SECTION 187.89. Notice of Availability of Mandatory Mediation

(a) Notice at Time of Presentation.

(1) Except in the case of an emergency and if requested by an enrollee, a facility-based physician shall, before providing a medical service or supply, provide a complete disclosure to an enrollee consistent with the notice requirements of §1467.051 of the Texas Insurance Code, that:

(A) explains that the facility-based physician does not have a contract with the enrollee's health benefit plan;

(B) discloses projected amounts for which the enrollee may be responsible; and

(C) discloses the circumstances under which the enrollee would be responsible for those amounts.

(2) Failure to provide notice under this section shall not subject a licensee to disciplinary action.

(b) Notice in Billing Statement.

(1) A facility-based physician who bills a patient covered by a preferred provider plan or a health benefit plan under Chapter 1551 of the Insurance Code that does not have a contract with the facility-based physician shall send a billing statement to the patient that contains a conspicuous, plain-language explanation of the mandatory mediation process under Chapter 1467 of the Insurance Code if the amount for which the enrollee is responsible to the physician, after copayments, deductibles, and coinsurance, including the amount unpaid by the administrator or insurer, is greater than $500.

(2) The written notice shall include a reference to TDI's website about the mediation process - http://www.tdi.state.tx.us/consumer/cpmmediation.html.

Source Note: The provisions of this §187.89 adopted to be effective May 2, 2010, 35 TexReg 3279; amended to be effective February 21, 2016, 41 TexReg 1119