28 Tex. Admin. Code § 180.2 - Filing a Complaint

(a) Any person may submit a complaint to the division for alleged administrative violations, except as provided in subsection (b) of this section.

(b) A health care provider cannot submit a complaint about a medical billing issue if the date of service for the medical billing issue was more than 12 months before the date of the complaint, unless the issue qualifies for an exception to the filing deadline under § 133.307(c)(1)(B) of this title, concerning medical fee dispute resolution. If the issue qualifies for an exception to the medical fee dispute resolution filing deadline under §133.307(c)(1)(B), then a health care provider cannot submit a complaint about that issue if the medical fee dispute resolution filing deadline in §133.307(c)(1)(B) has passed. This subsection does not apply to a health care provider submitting a complaint under Insurance Code Chapter 1305.

(c) A person may submit a complaint to the division:

(1) through the division's website;

(2) by email;

(3) through written correspondence;

(4) by fax; or

(5) in person. The division will help a person submitting an in-person complaint reduce the complaint to writing.

(d) A complaint submitted on the form provided by the division or in any other written format must contain the following information as applicable:

(1) complainant's name and contact information;

(2) name and contact information of the subject or parties of the complaint, if known;

(3) name and contact information of witnesses, if known;

(4) claim file information, including, but not limited to, the name, address, and date of injury of the injured employee, if known;

(5) the statement of the facts about the alleged violation, including the dates or time period the alleged violation occurred;

(6) the nature of the alleged violation, including the specific sections of the Act and division rules alleged to have been violated, if known;

(7) supporting documentation relevant to the allegation that may include, but is not limited to, medical bills, Explanation of Benefits statements, copies of payment invoices or checks, and medical reports, as applicable;

(8) supporting documentation for alleged fraud that may include photographs, video, audio, and surveillance recordings, and reports; and

(9) other sources of pertinent information, if known.

(e) Contact information may include, but is not limited to, name, address, telephone number, fax number, email address, business name, business address, business telephone number, and websites.

(f) A complaint must contain sufficient information for the division to investigate the complaint.

(g) On receipt of a complaint, the division will review, monitor, and may investigate the allegation against a person or entity who may have violated the Act or division rules.

(h) The division will assign priorities to complaints being investigated based on a risk-based complaint investigation system that considers:

(1) the severity of the alleged violation;

(2) whether the noncompliance or alleged violation is ongoing;

(3) whether a commissioner order has been violated; or

(4) other risk-based criteria the division determines necessary.

(i) A person commits an administrative violation if the person submits a complaint to the division that is:

(1) frivolous, as defined in § 180.1 of this title (relating to Definitions);

(2) groundless or made in bad faith; or

(3) done specifically for competitive or economic advantage.

Notes

28 Tex. Admin. Code § 180.2

The provisions of this §180.2 adopted to be effective March 14, 2002, 27 TexReg 1817; amended to be effective January 9, 2011, 35 TexReg 11873; Amended by Texas Register, Volume 49, Number 21, May 24, 2024, TexReg 3805, eff. 5/27/2024