benefit Plan Issuer

Sec. 1460.006.  DUTIES OF HEALTH BENEFIT PLAN ISSUER.  A health benefit plan issuer shall ensure that:
(1)  physicians currently in clinical practice are actively involved in the development of the standards used under this chapter; and
(2)  the measures and methodology used in the comparison programs described by Section 1460.003 are transparent and valid.
Added by Acts 2009, 81st Leg., R.S., Ch. 652 (H.B. 1888), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1460 - Standards Required Regarding Certain Physician Rankings by Health Benefit Plans › Section 1460.007. Sanctions; Disciplinary Actions

Sec. 1460.007.  SANCTIONS; DISCIPLINARY ACTIONS.  (a)  A health benefit plan issuer that violates this chapter or a rule adopted under this chapter is subject to sanctions and disciplinary actions under Chapters 82 and 84.
(b)  A violation of this chapter by a physician constitutes grounds for disciplinary action by the Texas Medical Board, including imposition of an administrative penalty.
Added by Acts 2009, 81st Leg., R.S., Ch. 652 (H.B. 1888), Sec. 1, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1461 - Discrimination Against Physician Based on Maintenance of Certification › Section 1461.001. Definitions

Sec. 1461.001.  DEFINITIONS.  In this chapter:
(1)  "Enrollee" means an individual who is eligible to receive health care services under a managed care plan.
(2)  "Maintenance of certification" has the meaning assigned by Section 151.002, Occupations Code.
(3)  "Managed care plan" means a health benefit plan under which health care services are provided to enrollees through contracts with physicians and that requires enrollees to use participating physicians or that provides a different level of coverage for enrollees who use participating physicians.  The term includes a health benefit plan issued by:
(A)  a health maintenance organization;
(B)  a preferred provider benefit plan issuer; or
(C)  any other entity that issues a health benefit plan, including an insurance company.
(4)  "Participating physician" means a physician who has directly or indirectly contracted with a health benefit plan issuer to provide services to enrollees.
(5)  "Physician" means an individual licensed to practice medicine in this state.
Added by Acts 2017, 85th Leg., R.S., Ch. 1121 (S.B. 1148), Sec. 1, eff. January 1, 2018.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1461 - Discrimination Against Physician Based on Maintenance of Certification › Section 1461.002. Applicability

Sec. 1461.002.  APPLICABILITY.  (a)  This chapter applies to a physician regardless of whether the physician is a participating physician.
(b)  This chapter applies to a person with whom a managed care plan issuer contracts to:
(1)  process or pay claims;
(2)  obtain the services of physicians to provide health care services to enrollees; or
(3)  issue verifications or preauthorizations.
Added by Acts 2017, 85th Leg., R.S., Ch. 1121 (S.B. 1148), Sec. 1, eff. January 1, 2018.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1461 - Discrimination Against Physician Based on Maintenance of Certification › Section 1461.003. Discrimination Based on Maintenance of Certification

Sec. 1461.003.  DISCRIMINATION BASED ON MAINTENANCE OF CERTIFICATION.  (a)  Except as provided by Subsection (b), a managed care plan issuer may not differentiate between physicians based on a physician's maintenance of certification in regard to:
(1)  paying the physician;
(2)  reimbursing the physician; or
(3)  directly or indirectly contracting with the physician to provide services to enrollees.
(b)  A managed care plan issuer may differentiate between physicians based on a physician's maintenance of certification only if the designation under law or certification or accreditation by a national certifying or accrediting organization of an entity described by Section 151.0515(a), Occupations Code, is contingent on the entity requiring a specific maintenance of certification by physicians seeking staff privileges or credentialing at the entity.
Added by Acts 2017, 85th Leg., R.S., Ch. 1121 (S.B. 1148), Sec. 1, eff. January 1, 2018.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter A. General Provisions › Section 1467.002. Applicability of Chapter

Sec. 1467.002.  APPLICABILITY OF CHAPTER.  This chapter applies to:
(1)  a health benefit plan offered by a health maintenance organization operating under Chapter 843;
(2)  a preferred provider benefit plan, including an exclusive provider benefit plan, offered by an insurer under Chapter 1301; and
(3)  an administrator of a health benefit plan, other than a health maintenance organization plan, under Chapter 1551, 1575, or 1579.
Added by Acts 2009, 81st Leg., R.S., Ch. 1290 (H.B. 2256), Sec. 1, eff. June 19, 2009.
Amended by:
Acts 2017, 85th Leg., R.S., Ch. 100 (S.B. 507), Sec. 2, eff. September 1, 2017.
Acts 2017, 85th Leg., R.S., Ch. 139 (H.B. 1428), Sec. 2, eff. September 1, 2017.
Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.02, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter A. General Provisions › Section 1467.003. Rules

Sec. 1467.003.  RULES.  (a)  The commissioner, the Texas Medical Board, and any other appropriate regulatory agency shall adopt rules as necessary to implement their respective powers and duties under this chapter.
(b)  Section 2001.0045, Government Code, does not apply to a rule adopted under this chapter.
Added by Acts 2009, 81st Leg., R.S., Ch. 1290 (H.B. 2256), Sec. 1, eff. June 19, 2009.
Amended by:
Acts 2017, 85th Leg., R.S., Ch. 100 (S.B. 507), Sec. 3, eff. September 1, 2017.
Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.02, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter A. General Provisions › Section 1467.004. Remedies Not Exclusive

Sec. 1467.004.  REMEDIES NOT EXCLUSIVE.  The remedies provided by this chapter are in addition to any other defense, remedy, or procedure provided by law, including the common law.
Added by Acts 2009, 81st Leg., R.S., Ch. 1290 (H.B. 2256), Sec. 1, eff. June 19, 2009.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter A. General Provisions › Section 1467.005. Reform

Sec. 1467.005.  REFORM.  This chapter may not be construed to prohibit:
(1)  a health benefit plan issuer or administrator from, at any time, offering a reformed claim settlement; or
(2)  an out-of-network provider from, at any time, offering a reformed charge for health care or medical services or supplies.
Added by Acts 2009, 81st Leg., R.S., Ch. 1290 (H.B. 2256), Sec. 1, eff. June 19, 2009.
Amended by:
Acts 2017, 85th Leg., R.S., Ch. 100 (S.B. 507), Sec. 4, eff. September 1, 2017.
Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.02, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter A. General Provisions › Section 1467.006. Benchmarking Database

Sec. 1467.006.  BENCHMARKING DATABASE.  (a)  In this section, "geozip area" means an area that includes all zip codes with identical first three digits.  For purposes of this section, a health care or medical service or supply provided at a location that does not have a zip code is considered to be provided in the geozip area closest to the location at which the service or supply is provided.
(b)  The commissioner shall select an organization to maintain a benchmarking database in accordance with this section.  The organization may not:
(1)  be affiliated with a health benefit plan issuer or administrator or a physician, health care practitioner, or other health care provider; or
(2)  have any other conflict of interest.
(c)  The benchmarking database must contain information necessary to calculate, with respect to a health care or medical service or supply, for each geozip area in this state:
(1)  the 80th percentile of billed charges of all physicians or health care providers who are not facilities; and
(2)  the 50th percentile of rates paid to participating providers who are not facilities.
(d)  The commissioner may adopt rules governing the submission of information for the benchmarking database described by Subsection (c).
Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.03, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter B. Mandatory Mediation for Out-of-Network Facilities › Section 1467.050. Applicability of Subchapter

Sec. 1467.050.  APPLICABILITY OF SUBCHAPTER.  (a)  This subchapter applies only with respect to a health benefit claim submitted by an out-of-network provider that is a facility.
(b)  This subchapter does not apply to a health benefit claim for the professional or technical component of a physician service.
Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.05, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter B. Mandatory Mediation for Out-of-Network Facilities › Section 1467.0505. Establishment and Administration of Mediation Program

Sec. 1467.0505.  ESTABLISHMENT AND ADMINISTRATION OF MEDIATION PROGRAM.  (a)  The commissioner shall establish and administer a mediation program to resolve disputes over out-of-network provider charges in accordance with this subchapter.
(b)  The commissioner:
(1)  shall adopt rules, forms, and procedures necessary for the implementation and administration of the mediation program, including the establishment of a portal on the department's Internet website through which a request for mediation under Section 1467.051 may be submitted; and
(2)  shall maintain a list of qualified mediators for the program.
Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.05, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter B. Mandatory Mediation for Out-of-Network Facilities › Section 1467.051. Availability of Mandatory Mediation

Sec. 1467.051.  AVAILABILITY OF MANDATORY MEDIATION.  (a)  An out-of-network provider or a health benefit plan issuer or administrator may request mediation of a settlement of an out-of-network health benefit claim through a portal on the department's Internet website if:
(1)  there is an amount billed by the provider and unpaid by the issuer or administrator after copayments, deductibles, and coinsurance for which an enrollee may not be billed; and
(2)  the health benefit claim is for:
(A)  emergency care;
(B)  an out-of-network laboratory service; or
(C)  an out-of-network diagnostic imaging service.
(b)  If a person requests mediation under this subchapter, the out-of-network provider or the provider's representative, and the health benefit plan issuer or the administrator, as appropriate, shall participate in the mediation.
(c)  Repealed by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 3.03(3), eff. September 1, 2019.
(d)  Repealed by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 3.03(3), eff. September 1, 2019.
Added by Acts 2009, 81st Leg., R.S., Ch. 1290 (H.B. 2256), Sec. 1, eff. June 19, 2009.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 467 (S.B. 481), Sec. 5, eff. September 1, 2015.
Acts 2017, 85th Leg., R.S., Ch. 100 (S.B. 507), Sec. 5, eff. September 1, 2017.
Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.06, eff. September 1, 2019.
Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.07, eff. September 1, 2019.
Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 3.03(3), eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter B. Mandatory Mediation for Out-of-Network Facilities › Section 1467.052. Mediator Qualifications

Sec. 1467.052.  MEDIATOR QUALIFICATIONS.  (a)  Except as provided by Subsection (b), to qualify for an appointment as a mediator under this subchapter a person must have completed at least 40 classroom hours of training in dispute resolution techniques in a course conducted by an alternative dispute resolution organization or other dispute resolution organization approved by the commissioner.
(b)  A person not qualified under Subsection (a) may be appointed as a mediator on agreement of the parties.
(c)  A person may not act as mediator for a claim settlement dispute if the person has been employed by, consulted for, or otherwise had a business relationship with a health benefit plan issuer or administrator or a physician, health care practitioner, or other health care provider during the three years immediately preceding the request for mediation.
(d)  The commissioner shall immediately terminate the approval of a mediator who no longer meets the requirements under this subchapter and rules adopted under this subchapter to serve as a mediator.
Added by Acts 2009, 81st Leg., R.S., Ch. 1290 (H.B. 2256), Sec. 1, eff. June 19, 2009.
Amended by:
Acts 2017, 85th Leg., R.S., Ch. 100 (S.B. 507), Sec. 7, eff. September 1, 2017.
Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.08, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter B. Mandatory Mediation for Out-of-Network Facilities › Section 1467.053. Appointment of Mediator; Fees

Sec. 1467.053.  APPOINTMENT OF MEDIATOR; FEES.  (a)  A mediation shall be conducted by one mediator.
(b)  Repealed by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 3.03(5), eff. September 1, 2019.
(b-1)  If the parties do not select a mediator by mutual agreement on or before the 30th day after the date the mediation is requested, the party requesting the mediation shall notify the commissioner, and the commissioner shall select a mediator from the commissioner's list of approved mediators.
(c)  Repealed by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 3.03(5), eff. September 1, 2019.
(d)  The mediator's fees shall be split evenly and paid by the health benefit plan issuer or administrator and the out-of-network provider.
Added by Acts 2009, 81st Leg., R.S., Ch. 1290 (H.B. 2256), Sec. 1, eff. June 19, 2009.
Amended by:
Acts 2017, 85th Leg., R.S., Ch. 100 (S.B. 507), Sec. 8, eff. September 1, 2017.
Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.09, eff. September 1, 2019.
Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 3.03(5), eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter B. Mandatory Mediation for Out-of-Network Facilities › Section 1467.054. Request and Preliminary Procedures for Mandatory Mediation

Sec. 1467.054.  REQUEST AND PRELIMINARY PROCEDURES FOR MANDATORY MEDIATION.  (a)  An out-of-network provider or a health benefit plan issuer or administrator may request mandatory mediation under this subchapter.
(b)  Repealed by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 3.03(6), eff. September 1, 2019.
(b-1)  The person who requests the mediation shall provide written notice on the date the mediation is requested in the form and manner provided by commissioner rule to:
(1)  the department; and
(2)  each other party.
(c)  Repealed by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 3.03(6), eff. September 1, 2019.
(d)  In an effort to settle the claim before mediation, all parties must participate in an informal settlement teleconference not later than the 30th day after the date on which a person submits a request for mediation under this subchapter.
(e)  A dispute to be mediated under this chapter that does not settle as a result of a teleconference conducted under Subsection (d) must be conducted in the county in which the health care or medical services were rendered.
(f)  Repealed by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 3.03(6), eff. September 1, 2019.
(g)  Repealed by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 3.03(6), eff. September 1, 2019.
Added by Acts 2009, 81st Leg., R.S., Ch. 1290 (H.B. 2256), Sec. 1, eff. June 19, 2009.
Amended by:
Acts 2017, 85th Leg., R.S., Ch. 100 (S.B. 507), Sec. 9, eff. September 1, 2017.
Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.10, eff. September 1, 2019.
Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 3.03(6), eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter B. Mandatory Mediation for Out-of-Network Facilities › Section 1467.055. Conduct of Mediation; Confidentiality

Sec. 1467.055.  CONDUCT OF MEDIATION; CONFIDENTIALITY.  (a)  A mediator may not impose the mediator's judgment on a party about an issue that is a subject of the mediation.
(b)  A mediation session is under the control of the mediator.
(c)  Except as provided by this chapter, the mediator must hold in strict confidence all information provided to the mediator by a party and all communications of the mediator with a party.
(c-1)  Information submitted by the parties to the mediator is confidential and not subject to disclosure under Chapter 552, Government Code.
(d)  Repealed by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 3.03(7), eff. September 1, 2019.
(e)  A party must have an opportunity during the mediation to speak and state the party's position.
(f)  Except on the agreement of the participating parties, a mediation may not last more than four hours.
(g)  A mediation shall be held not later than the 180th day after the date of the request for mediation.
(h)  Repealed by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 3.03(7), eff. September 1, 2019.
(i)  A health care or medical service or supply provided by an out-of-network provider may not be summarily disallowed.  This subsection does not require a health benefit plan issuer or administrator to pay for an uncovered service or supply.
(j)  A mediator may not testify in a proceeding, other than a proceeding to enforce this chapter, related to the mediation agreement.
(k)  On agreement of all parties, any deadline under this subchapter may be extended.
Added by Acts 2009, 81st Leg., R.S., Ch. 1290 (H.B. 2256), Sec. 1, eff. June 19, 2009.
Amended by:
Acts 2017, 85th Leg., R.S., Ch. 100 (S.B. 507), Sec. 10, eff. September 1, 2017.
Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.11, eff. September 1, 2019.
Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 3.03(7), eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter B. Mandatory Mediation for Out-of-Network Facilities › Section 1467.056. Matters Considered in Mediation; Agreed Resolution

Sec. 1467.056.  MATTERS CONSIDERED IN MEDIATION; AGREED RESOLUTION.  (a)  In a mediation under this subchapter, the parties shall evaluate whether:
(1)  the amount charged by the out-of-network provider for the health care or medical service or supply is excessive; and
(2)  the amount paid by the health benefit plan issuer or administrator represents the usual and customary rate for the health care or medical service or supply or is unreasonably low.
(b)  The out-of-network provider may present information regarding the amount charged for the health care or medical service or supply.  The health benefit plan issuer or administrator may present information regarding the amount paid by the issuer or administrator.
(c)  Nothing in this chapter prohibits mediation of more than one claim between the parties during a mediation.
(d)  The goal of the mediation is to reach an agreement between the out-of-network provider and the health benefit plan issuer or administrator, as applicable, as to the amount paid by the issuer or administrator to the out-of-network provider and the amount charged by the out-of-network provider.
Added by Acts 2009, 81st Leg., R.S., Ch. 1290 (H.B. 2256), Sec. 1, eff. June 19, 2009.
Amended by:
Acts 2017, 85th Leg., R.S., Ch. 100 (S.B. 507), Sec. 11, eff. September 1, 2017.
Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.12, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter B. Mandatory Mediation for Out-of-Network Facilities › Section 1467.0575. Right to File Action

Sec. 1467.0575.  RIGHT TO FILE ACTION.  Not later than the 45th day after the date that the mediator's report is provided to the department under Section 1467.060, either party to a mediation for which there was no agreement may file a civil action to determine the amount due to an out-of-network provider.  A party may not bring a civil action before the conclusion of the mediation process under this subchapter.
Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.13, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter B. Mandatory Mediation for Out-of-Network Facilities › Section 1467.060. Report of Mediator

Sec. 1467.060.  REPORT OF MEDIATOR.  Not later than the 45th day after the date the mediation concludes, the mediator shall report to the commissioner and the Texas Medical Board or other appropriate regulatory agency:
(1)  the names of the parties to the mediation; and
(2)  whether the parties reached an agreement.
Added by Acts 2009, 81st Leg., R.S., Ch. 1290 (H.B. 2256), Sec. 1, eff. June 19, 2009.
Amended by:
Acts 2017, 85th Leg., R.S., Ch. 100 (S.B. 507), Sec. 15, eff. September 1, 2017.
Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.14, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter B. -1. Mandatory Binding Arbitration for Other Providers › Section 1467.081. Applicability of Subchapter

Sec. 1467.081.  APPLICABILITY OF SUBCHAPTER.  This subchapter applies only with respect to a health benefit claim submitted by an out-of-network provider who is not a facility.
Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.15, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter B. -1. Mandatory Binding Arbitration for Other Providers › Section 1467.082. Establishment and Administration of Arbitration Program

Sec. 1467.082.  ESTABLISHMENT AND ADMINISTRATION OF ARBITRATION PROGRAM.  (a)  The commissioner shall establish and administer an arbitration program to resolve disputes over out-of-network provider charges in accordance with this subchapter.
(b)  The commissioner:
(1)  shall adopt rules, forms, and procedures necessary for the implementation and administration of the arbitration program, including the establishment of a portal on the department's Internet website through which a request for arbitration under Section 1467.084 may be submitted; and
(2)  shall maintain a list of qualified arbitrators for the program.
Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.15, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter B. -1. Mandatory Binding Arbitration for Other Providers › Section 1467.083. Issue to Be Addressed; Basis for Determination

Sec. 1467.083.  ISSUE TO BE ADDRESSED; BASIS FOR DETERMINATION.  (a)  The only issue that an arbitrator may determine under this subchapter is the reasonable amount for the health care or medical services or supplies provided to the enrollee by an out-of-network provider.
(b)  The determination must take into account:
(1)  whether there is a gross disparity between the fee billed by the out-of-network provider and:
(A)  fees paid to the out-of-network provider for the same services or supplies rendered by the provider to other enrollees for which the provider is an out-of-network provider; and
(B)  fees paid by the health benefit plan issuer to reimburse similarly qualified out-of-network providers for the same services or supplies in the same region;
(2)  the level of training, education, and experience of the out-of-network provider;
(3)  the out-of-network provider's usual billed charge for comparable services or supplies with regard to other enrollees for which the provider is an out-of-network provider;
(4)  the circumstances and complexity of the enrollee's particular case, including the time and place of the provision of the service or supply;
(5)  individual enrollee characteristics;
(6)  the 80th percentile of all billed charges for the service or supply performed by a health care provider in the same or similar specialty and provided in the same geozip area as reported in a benchmarking database described by Section 1467.006;
(7)  the 50th percentile of rates for the service or supply paid to participating providers in the same or similar specialty and provided in the same geozip area as reported in a benchmarking database described by Section 1467.006;
(8)  the history of network contracting between the parties;
(9)  historical data for the percentiles described by Subdivisions (6) and (7); and
(10)  an offer made during the informal settlement teleconference required under Section 1467.084(d).
Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.15, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter B. -1. Mandatory Binding Arbitration for Other Providers › Section 1467.084. Availability of Mandatory Arbitration

Sec. 1467.084.  AVAILABILITY OF MANDATORY ARBITRATION.  (a)  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 through a portal on the department's Internet website if:
(1)  there is a charge billed by the provider and unpaid by the issuer or administrator after copayments, coinsurance, and deductibles for which an enrollee may not be billed; and
(2)  the health benefit claim is 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; or
(D)  an out-of-network diagnostic imaging service.
(b)  If a person requests arbitration under this subchapter, the out-of-network provider or the provider's representative, and the health benefit plan issuer or the administrator, as appropriate, shall participate in the arbitration.
(c)  The person who requests the arbitration shall provide written notice on the date the arbitration is requested in the form and manner prescribed by commissioner rule to:
(1)  the department; and
(2)  each other party.
(d)  In an effort to settle the claim before arbitration, all parties must participate in an informal settlement teleconference not later than the 30th day after the date on which the arbitration is requested.  A health benefit plan issuer or administrator, as applicable, shall make a reasonable effort to arrange the teleconference.
(e)  The commissioner shall adopt rules providing requirements for submitting multiple claims to arbitration in one proceeding.  The rules must provide that:
(1)  the total amount in controversy for multiple claims in one proceeding may not exceed $5,000; and
(2)  the multiple claims in one proceeding must be limited to the same out-of-network provider.
Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.15, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter B. -1. Mandatory Binding Arbitration for Other Providers › Section 1467.085. Effect of Arbitration and Applicability of Other Law

Sec. 1467.085.  EFFECT OF ARBITRATION AND APPLICABILITY OF OTHER LAW.  (a)  Notwithstanding Section 1467.004, an out-of-network provider or health benefit plan issuer or administrator may not file suit for an out-of-network claim subject to this chapter until the conclusion of the arbitration on the issue of the amount to be paid in the out-of-network claim dispute.
(b)  An arbitration conducted under this subchapter is not subject to Title 7, Civil Practice and Remedies Code.
Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.15, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter B. -1. Mandatory Binding Arbitration for Other Providers › Section 1467.086. Selection and Approval of Arbitrator

Sec. 1467.086.  SELECTION AND APPROVAL OF ARBITRATOR.  (a)  If the parties do not select an arbitrator by mutual agreement on or before the 30th day after the date the arbitration is requested, the party requesting the arbitration shall notify the commissioner, and the commissioner shall select an arbitrator from the commissioner's list of approved arbitrators.
(b)  In selecting an arbitrator under this section, the commissioner shall give preference to an arbitrator who is knowledgeable and experienced in applicable principles of contract and insurance law and the health care industry generally.
(c)  In approving an individual as an arbitrator, the commissioner shall ensure that the individual does not have a conflict of interest that would adversely impact the individual's independence and impartiality in rendering a decision in an arbitration.  A conflict of interest includes current or recent ownership or employment of the individual or a close family member in any health benefit plan issuer or administrator or physician, health care practitioner, or other health care provider.
(d)  The commissioner shall immediately terminate the approval of an arbitrator who no longer meets the requirements under this subchapter and rules adopted under this subchapter to serve as an arbitrator.
Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.15, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter B. -1. Mandatory Binding Arbitration for Other Providers › Section 1467.087. Procedures

Sec. 1467.087.  PROCEDURES.  (a)  The arbitrator shall set a date for submission of all information to be considered by the arbitrator.
(b)  A party may not engage in discovery in connection with the arbitration.
(c)  On agreement of all parties, any deadline under this subchapter may be extended.
(d)  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.
(e)  The parties shall evenly split and pay the arbitrator's fees and expenses.
(f)  Information submitted by the parties to the arbitrator is confidential and not subject to disclosure under Chapter 552, Government Code.
Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.15, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter B. -1. Mandatory Binding Arbitration for Other Providers › Section 1467.088. Decision

Sec. 1467.088.  DECISION.  (a)  Not later than the 51st day after the date the arbitration is requested, an arbitrator shall provide the parties with a written decision in which the arbitrator:
(1)  determines whether the billed charge or the payment made by the health benefit plan issuer or administrator, as those amounts were last modified during the issuer's or administrator's internal appeal process, if the provider elects to participate, or the informal settlement teleconference required by Section 1467.084(d), as applicable, is the closest to the reasonable amount for the services or supplies determined in accordance with Section 1467.083(b); and
(2)  selects the amount determined to be closest under Subdivision (1) as the binding award amount.
(b)  An arbitrator may not modify the binding award amount selected under Subsection (a).
(c)  An arbitrator shall provide written notice in the form and manner prescribed by commissioner rule of the reasonable amount for the services or supplies and the binding award amount.  If the parties settle before a decision, the parties shall provide written notice in the form and manner prescribed by commissioner rule of the amount of the settlement.  The department shall maintain a record of notices provided under this subsection.
Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.15, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter B. -1. Mandatory Binding Arbitration for Other Providers › Section 1467.089. Effect of Decision

Sec. 1467.089.  EFFECT OF DECISION.  (a)  An arbitrator's decision under Section 1467.088 is binding.
(b)  Not later than the 45th day after the date of an arbitrator's decision under Section 1467.088, a party not satisfied with the decision may file an action to determine the payment due to an out-of-network provider.
(c)  In an action filed under Subsection (b), the court shall determine whether the arbitrator's decision is proper based on a substantial evidence standard of review.
(d)  Not later than the 30th day after the date of an arbitrator's decision under Section 1467.088, a health benefit plan issuer or administrator shall pay to an out-of-network provider any additional amount necessary to satisfy the binding award.
Added by Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.15, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter C. Bad Faith Participation › Section 1467.101. Bad Faith

Sec. 1467.101.  BAD FAITH.  (a)  The following conduct constitutes bad faith participation for purposes of this chapter:
(1)  failing to participate in the informal settlement teleconference under Section 1467.084(d) or an arbitration or mediation under this chapter;
(2)  failing to provide information the arbitrator or mediator believes is necessary to facilitate a decision or agreement; or
(3)  failing to designate a representative participating in the arbitration or mediation with full authority to enter into any agreement.
(b)  Failure to reach an agreement under Subchapter B is not conclusive proof of bad faith participation.
Added by Acts 2009, 81st Leg., R.S., Ch. 1290 (H.B. 2256), Sec. 1, eff. June 19, 2009.
Amended by:
Acts 2017, 85th Leg., R.S., Ch. 100 (S.B. 507), Sec. 17, eff. September 1, 2017.
Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.16, eff. September 1, 2019.
2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle F - Physicians and Health Care Providers › Chapter 1467 - Out-of-Network Claim Dispute Resolution › Subchapter C. Bad Faith Participation › Section 1467.102. Penalties

Sec. 1467.102.  PENALTIES.  (a)  Bad faith participation or otherwise failing to comply with Subchapter B-1 is grounds for imposition of an administrative penalty by the regulatory agency that issued a license or certificate of authority to the party who committed the violation.
(b)  Except for good cause shown, on a report of a mediator and appropriate proof of bad faith participation under Subchapter B, the regulatory agency that issued the license or certificate of authority shall impose an administrative penalty.
Added by Acts 2009, 81st Leg., R.S., Ch. 1290 (H.B. 2256), Sec. 1, eff. June 19, 2009.
Amended by:
Acts 2019, 86th Leg., R.S., Ch. 1342 (S.B. 1264), Sec. 2.16, eff. September 1, 2019.