SECTION 370.453. Balance Billing

(a) A provider may only seek reimbursement from a CHIP managed care organization for a covered service provided to a CHIP member. A provider may not seek reimbursement or attempt to obtain payment from a CHIP member, the CHIP member's family, or the CHIP member's guardian for a covered service.

(b) The provisions of subsection (a) of this section apply to all covered services provided to a CHIP member, including emergency services provided by an out-of-network provider, in compliance with federal regulations (42 C.F.R. §457.515(f)).

(c) The provisions of subsection (a) of this section do not apply to:

(1) co-payment authorized under Subchapter C, Division 2 of this title (relating to Cost-Sharing Requirements);

(2) a covered service of CHIP with a capped benefit level, once the CHIP member exceeds the benefit cap; or

(3) services that are not covered services under CHIP.

(d) Providers may not bill or take other recourse against the CHIP member, the CHIP member's family, or the CHIP member's guardian for claims denied as a result of error attributed to the provider or Claims Processing Entity.

(e) This rule applies to providers that participate in a CHIP managed care organization's network and out-of-network providers.

Source Note: The provisions of this §370.453 adopted to be effective September 1, 2006, 31 TexReg 6638; amended to be effective January 22, 2015, 39 TexReg 9889