Purpose; Scope; Definitions
Section 21.5001. Purpose
The purpose of this subchapter is to:
(1) prescribe the process for requesting, initiating, and conducting mandatory mediation and mandatory binding arbitration of claims as authorized in Insurance Code Chapter 1467 (concerning Out-of-Network Claim Dispute Resolution);
(2) facilitate the process for the investigation and review of a complaint filed with the department that relates to the settlement of an out-of-network claim under Insurance Code Chapter 1467;
(3) prescribe the contents of the explanation of benefits as required by Insurance Code §1271.008 (concerning Balance Billing Prohibition Notice), §1301.010 (concerning Balance Billing Prohibition Notice), §1551.015 (concerning Balance Billing Prohibition Notice), §1575.009 (concerning Balance Billing Prohibition Notice), and §1579.009 (concerning Balance Billing Prohibition Notice); and
(4) facilitate the collection of data as authorized in Insurance Code §1467.006 (concerning Benchmarking Database).
Section 21.5002. Scope
(a) This subchapter applies to a qualified mediation claim or qualified arbitration claim filed under health benefit plan coverage:
(1) issued by an insurer as a preferred provider benefit plan under Insurance Code Chapter 1301, concerning Preferred Provider Benefit Plans, including an exclusive provider benefit plan;
(2) administered by an administrator of a health benefit plan, other than a health maintenance organization (HMO) plan, under Insurance Code Chapters 1551, concerning Texas Employees Group Benefits Act; 1575, concerning Texas Public School Employees Group Benefits Program; 1579, concerning Texas School Employees Uniform Group Health Coverage; or 1682, concerning Health Benefits Provided by Certain Nonprofit Agricultural Organizations; or
(3) offered by an HMO operating under Insurance Code Chapter 843, concerning Health Maintenance Organizations.
(b) This subchapter does not apply to a claim for health benefits that is not a covered claim under the terms of the health benefit plan coverage.
(c) Except as provided in §21.5050 of this title (relating to Submission of Information), this subchapter applies to a claim for emergency care or health care or medical services or supplies, provided on or after January 1, 2020. A claim for health care or medical services or supplies provided before January 1, 2020, is governed by the rules in effect immediately before the effective date of this subsection, and those rules are continued in effect for that purpose
Section 21.5003. Definitions
The following words and terms have the following meanings when used in this subchapter unless the context clearly indicates otherwise.
(1) Administrator–Has the meaning assigned by Insurance Code §1467.001, concerning Definitions. The term also includes a nonprofit agricultural organization under Chapter 1682, concerning Health Benefits Provided by Certain Nonprofit Agricultural Organizations, offering a health benefit plan.
(2) Arbitration–Has the meaning assigned by Insurance Code §1467.001.
(3) Claim–A request to a health benefit plan for payment for health benefits under the terms of the health benefit plan’s coverage, including emergency care, or a health care or medical service or supply, or any combination of emergency care and health care or medical services and supplies, provided that the care, services, or supplies:
(A) are furnished for a single date of service; or
(B) if furnished for more than one date of service, are provided as a continuing or related course of treatment over a period of time for a specific medical problem or condition, or in response to the same initial patient complaint.
(4) Diagnostic imaging provider–Has the meaning assigned by Insurance Code §1467.001.
(5) Diagnostic imaging service–Has the meaning assigned by Insurance Code §1467.001.
(6) Emergency care–Has the meaning assigned by Insurance Code §1301.155, concerning Emergency Care.
(7) Emergency care provider–Has the meaning assigned by Insurance Code §1467.001.
(8) Enrollee–Has the meaning assigned by Insurance Code §1467.001.
(9) Facility–Has the meaning assigned by Health and Safety Code §324.001, concerning Definitions.
(10) Health benefit plan–A plan that provides coverage under:
(A) a health benefit plan offered by an HMO operating under Insurance Code Chapter 843, concerning Health Maintenance Organizations;
(B) a preferred provider benefit plan, including an exclusive provider benefit plan, offered by an insurer under Insurance Code Chapter 1301, concerning Preferred Provider Benefit Plans; or
(C) a plan, other than an HMO plan, under Insurance Code Chapters 1551, concerning Texas Employees Group Benefits Act; 1575, concerning Texas Public School Employees Group Benefits Program; 1579, concerning Texas School Employees Uniform Group Health Coverage; or 1682.
(11) Facility-based provider–Has the meaning assigned by Insurance Code §1467.001.
(12) Insurer–A life, health, and accident insurance company; health insurance company; or other company operating under: Insurance Code Chapters 841, concerning Life, Health, or Accident Insurance Companies; 842, concerning Group Hospital Service Corporations; 884, concerning Stipulated Premium Insurance Companies; 885, concerning Fraternal Benefit Societies; 982, concerning Foreign and Alien Insurance Companies; or 1501, concerning Health Insurance Portability and Availability Act, that is authorized to issue, deliver, or issue for delivery in this state a preferred provider benefit plan, including an exclusive provider benefit plan, under Insurance Code Chapter 1301.
(13) Mediation–Has the meaning assigned by Insurance Code §1467.001.
(14) Mediator–Has the meaning assigned by Insurance Code §1467.001.
(15) Out-of-network claim–A claim for payment for medical or health care services or supplies or both furnished by an out-of-network provider or a non-network provider.
(16) Out-of-network provider–Has the meaning assigned by Insurance Code §1467.001.
(17) Party–Has the meaning assigned by Insurance Code §1467.001.