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.

(d) Availability. With respect to a dispute that occurs on or after June 20, 2025, the out-of-network provider or the health benefit plan issuer or administrator may request mediation of a settlement of an out-of-network health benefit claim not later than the 180th day after the date an out-of-network provider receives the initial payment for a health care or medical service or supply. The initial payment could be zero dollars if the allowable amount was applied to an enrollee's deductible.

Source Note: The provisions of this §21.5010 adopted to be effective October 19, 2010, 35 TexReg 9300; amended to be effective November 3, 2016, 41 TexReg 8612; amended to be effective April 26, 2018, 43 TexReg 2423; amended to be effective December 23, 2019, 44 TexReg 7988; amended to be effective June 27, 2023, 48 TexReg 3409; amended to be effective February 19, 2026, 51 TexReg 900.