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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.

Mediation Eligibility

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 was filed with a PPO insurer on or after June 19, 2009, or was filed with ERS on or after September 1, 2010. 
  • 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)
  • 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 (not including copayments, deductibles, coinsurance, and amounts paid by the insurer or administrator directly to you), is more than $1,000
  • Your hospital-based physician did not provide a complete and accurate disclosure before providing a medical service or supply that
    • explained that the facility-based physician did not have a contract with your health benefit plan,
    • disclosed the amounts for which you may be responsible, and
    • disclosed the circumstances you would be responsible for those amounts.

If you are eligible, you may request mediation by completing and submitting the Health Insurance Mediation Request Form.  Also please complete the Mediation Authorization 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.

Additional Resources

Mediation Rules

Guide to ERS Insurance Appeals

Resource Page

Publications

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
Fax: 512-475-1771
E-mail: ConsumerProtection@tdi.texas.gov

Prevent Insurance Fraud

Insurance Fraud Toll-Free Hotline - 1-888-327-8818

Online Fraud Reporting

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Online Fraud Reporting for Insurance Companies
Online Fraud Reporting for Consumers

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 between 8 a.m. and 5 p.m., Central time, Monday-Friday, or visit our website

1-800-252-3439
463-6515
in Austin
www.tdi.texas.gov 


For more information contact:



Last updated: 07/21/2014



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