SB 481, 84th Legislature, Regular Session (2015) amended Insurance Code Chapter 1467 (Out-of-Network Claim Dispute Resolution). As a result, TDI must make conforming changes to 28 TAC Chapter 3, Subchapter X, §3.3705 and §3.3708 and Chapter 21, Subchapter PP. Both the statute and the rules provide for mediation of certain claims by certain facility-based physicians against enrollees of preferred provider benefit plans and health benefit plans provided under Insurance Code Chapter 1551 (Texas Employees Group Benefits Act).
SB 481 added assistant surgeons to the list of covered physicians and lowered the threshold amount for mediation from $1,000 to $500. Both changes apply for services provided on or after September 1, 2015. TDI is updating §3.3705 and §3.3708 and Subchapter PP to include these provisions, adopt a new mediation request form, make nonsubstantive changes to conform to agency style and usage guidelines, and make it clear that claims may not be unilaterally reduced to below the mediation threshold to avoid mediation.
The proposed rules are accessible on TDI’s website at www.tdi.texas.gov//rules/2016/index.html