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Texas Department of Insurance
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What doctors should know about Texas’ surprise billing law

Senate Bill 1264 bans balance billing patients with state-regulated plans for emergency care and care provided at in-network facilities when the patient didn’t have a choice of providers.

Providers covered by the law include:

  • Diagnostic imaging providers
  • Emergency care providers
  • Facility-based providers
  • Laboratory service providers

Instead of balance billing, doctors can request arbitration to resolve payment disputes in these cases. The law keeps patients out of the middle of those payment disputes.

What health plans are covered?

Texas law applies to:

  • State-regulated insurance plans. The ID cards for these plans have a “DOI” (for department of insurance) or “TDI” (Texas Department of Insurance) printed on them. (See examples.)
  • Coverage through the Employee Retirement System of Texas (HealthSelect or other ERS plans).
  • Coverage through the Teacher Retirement System of Texas (TRS ActiveCare and TRS Care).

Texas law does not apply to self-funded employer-sponsored health plans or Medicare. To learn about federal laws that apply to self-funded health plans, go to the Centers for Medicare & Medicaid Services’ webpage, Overview of rules & fact sheets.

Does this affect how I bill for services not covered by insurance?

No. The law applies only to covered services.

Can I still treat patients if I’m out-of-network?

Yes. The law doesn’t apply to situations where the patient chooses to see an out-of-network doctor. It applies to emergencies or cases where a doctor was assigned to the patient, such as an anesthesiologist assigned to a surgery or a radiologist who reviews an MRI at in-network facilities.

What if I’m out-of-network but work at an in-network facility?

Senate Bill 1264 includes an exception when patients choose an out-of-network doctor while getting care at an in-network facility. If a doctor wants to balance bill after a procedure at an in-network facility, the patient can be asked to sign a waiver at least 10 business days before the procedure.

No waiver is needed for office appointments or when a patient chooses to use an out-of-network facility.

How do I request arbitration?

Through the Texas Independent Dispute Resolution portal. Providers can submit requests between 20 and 90 days after receiving the first claim payment.

Learn more: FAQ: Mediation and arbitration requirements and processes

May I submit multiple claims for arbitration at the same time?

Yes, you can submit multiple claims totaling up to $5,000 with the same plan in a single arbitration request.

Is there a cost for arbitration?

Yes, the doctor and health plan must equally split the cost of the arbitrator. Arbitrators set their own fixed fees.

The health plan asked if I would agree to settle the dispute informally or go through arbitration outside the TDI process. Is that allowed?

Yes. Doctors and health plans are still free to work directly with each other to set up agreements or select their own arbitrators. 

For more information, contact:

Last updated: 1/5/2022