Issue to Be Addressed; Basis for Determination
(a) The only issue that an arbitrator may determine under this subchapter is the reasonable amount for the health care or medical services or supplies provided to the enrollee by an out-of-network provider.
(b) The determination must take into account:
(1) whether there is a gross disparity between the fee billed by the out-of-network provider and:
(A) fees paid to the out-of-network provider for the same services or supplies rendered by the provider to other enrollees for which the provider is an out-of-network provider; and
(B) fees paid by the health benefit plan issuer to reimburse similarly qualified out-of-network providers for the same services or supplies in the same region;
(2) the level of training, education, and experience of the out-of-network provider;
(3) the out-of-network provider’s usual billed charge for comparable services or supplies with regard to other enrollees for which the provider is an out-of-network provider;
(4) the circumstances and complexity of the enrollee’s particular case, including the time and place of the provision of the service or supply;
(5) individual enrollee characteristics;
(6) the 80th percentile of all billed charges for the service or supply performed by a health care provider in the same or similar specialty and provided in the same geozip area as reported in a benchmarking database described by Section 1467.006;
(7) the 50th percentile of rates for the service or supply paid to participating providers in the same or similar specialty and provided in the same geozip area as reported in a benchmarking database described by Section 1467.006;
(8) the history of network contracting between the parties;
(9) historical data for the percentiles described by Subdivisions (6) and (7); and
(10) an offer made during the informal settlement teleconference required under Section 1467.084(d).