FAQ: Mediation and arbitration requirements and processes

Arbitrators must use the following 10 factors to determine the reasonable amount for services:

1. Whether there is a gross disparity between the fee billed by the out-of-network provider and:
   • Fees paid to the out-of-network provider for the same services or supplies rendered by the provider to other enrollees for which the provider is an out-of-network provider.
   • Fees paid by the health benefit plan issuer to reimburse similarly qualified out-of-network providers for the same services or supplies in the same region.
2. The level of training, education, and experience of the out-of-network provider.
3. The out-of-network provider's usual billed charge for comparable services or supplies with regard to other enrollees for which the provider is an out-of-network provider.
4. The circumstances and complexity of the enrollee's case, including the time and place of the provision of the service or supply.
5. Individual enrollee characteristics.
6. The 80th percentile of all billed charges for the service or supply performed by a health care provider in the same or similar specialty and provided in the same geozip area as reported in the FAIR Health benchmarking database.
7. The 50th percentile of rates for the service or supply paid to participating providers in the same or similar specialty and provided in the same geozip area as reported in the FAIR Health benchmarking database.
8. The history of network contracting between the parties.
9. Historical data for the percentiles described by #6 and #7.
10. An offer made during the informal settlement teleconference.

No. The parties can agree to use an outside person to serve as a mediator or arbitrator.

If the dispute request was already entered into the IDR portal, you must send the outside mediator or arbitrator’s name and email address to IDR@tdi.texas.gov. We will give that person access to the portal. That mediator or arbitrator will need to provide information about the dispute resolution in the portal.

Each mediator and arbitrator determines the fixed fee they will charge per case.

Yes. Once a mediator or arbitrator is assigned to a case, each party involved in the dispute is required to pay half of the fixed fee.

1. Log into the IDR portal. (If you don’t already have a username and password, follow the instructions on the login screen.)
2. Click on the “Submit a new mediation / arbitration request” at the top of the page.
3. Answer the questions on the online form.

You can learn more about the process on our Mediation and arbitration of medical bills webpage.

1. Log into the IDR portal.
2. Click on the “Active requests” panel.
3. Click on the Request ID for the dispute you want to view.

If you know the Request ID, you can use the Search box in the “Active requests” panel or the “Search requests” option in the blue bar at the top of the page.

The health plan must:

1. Log into the IDR portal.
2. Open the request.
3. Open the “Informal teleconference information” panel.
4. Enter the required information.

After those steps are taken, each party will get an email confirming that the request was settled.

Only the health plan can enter the informal teleconference information into the IDR portal.

The parties can extend deadlines up until the “assignment deadline” date – the date we must assign a mediator or arbitrator to the dispute. To see the assignment deadline date, you can:

1. Log into the IDR portal.
2. Open the request.
3. Find “Assignment deadline” at the top of the page.

When you are no longer able to extend deadlines, you will see a message at the top of the “Request details” page that says, “You can no longer extend deadlines.”

One of the parties must:

1. Log into the IDR portal.
2. Open the request.
3. Go to the “Extend deadlines” section at the top of the page.
4. Enter the number of days they want to extend.
5. Click “Submit.”

After one party enters the request to extend the deadline, an email will go to the other party letting them know an extension request was made. The other party then needs to:

1. Log into the IDR portal.
2. Open the request.
3. Go to the “Extend deadlines” section at the top of the page. They will see the number of days requested for the extension.
4. They can click on the “Approve” or “Reject” button.

An email will go to the other party letting them know if the extension request was approved or rejected.
If the other party clicks “Reject” and there is still time to ask for an extension, another extension request can be made by either party.

1. Log into the IDR portal.
2. Open the request.
3. Go to the “Extend deadlines” section at the top of the page. You will see the number of days requested for the extension.
4. Click on the “Approve” or “Reject” button.

An email will go to the other party letting them know if the extension request was approved or rejected.

If one party clicks “Reject” and there is still time to ask for an extension, another extension request can be made by either party.

Unless the parties ask for an extension on the deadlines to resolve the request, TDI will assign a mediator or arbitrator 31 days after the request is filed on the IDR portal.

You can track this date by looking at the request’s assignment deadline. To see the assignment deadline, you can:

1. Log into the IDR portal.
2. Open the request.
3. Find “Assignment deadline” at the top of the page.

1. Log into the IDR portal.
2. Open the request.
3. Open the “Mediator selection” or “Arbitrator selection” panel.

There are three ways to select a mediator or arbitrator:

• Use one of the TDI certified mediators or arbitrators listed on the request.

  To review the list of five mediators or arbitrators that could be assigned to this request:

  1. Log into the IDR portal.
  2. Open the request.
  3. Open the “Mediator selection” or “Arbitrator selection” panel.

  Each party can remove up to two from the list. Thirty-one days after the request is filed, we will assign one of the mediators or arbitrators who are still on the list. Assignments are made by rotation.

• Select a TDI certified mediator or arbitrator not listed on this request.
  1. Pick someone on the list of TDI certified mediators and arbitrators.
  2. Ask the other party if they agree to use the mediator or arbitrator that you picked.
  3. Let us know who both parties agreed to use by sending the mediator or arbitrator’s name and email address to IDR@tdi.texas.gov.
• Select a mediator or arbitrator not certified by TDI.
  1. Ask the other party if they agree to use the mediator or arbitrator that you picked.
  2. Let us know who both parties agreed to use by sending the mediator or arbitrator’s name and email address to IDR@tdi.texas.gov.

  We will give the chosen mediator or arbitrator access to the portal. That mediator or arbitrator will need to provide information about the dispute resolution in the portal.

No, only the claim associated with the primary plan is eligible for IDR.

No, claims submitted to secondary plans are not eligible for IDR. Mark the claim ineligible using the code “Secondary plan.” TDI will approve the ineligibility.

Check the  Mediators and arbitrators for billing disputes webpage to find out if applications are being taken.

Yes. They must meet the qualifications for both.

After both parties agree to use you as a mediator or arbitrator, they must send us your name and email. When we get your information, we will send you an email with instructions for how to log into the IDR portal.

You can learn more about the process on our Mediation and arbitration of medical bills webpage.