Section 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.28 Tex. Admin. Code § 21.5021
Adopted by Texas Register, Volume 44, Number 51, December 20, 2019, TexReg 8015, eff. 12/23/2019; Amended by Texas Register, Volume 48, Number 25, June 23, 2023, TexReg 3414, eff. 6/27/2023