Mediation for Out-of-Network Hospital-based Health Care Provider Claims
If you have a dispute about an outstanding bill you received from an out-of-network hospital-based health care provider, you may be eligible to have your dispute resolved through mediation. Your participation is voluntary. If you elect mediation, your out-of-network hospital-based physician and your health care plan will meet to discuss the outstanding bill. If the mediation is unsuccessful, you may also be able to resolve the dispute in court.
You may request mediation if your claim meets the eligibility criteria:
- You have coverage through an insured preferred provider organization (PPO) plan or you have coverage through the Employees Retirement System of Texas (ERS). This program does not apply to self-funded ERISA plans, indemnity plans, Medicare, and Medicaid.
- Your claim is for a medical service or supply provided by an out-of-network hospital-based physician (such as a radiologist, an anesthesiologist, a pathologist, an emergency department physician, or a neonatologist). For services provided on or after September 1, 2015, mediation is also available for services provided by an assistant surgeon.
- You were provided a medical service or supply in a hospital that is a preferred provider under your preferred provider benefit plan
- The amount you owe the hospital-based physician for services provided before September 1, 2015, (not including copayments, deductibles, coinsurance, and amounts paid by the insurer or administrator directly to you), is more than $1,000. For services provided on or after September 1, 2015, this threshold is reduced to $500.
If you are eligible, you may request mediation by completing and submitting the Health Insurance Mediation and Authorization Request Form.
How Mediation Works
Within 30 days of your request for mediation, the parties must participate in an informal telephone conference. The carrier will tell you when this will occur. You may request that additional claims involving the same physician and carrier be mediated, but the other parties are not required to agree.
The actual mediation conference will be held within 180 days of your request for mediation. You have a right to a mediator appointed by the State Office of Administrative Hearings, or the parties may unanimously agree to use a different mediator. The carrier and the physician will each pay one half of the mediator's fees.
You are not required to attend the actual mediation, which must be held in the county where the services were provided. Your physician and your carrier will discuss resolution regardless of whether you attend. You may also choose to have a representative attend with you or in your place.
If you choose to attend, you will have an opportunity to state your position. A mediation may not last more than four hours unless the provider and carrier agree to mediate for longer.
The parties are not required to reach an agreement at mediation but, if no agreement is reached, the matter may be referred to a special judge for resolution. Requesting mediation does not limit your ability to take the matter to court.
Mediating a claim does not mean that you are no longer responsible for any payments. Instead, the goal of the mediation is to reach an agreement between you, your physician, and the carrier as to the amount charged by the physician, the amount paid by the carrier to the physician, and the amount paid by you to the physician.
Once your physician has received notice that you have requested mediation, your physician may not attempt to collect any payment (other than for copayments, deductibles, and coinsurance) until the mediation ends or the request to mediate is withdrawn.
Guide to ERS Insurance Appeals
- Your Health Care Coverage
- Helping You with Your Insurance Complaint
- Health Maintenance Organizations
- Health Care Coverage for Texas Children
- Insurance for Texans with Disabilities
File an Insurance Complaint
Read about TDI's consumer complaints process in the Helping You With Your Insurance Complaint publication. You may also e-mail, mail, or fax your complaint along with copies of your supporting documents to
Texas Department of Insurance
Consumer Protection Program (MC 111-1A)
P.O. Box 149091
Austin, TX 78714-9091
Prevent Insurance Fraud
Report fraud online at www.tdi.texas.gov/fraud/report.html or by calling 1-888-327-8818
For More Information or Assistance
For answers to general insurance questions or for information on filing an insurance-related complaint, call the Consumer Help Line at 1-800-252-3439 between 8 a.m. and 5 p.m., Central time, Monday-Friday, or visit our website at www.tdi.texas.gov.
For more information contact:
Last updated: 10/20/2016