Within 30 days of your request for mediation, the parties must participate in an informal telephone conference. Your insurance company will tell you when this will occur. You may request that additional claims involving the same provider and company be mediated, but the other parties aren't 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 provider and company will each pay one half of the mediator's fees.
You aren't required to attend the actual mediation, which must be held in the county where the services were provided. Your provider and company 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 attend, you'll get a chance to state your position. A mediation may not last more than four hours unless the provider and company agree to mediate for longer.
The parties aren't required to reach an agreement at mediation. But, if no agreement is reached, the matter may be referred to a judge for resolution. Requesting mediation doesn't mean you can't take the matter to court.
Mediating a claim doesn't mean that you don't have to pay any payments. Instead, the goal of the mediation is to reach an agreement between you, your provider, and the company as to the amount charged by the provider, the amount paid by the company to the provider, and the amount paid by you to the provider.
Once your provider has received notice that you have requested mediation, they 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payment (other than for copayments, deductibles, and coinsurance) until the mediation ends or the request to mediate is withdrawn.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 Employees Retirement System (ERS) insurance appeals (for state employees and retirees)
Guides
- Health care coverage guide
- Insurance complaint process
- HMO guide
- Health care coverage for Texas children
- Insurance for Texans with disabilities
File an insurance complaint
Read about TDI's insurance complaint process.