Texas Insurance Code Title 8, Chapter 1467 - Out-of-network Claim Dispute Resolution

SUBCHAPTER A GENERAL PROVISIONS

• Texas Section 1467.001 - Definitions
  In this chapter: (1) "Administrator" means: (A) an administering firm for a health benefit plan providing coverage under Chapter 1551; and (B) if applicable, the...
• Texas Section 1467.002 - Applicability Of Chapter
  This chapter applies to: (1) a preferred provider benefit plan offered by an insurer under Chapter 1301; and (2) an administrator of a health benefit...
• Texas Section 1467.003 - Rules
  The commissioner, the Texas Medical Board, and the chief administrative law judge shall adopt rules as necessary to implement their respective powers and duties under...
• Texas Section 1467.004 - Remedies Not Exclusive
  The remedies provided by this chapter are in addition to any other defense, remedy, or procedure provided by law, including the common law. Added by...

SUBCHAPTER B MANDATORY MEDIATION

• Texas Section 1467.005 - Reform
  This chapter may not be construed to prohibit: (1) an insurer offering a preferred provider benefit plan or administrator from, at any time, offering a...
• Texas Section 1467.051 - Availability Of Mandatory Mediation; Exception
  (a) An enrollee may request mediation of a settlement of an out-of-network health benefit claim if: (1) the amount for which the enrollee is responsible...
• Texas Section 1467.052 - Mediator Qualifications
  (a) Except as provided by Subsection (b), to qualify for an appointment as a mediator under this chapter a person must have completed at least...
• Texas Section 1467.053 - Appointment Of Mediator; Fees
  (a) A mediation shall be conducted by one mediator. (b) The chief administrative law judge shall appoint the mediator through a random assignment from a...
• Texas Section 1467.054 - Request And Preliminary Procedures For Mandatory Mediation
  (a) An enrollee may request mandatory mediation under this chapter. (b) A request for mandatory mediation must be provided to the department on a form...
• Texas Section 1467.055 - Conduct Of Mediation; Confidentiality
  (a) A mediator may not impose the mediator's judgment on a party about an issue that is a subject of the mediation. (b) A mediation...
• Texas Section 1467.056 - Matters Considered In Mediation; Agreed Resolution
  (a) In a mediation under this chapter, the parties shall: (1) evaluate whether: (A) the amount charged by the facility-based physician for the medical service...
• Texas Section 1467.057 - No Agreed Resolution
  (a) The mediator of an unsuccessful mediation under this chapter shall report the outcome of the mediation to the department, the Texas Medical Board, and...
• Texas Section 1467.058 - Continuation Of Mediation
  After a referral is made under Section 1467.057, the facility-based physician and the insurer or administrator may elect to continue the mediation to further determine...
• Texas Section 1467.059 - Mediation Agreement
  The mediator shall prepare a confidential mediation agreement and order that states: (1) the total amount for which the enrollee will be responsible to the...

SUBCHAPTER C BAD FAITH MEDIATION

• Texas Section 1467.060 - Report Of Mediator
  The mediator shall report to the commissioner and the Texas Medical Board: (1) the names of the parties to the mediation; and (2) whether the...
• Texas Section 1467.101 - Bad Faith
  (a) The following conduct constitutes bad faith mediation for purposes of this chapter: (1) failing to participate in the mediation; (2) failing to provide information...

SUBCHAPTER D COMPLAINTS; CONSUMER PROTECTION

• Texas Section 1467.102 - Penalties
  (a) Bad faith mediation, by a party other than the enrollee, is grounds for imposition of an administrative penalty by the regulatory agency that issued...
• Texas Section 1467.151 - Consumer Protection; Rules
  (a) The commissioner and the Texas Medical Board, as appropriate, shall adopt rules regulating the investigation and review of a complaint filed that relates to...

Last modified: September 28, 2016