28 Tex. Admin. Code § 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;
(3) offered by an HMO operating under
Insurance Code Chapter 843, concerning Health Maintenance Organizations;
or
(4) offered by a self-insured or
self-funded plan established by an employer under ERISA if the plan sponsor
submitted election according to §
21.5060 of this title (relating to
Election Submission Requirements).
(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. This subchapter applies to a claim filed for emergency
care or health care or medical services or supplies by the administrator of a
health benefit plan under Insurance Code Chapter 1682.
Notes
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