Texas Surprise Billing Disputes: FAQ

FAQ: Mediation Information From The Texas Department of Insurance


Senate Bill 1264, passed during the 2019 legislative session, outlines arbitration and mediation processes for certain billing disputes. The new law applies to bills for medical services or supplies received on or after January 1, 2020.

The law outlines two processes:
• Mediation: Used for billing disputes between out-of-network facilities and health plans.
• Arbitration: Used for billing disputes between out-of-network health care providers (not facilities) and health plans.

Mediation Timeline
Before a request for mediation is made: The provider should try resolving the payment dispute through the health plan’s internal appeal process.
A request for mediation can be made: 20 days after the date the out-of-network provider receives the first claim payment.
Day 1: Mediation is requested through the Independent Dispute Resolution portal. This starts a 30-day informal settlement period. During this time, the facility and health plan can:
• Settle in an informal teleconference. or
• Select a mediator that both parties agree on. The parties can choose their own or one from our list. If a mediator is selected, the parties must tell us and the chosen mediator.
Day 31: On or after this date, we will assign a mediator if one has not been agreed to by the parties.
Day 180: Mediation must have taken place by this date.
Before a request for arbitration is made: The provider should try resolving the payment dispute through the health plan’s internal appeal process.

45 days after mediation concludes: The mediator must file a report on the Independent Dispute Resolution portal.
The report must list the parties involved and if an agreement was reached.
Within 45 days after the mediator’s report is provided to us: Either party can file an action in civil court.

Arbitration Timeline
A request for arbitration can be made:
Between 20 and 90 days after the date the out- of-network provider receives the first claim payment.
Day 1: Arbitration is requested through the Independent Dispute Resolution portal. This starts a 30-day informal settlement period. During this time, the provider and health plan can:
• Settle in an informal teleconference. or
• Select an arbitrator that both parties agree on. The parties can choose their own or one from our list. If an arbitrator is selected, the parties must tell us and the chosen arbitrator.
Day 31: On or after this date, we will assign an arbitrator if one has not been agreed to by the parties.
Day 51: By this date: (1) arbitration must have taken place, (2) the arbitrator must have notified the parties of the final decision, and (3) the arbitrator must have filed a report on the Independent Dispute Resolution portal.
The report must list the parties involved, which party was closest to the reasonable amount, and the award amount.


Within 45 days after the arbitrator’s decision:
Either party can file an action in civil court.
What are the 10 factors that must be considered during arbitration?
Arbitrators must use the following 10 factors to determine the reasonable amount for services:

Source of information to conduct the mediation or arbitration


Mediators
The mediator decides the timing, information, and how the parties involved in the dispute will send the information to them.
The mediator can request information from each party by email and phone.

Arbitrators
The arbitrator decides the timing and how the parties involved in the dispute will send the information to them.

The parties involved in the dispute will provide health care cost information based on 10 factors listed in Texas Insurance Code Section 1467.083.


How will mediations and arbitrations be conducted?
Most mediations can be conducted by phone and electronic communication. Arbitrations can be conducted using electronic communication and online sources.

Are the mediation and arbitration processes final?
Either party can file an action in civil court within 45 days after the mediator’s report is filed in the Independent Dispute Resolution portal
The arbitrator’s decision is binding, but either party can file an action in civil court within 45 days after the arbitrator’s decision.