28 Tex. Admin. Code § 21.5020 - Qualified Arbitration Claim Criteria
(a) Required criteria. An out-of-network
provider that is not a facility or a health benefit plan issuer or
administrator may request mandatory binding arbitration of an out-of-network
claim under §
21.5021 of this title (relating to
Arbitration Request Procedure) if the claim complies with the criteria
specified in this section. An out-of-network claim that complies with those
criteria is referred to as a "qualified arbitration claim" in this subchapter.
(1) The health benefit claim must be 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 provided in connection with a health care or
medical service or supply provided by a participating provider; or
(D) an out-of-network diagnostic imaging
service provided in connection with a health care or medical service or supply
provided by a participating provider; and
(2) The health benefit claim must be for a
charge billed by the provider and unpaid by the health benefit plan issuer or
administrator after copayments, coinsurance, and deductibles for which an
enrollee may not be billed.
(b) Availability. 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. The initial payment could
be zero dollars if the allowable amount was applied to an enrollee's
deductible.
(c) Ineligible claims.
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.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.