28 Tex. Admin. Code § 21.5030 - Complaint Resolution
(a) Written
complaint.
A party may submit a written complaint on the department's website regarding the settlement of an out-of-network health benefit claim that is subject to Insurance Code Chapter 1467.
(b) Complaint information. The recommended
information for filing a complaint under subsection (a) of this section,
includes:
(1) whether the complaint is within
the scope of Insurance Code Chapter 1467 (concerning Out-of-Network Claim
Dispute Resolution);
(2) whether
emergency care, health care, or a medical service have been delayed or have not
been given;
(3) whether the health
care, medical service, or supply, or a combination of health care, medical
service, or supply, that is the subject of the complaint was for emergency
care; and
(4) specific information
about the qualified mediation claim or qualified arbitration claim, including:
(A) the name, type, and specialty of the
provider;
(B) the type of service
performed or supplies provided;
(C)
the city and county where the service or supply was performed; and
(D) the dollar amount of the disputed
claim.
(c)
Department processing. The department will maintain procedures to ensure that a
written complaint made through the department's website under this section is
not dismissed without appropriate consideration, including:
(1) review of all of the information
submitted in the written complaint;
(2) contact with the parties that are the
subject of the complaint; and
(3)
review of the responses received from the subjects of the complaint to
determine if and what further action is required, as appropriate.
Notes
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