Tex.
Ins. Code Section 1575.009
Balance Billing Prohibition Notice
(a)
The administrator of a managed care plan provided under the group program shall provide written notice in accordance with this section in an explanation of benefits provided to the enrollee and the physician or health care provider in connection with a health care or medical service or supply or transport provided by an out-of-network provider. The notice must include:(1)
a statement of the billing prohibition under Section 1575.171 (Emergency Care Payments), 1575.172 (Out-of-network Facility-based Provider Payments), 1575.173 (Out-of-network Diagnostic Imaging Provider or Laboratory Service Provider Payments), or 1575.174 (Out-of-network Emergency Medical Services Provider Payments), as applicable;(2)
the total amount the physician or provider may bill the enrollee under the enrollee’s managed care plan and an itemization of copayments, coinsurance, deductibles, and other amounts included in that total; and(3)
for an explanation of benefits provided to the physician or provider, information required by commissioner rule advising the physician or provider of the availability of mediation or arbitration, as applicable, under Chapter 1467 (Out-of-network Claim Dispute Resolution).(b)
The administrator shall provide the explanation of benefits with the notice required by this section to a physician or health care provider not later than the date the administrator makes a payment under Section 1575.171 (Emergency Care Payments), 1575.172 (Out-of-network Facility-based Provider Payments), 1575.173 (Out-of-network Diagnostic Imaging Provider or Laboratory Service Provider Payments), or 1575.174 (Out-of-network Emergency Medical Services Provider Payments), as applicable.(1)
a statement of the billing prohibition under Section 1575.171 (Emergency Care Payments), 1575.172 (Out-of-network Facility-based Provider Payments), or 1575.173 (Out-of-network Diagnostic Imaging Provider or Laboratory Service Provider Payments), as applicable;(2)
the total amount the physician or provider may bill the enrollee under the enrollee’s managed care plan and an itemization of copayments, coinsurance, deductibles, and other amounts included in that total; and(3)
for an explanation of benefits provided to the physician or provider, information required by commissioner rule advising the physician or provider of the availability of mediation or arbitration, as applicable, under Chapter 1467 (Out-of-network Claim Dispute Resolution).(b)
The administrator shall provide the explanation of benefits with the notice required by this section to a physician or health care provider not later than the date the administrator makes a payment under Section 1575.171 (Emergency Care Payments), 1575.172 (Out-of-network Facility-based Provider Payments), or 1575.173 (Out-of-network Diagnostic Imaging Provider or Laboratory Service Provider Payments), as applicable.
Source:
Section 1575.009 — Balance Billing Prohibition Notice, https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1575.htm#1575.009 (accessed May 11, 2024).
