Required Explanation of Benefits
A health benefit plan issuer or administrator subject to 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), or §1579.009 (concerning Balance Billing Prohibition Notice) must provide written notice in accordance with this section in an explanation of benefits in connection with a health care or medical service or supply provided by a non-network provider or an out-of-network provider:
(1) To the enrollee and physician or provider, which must include:
(A) a statement of the billing prohibition, as applicable; and
(B) the total amount the physician or provider may bill the enrollee under the health benefit plan and an itemization of copayments, coinsurance, deductibles, and other amounts included in that total;
(2) To the physician or provider, a conspicuous statement in not less than 10-point boldface type that is substantially similar to the following: “If you disagree with the payment amount, you can request mediation or arbitration. To learn more and submit a request, go to www.tdi.texas.gov. After you submit a complete request, you must notify [HEALTH BENEFIT PLAN ISSUER OR ADMINISTRATOR NAME] at [EMAIL].”