28 Tex. Admin. Code § 21.5021 - Arbitration Request Procedure
(a) Arbitration
request and notice.
(1) An out-of-network
provider or a health benefit plan issuer or administrator may request
arbitration. To be eligible for arbitration, the party requesting arbitration
must complete the arbitration 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 arbitration
must provide written notice to each other party on the date the arbitration 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 arbitration must send the arbitration 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 arbitration
in the claim, the 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 arbitration
must send the arbitration 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 arbitration request, including:
(1) provider details, including identifying
the provider type, provider contact information, and provider 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 a 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, the date of the teleconference, and
settlement offer amounts.
(d)
Arbitrator selection.
(1) The parties must
notify the department, through the department's website, on or before 30 days
from the date arbitration was requested if:
(A) the parties agree to a
settlement;
(B) the parties agree
to the selection of an arbitrator; or
(C) the parties agree to extend the deadline
to have the department select an arbitrator 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 an arbitrator after the 30th day from the date the
arbitration is requested. The parties must pay the nonrefundable arbitrator's
fee to the arbitrator when the arbitrator is assigned. Failure to pay the
arbitrator when the arbitrator is assigned constitutes bad faith participation,
and the arbitrator may award the binding amount to the other party.
(e) Submission of information.
(1) The arbitrator must submit information,
as specified on the department's website, to the department at the completion
of the arbitration, including:
(A) the name of
the arbitrator, the date when the arbitrator was selected, the date of the
decision, the date of the arbitrator report, and when payment was made;
and
(B) the written decision,
including any final offers made during the health benefit plan issuer's or
administrator's internal appeal process or informal settlement, reasonable
amount for the services or supplies, and the binding award amount.
(2) If the parties settle the
dispute before the arbitrator's decision, the parties must submit information,
as specified on the department's website, to the department, including:
(A) the date of the settlement; and
(B) the amount of the settlement.
(f) Arbitrator approval
and removal.
(1) Arbitrators may apply to the
department using a method as determined by the Commissioner, including through
an application on the department's website or the department's procurement
process. An individual or entities that employ arbitrators may apply for
approval.
(2) A list of qualified
arbitrators will be maintained on the department's website. An arbitrator must
notify the department immediately if the arbitrator wants to voluntarily
withdraw from the list.
(3) At the
discretion of the department, an arbitrator may be removed from the list of
qualified arbitrators 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) Arbitration
process.
(1) A party may request arbitration
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 must submit written
information to an arbitrator 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 arbitrator must evaluate only the
factors specified in Insurance Code §
1467.083, concerning
Issue to Be Addressed; Basis for Determination.
(4) The arbitrator must provide the parties
an opportunity to review the written information submitted by the other party,
submit additional written information, and respond in writing to the arbitrator
on the time line set by the arbitrator.
(5) Each party is responsible for reviewing
the list of arbitrators and notifying the department within 10 days of the
request for arbitration if there is a conflict of interest with any of the
arbitrators on the list to avoid the department assigning an arbitrator with a
conflict of interest.
(6) If a
party does not respond to the arbitrator's request for information, the dispute
will be decided based on the available information received by the arbitrator
without an opportunity for reconsideration.
(7) The submission of multiple claims to
arbitration in one proceeding must be for the same provider and the same health
benefit plan issuer or administrator and the total amount in controversy may
not exceed $5,000.
(h)
Assistance. Assistance with submitting a request for arbitration is available
on the department's website at www.tdi.texas.gov.
Notes
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