State Law

Texas Admin. Code-Title 28-Part 1-Chapter 21-Subchapter PP-Division 4. Complaint Resolution and Outreach

08/24/2023 Texas Section 21.5030

Complaint Resolution

OON-Payment Issues

(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 has been delayed or has 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.