PART 1. TEXAS DEPARTMENT OF INSURANCE
CHAPTER 21. TRADE PRACTICES
The commissioner of insurance adopts amendments to 28 TAC §§21.113, 21.2505, 21.4902, 21.5001, 21.5002, 21.5010, 21.5011, 21.5020, 21.5021, and 21.5040, concerning trade practices, and the repeal of Chapter 21, Subchapter QQ. The commissioner adopts §21.5011 and §21.5021 with changes to the proposed text published in the February 10, 2023, issue of the Texas Register (48 TexReg 628). These sections will be republished. Changes to §21.5011 and §21.5021 are nonsubstantive and revised for consistency with agency drafting style.
The commissioner adopts §§21.113, 21.2505, 21.4902, 21.5001, 21.5002, 21.5010, 21.5020, and 21.5040 and the repeal of Chapter 21, Subchapter QQ, without changes to the proposed text as published in both the February 10, 2023, issue of the Texas Register, and the correction of error published in the February 24, 2023, issue of the Texas Register (48 TexReg 1184). These sections will not be republished.
REASONED JUSTIFICATION.
The amendments to §§21.4902, 21.5001, 21.5002, and 21.5040 are necessary to implement House Bill 3924, 87th Legislature, 2021, and Insurance Code Chapter 1275. HB 3924 permits a nonprofit agricultural organization under Insurance Code Chapter 1682 to offer a health benefit plan. These health benefit plans are subject to the requirements of Chapter 1275, which create similar requirements for out-of-network billing that already exist for HMOs and Preferred Provider Benefit Plans, as well as for health benefit plans administered by the Employees Retirement Systems of Texas and Teacher Retirement System of Texas plans under Insurance Code Chapters 1551, 1575, and 1579. The amendments clarify the applicability of Subchapters OO and PP to health benefit plans offered by nonprofit agricultural organizations.
The amendments to §§21.5010, 21.5011, 21.5020, and 21.5021 are necessary to implement Senate Bill 1264, 86th Legislature, 2019, and Insurance Code Chapter 1467. SB 1264 prohibits balance billing for certain health benefit claims under certain health benefit plans, provides exceptions to balance billing prohibitions, and authorizes an independent dispute resolution process for claim disputes between certain out-of-network providers and health benefit plan issuers and administrators. The amendments clarify the independent dispute resolution requirements to ensure efficient processing of mediation and arbitration of claims.
The amendments to §21.113 and §21.2505 remove outdated Texas Department of Insurance (TDI) mailing addresses. The amendments also make nonsubstantive changes throughout to reflect current agency drafting style and plain language preferences.
The repeal of Subchapter QQ is necessary because the information technology waiver previously granted under Insurance Code Chapter 1661 to certain health benefit plan issuers expired in 2012. Before January 1, 2012, a health benefit plan issuer could apply for a waiver from the information technology requirements under Chapter 1661. All waivers previously approved by the commissioner under §21.5103 expired September 1, 2013. Subchapter QQ implemented Insurance Code §1661.008, which expired.
The amendments to specific sections and the repeal are described in the following paragraphs, organized by subchapter.
Subchapter B. Advertising, Certain Trade Practices, and Solicitation.
Section 21.113. The adopted amendments to §21.113 replace inaccurate references to "Figure: 28 TAC §21.113(1)(5)" with "Figure: 28 TAC §21.113(l)(5)" for accuracy and consistency. The amendments also remove reference to TDI's mailing address in §21.113(l)(2) because the address is no longer accurate and TDI no longer keeps physical copies of the referenced form in hard copy format. The referenced form is available in Figure: 28 TAC §21.113(l)(5) for ease of access.
Amendments update references to the titles of 28 TAC Chapter 3, Subchapters S and Y, and add references to the titles of Insurance Code Chapter 1214; Chapter 541, Subchapter B; and Chapter 541 to ensure consistency and accuracy in Administrative Code and Insurance Code references. An amendment to Figure: 28 TAC §21.113(l)(5) restructures it so that Item (6) is shown before Item (7).
Amendments also include changes to conform with current agency drafting style and plain language preferences. The amendments include correcting punctuation and revising capitalization of policy types listed in §21.113(d)(19). These amendments do not change the policy types listed.
Other amendments include corrections to punctuation and capitalization and, where appropriate, replacing "prior to" and "prior to such" with "before," "which" with "that" or "the," "conjunction therewith of" with "proximity to," "or" with "of," "division" with "title," "pre-existing" with "preexisting," "utilizes" with "uses," "low cost" with "low-cost," "consummate" with "complete," "such" with "the" or "these," "in order to" with "to," "who" with "that," "acknowledgement" with " acknowledgment," "shall" and "shall be" with alternative words as appropriate in the context of the provision; inserting the word "the"; and deleting "that," "as such," "such time as," "and," and "which is."
Subchapter Q. Complaint Records to Be Maintained.
Section 21.2505. The adopted amendments to §21.2505 remove reference to TDI's former mailing address where insurers were able to request the recommended complaint record maintenance form. TDI no longer provides physical copies of the referenced form. The amendments provide TDI's website where insurers may access the form.
Subchapter OO. Disclosures by Out-of-Network Providers.
Section 21.4902. The adopted amendments to §21.4902 add the defined terms "administrator" and "health benefit plan" to the section. The addition of these defined terms clarifies the applicability of Insurance Code Chapter 1682 and ensures consistency of the language used in Chapter 21, Subchapters OO and PP.
Subchapter PP. Out-of-Network Claim Dispute Resolution.
Section 21.5001. The adopted amendments to §21.5001 expressly incorporate a reference to Insurance Code §1275.003 into the purpose statement of §21.5001 to clarify that administrators operating under Insurance Code Chapter 1275 must comply with the requirements in the subchapter. The amendments also remove unnecessary punctuation.
Section 21.5002. The adopted amendment to §21.5002 clarifies that the subchapter applies to a claim filed for certain care or services by the administrator of a health benefit plan under Insurance Code Chapter 1682.
Section 21.5010. The adopted amendments to §21.5010 clarify that an out-of-network health benefit claim for an out-of-network laboratory or out-of-network diagnostic imaging service must be in connection with a health care or medical service or supply provided by a participating provider.
Section 21.5011. The adopted amendments to §21.5011 clarify that TDI may remove a mediator from the list of qualified mediators in certain circumstances, including failure to comply with any requirement under Insurance Code Chapter 1467 or rules adopted under Insurance Code §1467.003. The amendments also make nonsubstantive grammatical changes to §21.5011(e)(1) by adding "the" and "the date" for clarity.
The text of §21.5011(f)(3) as proposed has been changed to add "Insurance Code" to two citations for consistency with agency drafting style.
Section 21.5020. The adopted amendments to §21.5020 clarify that an out-of-network health benefit claim for an out-of-network laboratory or out-of-network diagnostic imaging service must be in connection with a health care or medical service or supply provided by a participating provider.
Section 21.5021. The adopted amendments to §21.5021 clarify that TDI may remove an arbitrator from the list of qualified arbitrators in certain circumstances, including failure to comply with any requirement under Insurance Code Chapter 1467 or rules adopted under Insurance Code §1467.003.
The amendments also specify that an arbitrator must evaluate only the factors found in §1467.083. Finally, the amendments remove unnecessary punctuation and add "the" and "the date" to §21.5021(e)(1) for clarity.
The text of §21.5021(f)(3) as proposed has been changed to add "Insurance Code" to two citations for consistency with agency drafting style.
Section 21.5040. The adopted amendments to §21.5040 expressly incorporate a reference to Insurance Code §1275.003 into the list of cited Insurance Code provisions under which health benefit plan issuers or administrators must provide the explanation of benefits according to the section. The amendments also clarify that the written notice required under the section must specify that the itemization of copayments, coinsurance, deductibles, and other amounts required under §21.5040(1)(B) is at an in-network cost-sharing level.
Amendments add the word "and" to the end of subparagraph (B) to clarify that a health benefit plan issuer or administrator subject to §21.5040 must provide the physician or provider with a written notice in an explanation of benefits that includes the requirements in paragraphs (1) and (2). The amendments also correct capitalization and delete unnecessary punctuation in the section.
Subchapter QQ. Health Information Technology.
Sections 21.5101 - 21.5103. These sections make up the entirety of Subchapter QQ and are repealed. Subchapter QQ is no longer necessary because the statutory provision it implemented expired.
SUMMARY OF COMMENTS AND AGENCY RESPONSE.
Commenters: TDI received comments from three commenters. Commenters in support of the proposal were Superior Health Plan of Texas and Texas Association of Health Plans. A commenter in support of the proposal with changes was Family Hospital Systems.
General comments
Comment. A commenter expresses concern regarding the functionality of certain provisions in Insurance Code Chapter 1467. The commenter requests that arbitration replace mediation and that mediation fees be removed. The commenter notes that arbitration is already used for professional fee disputes. The commenter also requests lawmakers define "good faith negotiations" to require the payor to disclose contract terms with clients to further resolution of disputes of overpayments or allowed minimums. The commenter suggests requiring health plans to state requirements for participation as in-network providers and suggests compelling participation as an in-network provider if certain requirements are met.
Agency Response. TDI declines to make the suggested changes. The requested amendments are outside the scope of TDI's statutory rulemaking authority.
Comment on §21.5010
Comment. A commenter expresses support for the addition of language to clarify that a qualified mediation claim must be for an out-of-network laboratory service or out-of-network diagnostic imaging service provided in connection with a health care or medical service or supply provided by a participating provider.
Agency Response. TDI appreciates the support.
Comment on §21.5011
Comment. A commenter asks whether a health plan may request the removal of a mediator because of ongoing issues or concerns the plan experiences with the mediator.
Agency Response. TDI may remove mediators for failing to comply with the requirements in Insurance Code Chapter 1467 or the rules adopted under that chapter. Health plans may provide feedback, make complaints, or express concerns through the consumer complaint portal on TDI's website. TDI will review complaints under Insurance Code §1467.101 and §1467.151, and rules under 28 TAC §§21.5011, 21.5021, and 21.5030.
Comment on §21.5020
Comment. A commenter asks whether claim information from an out-of-network laboratory or out-of-network diagnostic imaging service will be included on the IDR portal and whether failure to include the claim information would render the claim in dispute ineligible for mediation. The commenter states that failing to include the claim information would make it difficult to find the corresponding claim on file with the plan. The commenter expresses concern about identifying eligible claims.
Agency Response. TDI declines to make changes to the rule text to require new or additional information be entered into the IDR portal. The proposed changes to §21.5020 do not amend applicability or requirements under Insurance Code Chapter 1467. The amendments align the rule text language with statutory requirements under Insurance Code §§1271.158, 1275.053, 1301.165, 1575.173, and 1579.111. TDI encourages health plans to contact providers with contact information entered into the IDR portal during the dispute resolution process, including if the plan has reason to believe a claim is ineligible.
SUBCHAPTER B. ADVERTISING, CERTAIN TRADE PRACTICES, AND SOLICITATION
DIVISION 1. INSURANCE ADVERTISING
STATUTORY AUTHORITY.
The commissioner adopts amendments to §21.113 under Insurance Code §§541.401(a), 1201.101, and 36.001.
Insurance Code §541.401(a) authorizes the commissioner to adopt and enforce reasonable rules necessary to accomplish the purposes of Insurance Code Chapter 541.
Insurance Code §1201.101 provides that the commissioner adopt reasonable rules under the section establishing specific standards, including standards that address the nonduplication of coverage.
Insurance Code §36.001 provides that the commissioner may adopt any rules necessary and appropriate to implement the powers and duties of TDI under the Insurance Code and other laws of this state.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June 7, 2023.
TRD-202302115
Jessica Barta
General Counsel
Texas Department of Insurance
Effective date: June 27, 2023
Proposal publication date: February 10, 2023
For further information, please call: (512) 676-6555
STATUTORY AUTHORITY. The commissioner adopts amendments to §21.2505 under Insurance Code §§541.401(a), 542.014, and 36.001.
Insurance Code §541.401(a) authorizes the commissioner to adopt and enforce reasonable rules necessary to accomplish the purposes of Insurance Code Chapter 541.
Insurance Code §542.014 provides that the commissioner adopt reasonable rules as necessary to implement and augment the purposes and provisions of Insurance Code Chapter 542, Subchapter A.
Insurance Code §36.001 provides that the commissioner may adopt any rules necessary and appropriate to implement the powers and duties of TDI under the Insurance Code and other laws of this state.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June 7, 2023.
TRD-202302116
Jessica Barta
General Counsel
Texas Department of Insurance
Effective date: June 27, 2023
Proposal publication date: February 10, 2023
For further information, please call: (512) 676-6555
STATUTORY AUTHORITY. The commissioner adopts amendments to §21.4902 under Insurance Code §§1275.004, 1467.003, and 36.001.
Insurance Code §1275.004 states that Insurance Code Chapter 1467 applies to a health benefit plan to which Insurance Code Chapter 1275 applies, and the administrator of a health benefit plan to which Chapter 1275 applies is an administrator for purposes of Chapter 1467.
Insurance Code §1467.003 requires the commissioner to adopt rules as necessary to implement the commissioner's powers and duties under Insurance Code Chapter 1467.
Insurance Code §36.001 provides that the commissioner may adopt any rules necessary and appropriate to implement the powers and duties of TDI under the Insurance Code and other laws of this state.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June 7, 2023.
TRD-202302117
Jessica Barta
General Counsel
Texas Department of Insurance
Effective date: June 27, 2023
Proposal publication date: February 10, 2023
For further information, please call: (512) 676-6555
DIVISION 1. GENERAL PROVISIONS
STATUTORY AUTHORITY. The commissioner adopts amendments to §21.5001 and §21.5002 under Insurance Code §§1275.004, 1301.007, 1467.003, and 36.001.
Insurance Code §1275.004 states that Insurance Code Chapter 1467 applies to a health benefit plan to which Insurance Code Chapter 1275 applies, and the administrator of a health benefit plan to which Chapter 1275 applies is an administrator for purposes of Chapter 1467.
Insurance Code §1301.007 provides that the commissioner adopt rules as necessary to implement Insurance Code Chapter 1301 and ensure reasonable accessibility and availability of preferred provider services to residents of this state.
Insurance Code §1467.003 requires the commissioner to adopt rules as necessary to implement the commissioner's powers and duties under Insurance Code Chapter 1467.
Insurance Code §36.001 provides that the commissioner may adopt any rules necessary and appropriate to implement the powers and duties of TDI under the Insurance Code and other laws of this state.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June 7, 2023.
TRD-202302118
Jessica Barta
General Counsel
Texas Department of Insurance
Effective date: June 27, 2023
Proposal publication date: February 10, 2023
For further information, please call: (512) 676-6555
STATUTORY AUTHORITY. The commissioner adopts amendments to §21.5010 and §21.5011 under Insurance Code §§1467.003, 1467.0505, and 36.001.
Insurance Code §1467.003 requires the commissioner to adopt rules as necessary to implement the commissioner's powers and duties under Insurance Code Chapter 1467.
Insurance Code §1467.0505 provides that the commissioner adopt rules, forms, and procedures necessary for the implementation and administration of the mediation program.
Insurance Code §36.001 provides that the commissioner may adopt any rules necessary and appropriate to implement the powers and duties of TDI under the Insurance Code and other laws of this state.
§21.5011.Mediation Request Procedure.
(a) Mediation request and notice.
(1) An out-of-network provider that is a facility or a health benefit plan issuer or administrator may request mediation. To be eligible for mediation, the party requesting mediation must complete the mediation request information required on the department's website at www.tdi.texas.gov, as specified in subsection (b) of this section.
(2) The party who requests the mediation must provide written notice to each other party on the date the mediation is requested. The notification must contain the information as specified on the department's website, including the necessary claim information and contact information of the parties. A health benefit plan issuer or administrator requesting mediation must send the mediation notification to the mailing address or email address specified in the claim submitted by the provider. If a provider does not specify an address to receive notice requesting mediation in the claim, a health benefit plan issuer or administrator may provide notice to the provider at the provider's last known address the issuer or administrator has on file for the provider. A provider requesting mediation must send the mediation notification to the email address specified in the explanation of benefits by the health benefit plan issuer or administrator.
(b) Submission of request. The requesting party must submit information necessary to complete the initial mediation request, including:
(1) facility details, including identifying the facility type, facility contact information, and facility representative information;
(2) claim information, including the claim number, type of service or supply provided, date of service, billed amount, amount paid, and balance; and
(3) relevant information from the enrollee's health benefit plan identification card or other similar document, including plan number and group number.
(c) Notice of teleconference outcome. Parties must submit additional information on the department's website at the completion of the informal settlement teleconference period, including the date the teleconference request was received and the date of the teleconference.
(d) Mediator selection.
(1) The parties must notify the department through the department's website on or before 30 days from the date the mediation is requested if:
(A) the parties agree to a settlement;
(B) the parties agree to the selection of a mediator; or
(C) the parties agree to extend the deadline to have the department select a mediator and notify the department of new deadlines.
(2) If the department is not given notification under paragraph (1) of this subsection, the department will assign a mediator after the 30th day from the date the mediation is requested. The parties must pay the nonrefundable mediator's fee to the mediator when the mediator is assigned. Failure to pay the mediator when the mediator is assigned constitutes bad faith participation.
(e) Submission of information. Parties must submit information, as specified on the department's website, to the department at the completion of the mediation or informal settlement, including:
(1) the name of the mediator, the date when the mediator was selected, the date when the mediation was held, the date of the agreement, the date of the mediator report, and when payment was made; and
(2) the agreement, including the original billed amount, payment amount, and the total agreed amount.
(f) Mediator approval and removal.
(1) Mediators may apply to the department using a method as determined by the Commissioner, including through an application on the department's website or through the department's procurement process. An individual or entities that employ mediators may apply for approval.
(2) A list of qualified mediators will be maintained on the department's website. A mediator must notify the department immediately if the mediator wants to voluntarily withdraw from the list.
(3) At the discretion of the department, a mediator may be removed from the list of qualified mediators in certain circumstances, including failure to comply with any requirement under Insurance Code Chapter 1467, concerning Out-of-Network Claim Dispute Resolution, or rules adopted under Insurance Code §1467.003, concerning Rules.
(g) Mediation process.
(1) A party may request mediation after 20 days from the date an out-of-network provider receives the initial payment for a health benefit claim, during which time the out-of-network provider may attempt to resolve a claim payment dispute through the health benefit plan issuer's or administrator's internal appeal process.
(2) The parties may submit written information to a mediator concerning the amount charged by the out-of-network provider for the health care or medical service or supply and the amount paid by the health benefit plan issuer or administrator.
(3) The parties must evaluate the factors specified in Insurance Code §1467.056, concerning Matters Considered in Mediation; Agreed Resolution.
(4) Each party is responsible for reviewing the list of mediators and notifying the department within 10 days of the request for mediation whether there is a conflict of interest with any of the mediators on the list to avoid the department assigning a mediator with a conflict of interest.
(5) The parties may agree to aggregate claims between the same facility and same health benefit plan issuer or administrator for mediation.
(h) Assistance. Assistance with submitting a request for mediation is available on the department's website at www.tdi.texas.gov.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June 7, 2023.
TRD-202302119
Jessica Barta
General Counsel
Texas Department of Insurance
Effective date: June 27, 2023
Proposal publication date: February 10, 2023
For further information, please call: (512) 676-6555
STATUTORY AUTHORITY. The commissioner adopts amendments to §21.5020 and §21.5021 under Insurance Code §§1467.003, 1467.082, and 36.001.
Insurance Code §1467.003 requires the commissioner to adopt rules as necessary to implement the commissioner's powers and duties under Insurance Code Chapter 1467.
Insurance Code §1467.082 requires the commissioner to adopt rules, forms, and procedures necessary for the implementation and administration of the arbitration program.
Insurance Code §36.001 provides that the commissioner may adopt any rules necessary and appropriate to implement the powers and duties of TDI under the Insurance Code and other laws of this state.
§21.5021.Arbitration Request Procedure.
(a) Arbitration request and notice.
(1) An out-of-network provider or a health benefit plan issuer or administrator may request arbitration. To be eligible for arbitration, the party requesting arbitration must complete the arbitration request information required on the department's website at www.tdi.texas.gov, as specified in subsection (b) of this section.
(2) The party who requests the arbitration must provide written notice to each other party on the date the arbitration is requested. The notification must contain the information as specified on the department's website, including the necessary claim information and contact information of the parties. A health benefit plan issuer or administrator requesting arbitration must send the arbitration notification to the mailing address or email address specified in the claim submitted by the provider. If a provider does not specify an address to receive notice requesting arbitration in the claim, the health benefit plan issuer or administrator may provide notice to the provider at the provider's last known address the issuer or administrator has on file for the provider. A provider requesting arbitration must send the arbitration notification to the email address specified in the explanation of benefits by the health benefit plan issuer or administrator.
(b) Submission of request. The requesting party must submit information necessary to complete the initial arbitration request, including:
(1) provider details, including identifying the provider type, provider contact information, and provider representative information;
(2) claim information, including the claim number, type of service or supply provided, date of service, billed amount, amount paid, and balance; and
(3) relevant information from the enrollee's health benefit plan identification card or a similar document, including plan number and group number.
(c) Notice of teleconference outcome. Parties must submit additional information on the department's website at the completion of the informal settlement teleconference period, including the date the teleconference request was received, the date of the teleconference, and settlement offer amounts.
(d) Arbitrator selection.
(1) The parties must notify the department, through the department's website, on or before 30 days from the date arbitration was requested if:
(A) the parties agree to a settlement;
(B) the parties agree to the selection of an arbitrator; or
(C) the parties agree to extend the deadline to have the department select an arbitrator and notify the department of new deadlines.
(2) If the department is not given notification under paragraph (1) of this subsection, the department will assign an arbitrator after the 30th day from the date the arbitration is requested. The parties must pay the nonrefundable arbitrator's fee to the arbitrator when the arbitrator is assigned. Failure to pay the arbitrator when the arbitrator is assigned constitutes bad faith participation, and the arbitrator may award the binding amount to the other party.
(e) Submission of information.
(1) The arbitrator must submit information, as specified on the department's website, to the department at the completion of the arbitration, including:
(A) the name of the arbitrator, the date when the arbitrator was selected, the date of the decision, the date of the arbitrator report, and when payment was made; and
(B) the written decision, including any final offers made during the health benefit plan issuer's or administrator's internal appeal process or informal settlement, reasonable amount for the services or supplies, and the binding award amount.
(2) If the parties settle the dispute before the arbitrator's decision, the parties must submit information, as specified on the department's website, to the department, including:
(A) the date of the settlement; and
(B) the amount of the settlement.
(f) Arbitrator approval and removal.
(1) Arbitrators may apply to the department using a method as determined by the Commissioner, including through an application on the department's website or the department's procurement process. An individual or entities that employ arbitrators may apply for approval.
(2) A list of qualified arbitrators will be maintained on the department's website. An arbitrator must notify the department immediately if the arbitrator wants to voluntarily withdraw from the list.
(3) At the discretion of the department, an arbitrator may be removed from the list of qualified arbitrators in certain circumstances, including failure to comply with any requirement under Insurance Code Chapter 1467, concerning Out-of-Network Claim Dispute Resolution, or rules adopted under Insurance Code §1467.003, concerning Rules.
(g) Arbitration process.
(1) A party may request arbitration after 20 days from the date an out-of-network provider receives the initial payment for a health benefit claim, during which time the out-of-network provider may attempt to resolve a claim payment dispute through the health benefit plan issuer's or administrator's internal appeal process.
(2) The parties must submit written information to an arbitrator concerning the amount charged by the out-of-network provider for the health care or medical service or supply, and the amount paid by the health benefit plan issuer or administrator.
(3) The arbitrator must evaluate only the factors specified in Insurance Code §1467.083, concerning Issue to Be Addressed; Basis for Determination.
(4) The arbitrator must provide the parties an opportunity to review the written information submitted by the other party, submit additional written information, and respond in writing to the arbitrator on the time line set by the arbitrator.
(5) Each party is responsible for reviewing the list of arbitrators and notifying the department within 10 days of the request for arbitration if there is a conflict of interest with any of the arbitrators on the list to avoid the department assigning an arbitrator with a conflict of interest.
(6) If a party does not respond to the arbitrator's request for information, the dispute will be decided based on the available information received by the arbitrator without an opportunity for reconsideration.
(7) The submission of multiple claims to arbitration in one proceeding must be for the same provider and the same health benefit plan issuer or administrator and the total amount in controversy may not exceed $5,000.
(h) Assistance. Assistance with submitting a request for arbitration is available on the department's website at www.tdi.texas.gov.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June 7, 2023.
TRD-202302120
Jessica Barta
General Counsel
Texas Department of Insurance
Effective date: June 27, 2023
Proposal publication date: February 10, 2023
For further information, please call: (512) 676-6555
STATUTORY AUTHORITY. The commissioner adopts amendments to §21.5040 under Insurance Code §§1275.003, 1275.004, 1301.007, 1467.003, and 36.001.
Insurance Code §1275.003 requires an explanation of benefits to contain information required by commissioner rule advising the physician or provider of the availability of mediation or arbitration, as applicable, under Insurance Code Chapter 1467.
Insurance Code §1275.004 states that Insurance Code Chapter 1467 applies to a health benefit plan to which Insurance Code Chapter 1275 applies, and the administrator of a health benefit plan to which Chapter 1275 applies is an administrator for purposes of Chapter 1467.
Insurance Code §1301.007 provides that the commissioner adopt rules as necessary to implement Insurance Code Chapter 1301 and ensure reasonable accessibility and availability of preferred provider services to residents of this state.
Insurance Code §1467.003 requires the commissioner to adopt rules as necessary to implement the commissioner's powers and duties under Insurance Code Chapter 1467.
Insurance Code §36.001 provides that the commissioner may adopt any rules necessary and appropriate to implement the powers and duties of TDI under the Insurance Code and other laws of this state.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June 7, 2023.
TRD-202302121
Jessica Barta
General Counsel
Texas Department of Insurance
Effective date: June 27, 2023
Proposal publication date: February 10, 2023
For further information, please call: (512) 676-6555
STATUTORY AUTHORITY. The commissioner adopts the repeal of §§21.5101 - 21.5103 under Insurance Code §1661.009(a) and §36.001.
Insurance Code §1661.009(a) provides that the commissioner adopt rules as necessary to implement Insurance Code Chapter 1661.
Insurance Code §36.001 provides that the commissioner may adopt any rules necessary and appropriate to implement the powers and duties of TDI under the Insurance Code and other laws of this state.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on June 7, 2023.
TRD-202302114
Jessica Barta
General Counsel
Texas Department of Insurance
Effective date: June 27, 2023
Proposal publication date: February 17, 2023
For further information, please call: (512) 676-6555