Texas Department of Insurance: Independent Dispute Resolution (10-Factor Criteria)

1. whether there is a gross disparity between the fee billed by the out-of- network provider; and, (a) 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, and (b) 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. level of training, education, and experience of the out-of-network provider.

3. 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. circumstances and complexity of the enrollee’s particular 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 benchmarking database. (Please include the specific dollar amount for the Benchmark as of the date of the Provider’s service).

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 benchmarking database. (Please include the specific dollar amount for the Benchmark as of the date of the Provider’s service).

8. history of network contracting between the parties.

9. historical data for the percentiles described by Subdivisions 6 and 7, above.

10. offers made during the informal settlement teleconference. (Please confirm that the Last Final Offers of both the Plan and the Provider are accurately stated on the IDR Portal, or explain any discrepancy.)