28 Tex. Admin. Code § 21.5010 - Qualified Mediation Claim Criteria
(a)
Required criteria. An out-of-network provider that is a facility or a health
benefit plan issuer or administrator may request mandatory mediation of an
out-of-network claim under §
21.5011 of this title (relating to
Mediation Request Procedure) if the claim complies with the criteria specified
in this subsection. An out-of-network claim that complies with those criteria
is referred to as a "qualified mediation claim" in this subchapter.
(1) The out-of-network health benefit claim
must be for:
(A) emergency care;
(B) an out-of-network laboratory service
provided in connection with a health care or medical service or supply provided
by a participating provider; or
(C)
an out-of-network diagnostic imaging service provided in connection with a
health care or medical service or supply provided by a participating
provider.
(2) There is an
amount billed by the provider and unpaid by the health benefit plan issuer or
administrator after copayments, deductibles, and coinsurance, for which an
enrollee may not be billed.
(b) Submission of multiple claim forms. The
use of more than one form in the submission of a claim, as defined in §
21.5003 of this title (relating to
Definitions), does not prevent eligibility of a claim for mandatory mediation
under this subchapter if the claim otherwise meets the requirements of this
section.
(c) Ineligible claims.
This division does not require a health benefit plan issuer or administrator to
pay for an uncovered service or supply.
Notes
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