CHAPTER 1467. OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION
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
Sec. 1467.001. DEFINITIONS. In this chapter:
(1) "Administrator" means:
(A) an administering firm for a health benefit plan providing
coverage under Chapter 1551; and
(B) if applicable, the claims administrator for the health
benefit plan.
(2) "Chief administrative law judge" means the chief
administrative law judge of the State Office of Administrative
Hearings.
(3) "Enrollee" means an individual who is eligible to receive
benefits through a preferred provider benefit plan or a health
benefit plan under Chapter 1551.
(4) "Facility-based physician" means a radiologist, an
anesthesiologist, a pathologist, an emergency department
physician, or a neonatologist:
(A) to whom the facility has granted clinical privileges; and
(B) who provides services to patients of the facility under
those clinical privileges.
(5) "Mediation" means a process in which an impartial mediator
facilitates and promotes agreement between the insurer offering a
preferred provider benefit plan or the administrator and a
facility-based physician or the physician's representative to
settle a health benefit claim of an enrollee.
(6) "Mediator" means an impartial person who is appointed to
conduct a mediation under this chapter.
(7) "Party" means an insurer offering a preferred provider
benefit plan, an administrator, or a facility-based physician or
the physician's representative who participates in a mediation
conducted under this chapter. The enrollee is also considered a
party to the mediation.
Added by Acts 2009, 81st Leg., R.S., Ch.
1290, Sec. 1, eff. June 19, 2009.
Sec. 1467.002. APPLICABILITY OF CHAPTER. This chapter applies
to:
(1) a preferred provider benefit plan offered by an insurer
under Chapter 1301; and
(2) an administrator of a health benefit plan, other than a
health maintenance organization plan, under Chapter 1551.
Added by Acts 2009, 81st Leg., R.S., Ch.
1290, Sec. 1, eff. June 19, 2009.
Sec. 1467.003. RULES. The commissioner, the Texas Medical
Board, and the chief administrative law judge shall adopt rules
as necessary to implement their respective powers and duties
under this chapter.
Added by Acts 2009, 81st Leg., R.S., Ch.
1290, Sec. 1, eff. June 19, 2009.
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, Sec. 1, eff. June 19, 2009.
Sec. 1467.005. REFORM. This chapter may not be construed to
prohibit:
(1) an insurer offering a preferred provider benefit plan or
administrator from, at any time, offering a reformed claim
settlement; or
(2) a facility-based physician from, at any time, offering a
reformed charge for medical services.
Added by Acts 2009, 81st Leg., R.S., Ch.
1290, Sec. 1, eff. June 19, 2009.
SUBCHAPTER B. MANDATORY MEDIATION
Sec. 1467.051. AVAILABILITY OF MANDATORY MEDIATION; EXCEPTION.
(a) An enrollee may request mediation of a settlement of an
out-of-network health benefit claim if:
(1) the amount for which the enrollee is responsible to a
facility-based physician, after copayments, deductibles, and
coinsurance, including the amount unpaid by the administrator or
insurer, is greater than $1,000; and
(2) the health benefit claim is for a medical service or supply
provided by a facility-based physician in a hospital that is a
preferred provider or that has a contract with the administrator.
(b) Except as provided by Subsections (c) and (d), if an
enrollee requests mediation under this subchapter, the
facility-based physician or the physician's representative and
the insurer or the administrator, as appropriate, shall
participate in the mediation.
(c) Except in the case of an emergency and if requested by the
enrollee, a facility-based physician shall, before providing a
medical service or supply, provide a complete disclosure to an
enrollee that:
(1) explains that the facility-based physician does not have a
contract with the enrollee's health benefit plan;
(2) discloses projected amounts for which the enrollee may be
responsible; and
(3) discloses the circumstances under which the enrollee would
be responsible for those amounts.
(d) A facility-based physician who makes a disclosure under
Subsection (c) and obtains the enrollee's written acknowledgment
of that disclosure may not be required to mediate a billed charge
under this subchapter if the amount billed is less than or equal
to the maximum amount projected in the disclosure.
Added by Acts 2009, 81st Leg., R.S., Ch.
1290, Sec. 1, eff. June 19, 2009.
Sec. 1467.052. MEDIATOR QUALIFICATIONS. (a) Except as provided
by Subsection (b), to qualify for an appointment as a mediator
under this chapter 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 chief administrative law judge.
(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 an insurer offering
the preferred provider benefit plan or a physician during the
three years immediately preceding the request for mediation.
Added by Acts 2009, 81st Leg., R.S., Ch.
1290, Sec. 1, eff. June 19, 2009.
Sec. 1467.053. APPOINTMENT OF MEDIATOR; FEES. (a) A mediation
shall be conducted by one mediator.
(b) The chief administrative law judge shall appoint the
mediator through a random assignment from a list of qualified
mediators maintained by the State Office of Administrative
Hearings.
(c) Notwithstanding Subsection (b), a person other than a
mediator appointed by the chief administrative law judge may
conduct the mediation on agreement of all of the parties and
notice to the chief administrative law judge.
(d) The mediator's fees shall be split evenly and paid by the
insurer or administrator and the facility-based physician.
Added by Acts 2009, 81st Leg., R.S., Ch.
1290, Sec. 1, eff. June 19, 2009.
Sec. 1467.054. REQUEST AND PRELIMINARY PROCEDURES FOR MANDATORY
MEDIATION. (a) An enrollee may request mandatory mediation
under this chapter.
(b) A request for mandatory mediation must be provided to the
department on a form prescribed by the commissioner and must
include:
(1) the name of the enrollee requesting mediation;
(2) a brief description of the claim to be mediated;
(3) contact information, including a telephone number, for the
requesting enrollee and the enrollee's counsel, if the enrollee
retains counsel;
(4) the name of the facility-based physician and name of the
insurer or administrator; and
(5) any other information the commissioner may require by rule.
(c) On receipt of a request for mediation, the department shall
notify the facility-based physician and insurer or administrator
of the request.
(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 the enrollee
submits a request for mediation under this section.
(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 medical services
were rendered.
(f) The enrollee may elect to participate in the mediation. A
mediation may not proceed without the consent of the enrollee.
An enrollee may withdraw the request for mediation at any time
before the mediation.
(g) Notwithstanding Subsection (f), mediation may proceed
without the participation of the enrollee or the enrollee's
representative if the enrollee or representative is not present
in person or through teleconference.
Added by Acts 2009, 81st Leg., R.S., Ch.
1290, Sec. 1, eff. June 19, 2009.
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.
(d) If the enrollee is participating in the mediation in person,
at the beginning of the mediation the mediator shall inform the
enrollee that if the enrollee is not satisfied with the mediated
agreement, the enrollee may file a complaint with:
(1) the Texas Medical Board against the facility-based physician
for improper billing; and
(2) the department for unfair claim settlement practices.
(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) Except at the request of an enrollee, a mediation shall be
held not later than the 180th day after the date of the request
for mediation.
(h) On receipt of notice from the department that an enrollee
has made a request for mediation that meets the requirements of
this chapter, the facility-based physician may not pursue any
collection effort against the enrollee who has requested
mediation for amounts other than copayments, deductibles, and
coinsurance before the earlier of:
(1) the date the mediation is completed; or
(2) the date the request to mediate is withdrawn.
(i) A service provided by a facility-based physician may not be
summarily disallowed. This subsection does not require an
insurer or administrator to pay for an uncovered service.
(j) A mediator may not testify in a proceeding, other than a
proceeding to enforce this chapter, related to the mediation
agreement.
Added by Acts 2009, 81st Leg., R.S., Ch.
1290, Sec. 1, eff. June 19, 2009.
Sec. 1467.056. MATTERS CONSIDERED IN MEDIATION; AGREED
RESOLUTION. (a) In a mediation under this chapter, the parties
shall:
(1) evaluate whether:
(A) the amount charged by the facility-based physician for the
medical service or supply is excessive; and
(B) the amount paid by the insurer or administrator represents
the usual and customary rate for the medical service or supply or
is unreasonably low; and
(2) as a result of the amounts described by Subdivision (1),
determine the amount, after copayments, deductibles, and
coinsurance are applied, for which an enrollee is responsible to
the facility-based physician.
(b) The facility-based physician may present information
regarding the amount charged for the medical service or supply.
The insurer or administrator may present information regarding
the amount paid by the insurer.
(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 among the
enrollee, the facility-based physician, and the insurer or
administrator, as applicable, as to the amount paid by the
insurer or administrator to the facility-based physician, the
amount charged by the facility-based physician, and the amount
paid to the facility-based physician by the enrollee.
Added by Acts 2009, 81st Leg., R.S., Ch.
1290, Sec. 1, eff. June 19, 2009.
Sec. 1467.057. NO AGREED RESOLUTION. (a) The mediator of an
unsuccessful mediation under this chapter shall report the
outcome of the mediation to the department, the Texas Medical
Board, and the chief administrative law judge.
(b) The chief administrative law judge shall enter an order of
referral of a matter reported under Subsection (a) to a special
judge under Chapter 151, Civil Practice and Remedies Code, that:
(1) names the special judge on whom the parties agreed or
appoints the special judge if the parties did not agree on a
judge;
(2) states the issues to be referred and the time and place on
which the parties agree for the trial;
(3) requires each party to pay the party's proportionate share
of the special judge's fee; and
(4) certifies that the parties have waived the right to trial by
jury.
(c) A trial by the special judge selected or appointed as
described by Subsection (b) must proceed under Chapter 151, Civil
Practice and Remedies Code, except that the special judge's
verdict is not relevant or material to any other balance bill
dispute and has no precedential value.
(d) Notwithstanding any other provision of this section, Section
151.012, Civil Practice and Remedies Code, does not apply to a
mediation under this chapter.
Added by Acts 2009, 81st Leg., R.S., Ch.
1290, Sec. 1, eff. June 19, 2009.
Sec. 1467.058. CONTINUATION OF MEDIATION. After a referral is
made under Section 1467.057, the facility-based physician and the
insurer or administrator may elect to continue the mediation to
further determine their responsibilities. Continuation of
mediation under this section does not affect the amount of the
billed charge to the enrollee.
Added by Acts 2009, 81st Leg., R.S., Ch.
1290, Sec. 1, eff. June 19, 2009.
Sec. 1467.059. MEDIATION AGREEMENT. The mediator shall prepare
a confidential mediation agreement and order that states:
(1) the total amount for which the enrollee will be responsible
to the facility-based physician, after copayments, deductibles,
and coinsurance; and
(2) any agreement reached by the parties under Section 1467.058.
Added by Acts 2009, 81st Leg., R.S., Ch.
1290, Sec. 1, eff. June 19, 2009.
Sec. 1467.060. REPORT OF MEDIATOR. The mediator shall report to
the commissioner and the Texas Medical Board:
(1) the names of the parties to the mediation; and
(2) whether the parties reached an agreement or the mediator
made a referral under Section 1467.057.
Added by Acts 2009, 81st Leg., R.S., Ch.
1290, Sec. 1, eff. June 19, 2009.
SUBCHAPTER C. BAD FAITH MEDIATION
Sec. 1467.101. BAD FAITH. (a) The following conduct
constitutes bad faith mediation for purposes of this chapter:
(1) failing to participate in the mediation;
(2) failing to provide information the mediator believes is
necessary to facilitate an agreement; or
(3) failing to designate a representative participating in the
mediation with full authority to enter into any mediated
agreement.
(b) Failure to reach an agreement is not conclusive proof of bad
faith mediation.
(c) A mediator shall report bad faith mediation to the
commissioner or the Texas Medical Board, as appropriate,
following the conclusion of the mediation.
Added by Acts 2009, 81st Leg., R.S., Ch.
1290, Sec. 1, eff. June 19, 2009.
Sec. 1467.102. PENALTIES. (a) Bad faith mediation, by a party
other than the enrollee, 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 mediation, 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, Sec. 1, eff. June 19, 2009.
SUBCHAPTER D. COMPLAINTS; CONSUMER PROTECTION
Sec. 1467.151. CONSUMER PROTECTION; RULES. (a) The
commissioner and the Texas Medical Board, as appropriate, shall
adopt rules regulating the investigation and review of a
complaint filed that relates to the settlement of an
out-of-network health benefit claim that is subject to this
chapter. The rules adopted under this section must:
(1) distinguish among complaints for out-of-network coverage or
payment and give priority to investigating allegations of delayed
medical care;
(2) develop a form for filing a complaint and establish an
outreach effort to inform enrollees of the availability of the
claims dispute resolution process under this chapter;
(3) ensure that a complaint is not dismissed without appropriate
consideration;
(4) ensure that enrollees are informed of the availability of
mandatory mediation; and
(5) require the administrator to include a notice of the claims
dispute resolution process available under this chapter with the
explanation of benefits sent to an enrollee.
(b) The department and the Texas Medical Board shall maintain
information:
(1) on each complaint filed that concerns a claim or mediation
subject to this chapter; and
(2) related to a claim that is the basis of an enrollee
complaint, including:
(A) the type of services that gave rise to the dispute;
(B) the type and specialty of the facility-based physician who
provided the out-of-network service;
(C) the county and metropolitan area in which the medical
service or supply was provided;
(D) whether the medical service or supply was for emergency
care; and
(E) any other information about:
(i) the insurer or administrator that the commissioner by rule
requires; or
(ii) the physician that the Texas Medical Board by rule
requires.
(c) The information collected and maintained by the department
and the Texas Medical Board under Subsection (b)(2) is public
information as defined by Section 552.002, Government Code, and
may not include personally identifiable information or medical
information.
(d) A facility-based physician who fails to provide a disclosure
under Section 1467.051 is not subject to discipline by the Texas
Medical Board for that failure and a cause of action is not
created by a failure to disclose as required by Section 1467.051.
Added by Acts 2009, 81st Leg., R.S., Ch.
1290, Sec. 1, eff. June 19, 2009.