28 Tex. Admin. Code § 21.5011 - Mediation Request Procedure
(a) Mediation
request and notice.
(1) An out-of-network
provider that is a facility or a health benefit plan issuer or administrator
may request mediation. To be eligible for mediation, the party requesting
mediation must complete the mediation request information required on the
department's website at www.tdi.texas.gov, as specified in subsection
(b) of this section.
(2) The party
who requests the mediation must provide written notice to each other party on
the date the mediation is requested. The notification must contain the
information as specified on the department's website, including the necessary
claim information and contact information of the parties. A health benefit plan
issuer or administrator requesting mediation must send the mediation
notification to the mailing address or email address specified in the claim
submitted by the provider. If a provider does not specify an address to receive
notice requesting mediation in the claim, a health benefit plan issuer or
administrator may provide notice to the provider at the provider's last known
address the issuer or administrator has on file for the provider. A provider
requesting mediation must send the mediation notification to the email address
specified in the explanation of benefits by the health benefit plan issuer or
administrator.
(b)
Submission of request. The requesting party must submit information necessary
to complete the initial mediation request, including:
(1) facility details, including identifying
the facility type, facility contact information, and facility representative
information;
(2) claim information,
including the claim number, type of service or supply provided, date of
service, billed amount, amount paid, and balance; and
(3) relevant information from the enrollee's
health benefit plan identification card or other similar document, including
plan number and group number.
(c) Notice of teleconference outcome. Parties
must submit additional information on the department's website at the
completion of the informal settlement teleconference period, including the date
the teleconference request was received and the date of the
teleconference.
(d) Mediator
selection.
(1) The parties must notify the
department through the department's website on or before 30 days from the date
the mediation is requested if:
(A) the parties
agree to a settlement;
(B) the
parties agree to the selection of a mediator; or
(C) the parties agree to extend the deadline
to have the department select a mediator and notify the department of new
deadlines.
(2) If the
department is not given notification under paragraph (1) of this subsection,
the department will assign a mediator after the 30th day from the date the
mediation is requested. The parties must pay the nonrefundable mediator's fee
to the mediator when the mediator is assigned. Failure to pay the mediator when
the mediator is assigned constitutes bad faith participation.
(e) Submission of information.
Parties must submit information, as specified on the department's website, to
the department at the completion of the mediation or informal settlement,
including:
(1) the name of the mediator, the
date when the mediator was selected, the date when the mediation was held, the
date of the agreement, the date of the mediator report, and when payment was
made; and
(2) the agreement,
including the original billed amount, payment amount, and the total agreed
amount.
(f) Mediator
approval and removal.
(1) Mediators may apply
to the department using a method as determined by the Commissioner, including
through an application on the department's website or through the department's
procurement process. An individual or entities that employ mediators may apply
for approval.
(2) A list of
qualified mediators will be maintained on the department's website. A mediator
must notify the department immediately if the mediator wants to voluntarily
withdraw from the list.
(3) At the
discretion of the department, a mediator may be removed from the list of
qualified mediators in certain circumstances, including failure to comply with
any requirement under Insurance Code Chapter 1467, concerning Out-of-Network
Claim Dispute Resolution, or rules adopted under Insurance Code §
1467.003, concerning
Rules.
(g) Mediation
process.
(1) A party may request mediation
after 20 days from the date an out-of-network provider receives the initial
payment for a health benefit claim, during which time the out-of-network
provider may attempt to resolve a claim payment dispute through the health
benefit plan issuer's or administrator's internal appeal process.
(2) The parties may submit written
information to a mediator concerning the amount charged by the out-of-network
provider for the health care or medical service or supply and the amount paid
by the health benefit plan issuer or administrator.
(3) The parties must evaluate the factors
specified in Insurance Code §
1467.056, concerning
Matters Considered in Mediation; Agreed Resolution.
(4) Each party is responsible for reviewing
the list of mediators and notifying the department within 10 days of the
request for mediation whether there is a conflict of interest with any of the
mediators on the list to avoid the department assigning a mediator with a
conflict of interest.
(5) The
parties may agree to aggregate claims between the same facility and same health
benefit plan issuer or administrator for mediation.
(h) Assistance. Assistance with submitting a
request for mediation is available on the department's website at
www.tdi.texas.gov.
Notes
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