Section 21.5030 - Complaint Resolution(a) Written complaint. A party may submit a written complaint on the department's website regarding the settlement of an out-of-network health benefit claim that is subject to Insurance Code Chapter 1467.
(b) Complaint information. The recommended information for filing a complaint under subsection (a) of this section, includes: (1) whether the complaint is within the scope of Insurance Code Chapter 1467 (concerning Out-of-Network Claim Dispute Resolution);(2) whether emergency care, health care, or a medical service have been delayed or have not been given;(3) whether the health care, medical service, or supply, or a combination of health care, medical service, or supply, that is the subject of the complaint was for emergency care; and(4) specific information about the qualified mediation claim or qualified arbitration claim, including: (A) the name, type, and specialty of the provider;(B) the type of service performed or supplies provided;(C) the city and county where the service or supply was performed; and(D) the dollar amount of the disputed claim.(c) Department processing. The department will maintain procedures to ensure that a written complaint made through the department's website under this section is not dismissed without appropriate consideration, including: (1) review of all of the information submitted in the written complaint;(2) contact with the parties that are the subject of the complaint; and(3) review of the responses received from the subjects of the complaint to determine if and what further action is required, as appropriate.28 Tex. Admin. Code § 21.5030
The provisions of this §21.5030 adopted to be effective October 19, 2010, 35 TexReg 9300; Amended by Texas Register, Volume 41, Number 44, October 28, 2016, TexReg 8618, eff. 11/3/2016; Amended by Texas Register, Volume 43, Number 16, April 20, 2018, TexReg 2429, eff. 4/26/2018; Amended by Texas Register, Volume 44, Number 51, December 20, 2019, TexReg 8017, eff. 12/23/2019