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A new law limits when Texas health care providers can bill some patients. As a provider, you might be confused about your responsibilities under Senate Bill 1264. If you’re a health care provider yourself or you handle billing for a medical practice, you’re probably looking for more clarification. Watch this video for more information about the new surprise billing legislation.
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We know health care is complex and ever-changing, so let us break it down for you. Stay relevant by watching other videos in our Blue BuzzSM series.
What's up docs? In this video we're talking to Texas health care providers.
You might be confused about your responsibilitiesunder our state's new surprise bill and legislation.
Chances are - whether you're part of an insurance network or not - you're going to want some clarification.
So, here's what you need to know. There's a new law that limits when
Texas health care providers can bill some patients. Providers should not send patients
a bill for amounts above the deductible, copay or coinsurance for some services.
Sending a bill for more than these patientshare amounts is called "Balance Billing."
And limitations on balance billing apply in three situations.
First, providers should not balance bill foremergency services and supplies. Period.
Second, providers who practice at an in-networkfacility but out-of-network themselves.
Well, they shouldn't be balance billing either.
For example, a patient has let's say surgery at an in-network hospital
but the anesthesiologist who treats them is out of network.
Lastly, an in-network doctor uses an out-of-network provider for diagnostic imaging or lab work.
Well they shouldn't send a balance bill either.
For now, this law only applies to patientswith fully insured, state regulated plans
issued to groups and individualsthrough HMOs, PPOs and EPOs.
You can tell by looking at a patient's I.D. card. It applies to anyone with a
Blue Cross and Blue Shield of Texas I.D. card that has the letters "TDI" printed on it.
Now other insurers might note these plans with the letters "DOI" so keep that in mind.
There are a select few of employer-sponsoredplans that are covered by the law like the
Employees Retirement System of Texas or ERSand the Teacher Retirement System of Texas or TRS.
But please note the law does not apply to Medicare. And you can always call our
Provider Customer Service line to learn whether or not your patient is covered by this new law.
So please don't hesitate. For more information though
please check out our video on surprise billing and get the full scoop on the law.
Now in some non-emergency situations patients can still choose an out-of-network doctor
while getting care at an in-network facility. If you're going to send a balance bill to a
patient covered by this new law, the patient will need to agree to this waiver form
at least ten business days before the procedure. The patient then has five business days
to change their mind and withdraw the waiver. The waiver is not applicable
however in instances where a patient does not have a choice of providers.
You can get a copy of this waiver form by going to the Texas Department of Insurance website.
If Blue Cross and Blue Shield of Texas processesone of your claims according to this new law,
you'll see it on the Provider Claim Summaryor the Electronic Remittance Advice that we
send you once the claim is finalized. Now if you have questions about whether
a claim is subject to the law or questions about the information that you see
simply call our Provider Customer Service team. Now let's say you don't quite agree with
the payment amount that you receive from the insurer. First, you'll want to follow
our normal appeal process. And if that doesn't address your questions you can request
mediation or arbitration through the Texas Department of Insurance's online portal.
This process is outlined on the same provider claims summary that I mentioned earlier.
Now if you're managing a Blue Cross and Blue Shield of Texas claim you must let us know
when you request either mediation or arbitration through the TDI.
To do this, just send us an e-mail at the address on the screen.
So what exactly happens when you file one of these requests with the TDI?
Well, first we'll meet by phone and try to reach an agreement.
And if the negotiation is successful, great! We'll route a claim for adjustment and notify
the Texas Department of Insurance that the issue is resolved. Case closed!
Now, if we can't come to an agreement, then there are two different processes that
you might go through, depending on what type of provider you are.
So, mediation is only available to out-of-network facilities.
In this process, an independent third party helps negotiate a resolution between
Blue Cross and Blue Shieldof Texas and the facility.
Now arbitration, contrary to mediation, isonly available to out-of-network providers
other than facilities. In this process, an independent third-party reviews information submitted
by both sides and then makes a decision about the reasonable amount to be paid for the claim.
Now there's a window of opportunity for whena provider can submit a request for arbitration
and that's between 20 and 90 days after receiving the very first claim payment.
If you have any questions, please just call our Provider Customer Service line
and we'll be happy to help. Now this is a new process for everyone
and that's what we have the trained staff ready to provide directions for handling these requests.
But if you really want to avoid all the hassle, join the network!
We're always looking for high-quality providers across the state,
so simply visit our "Provider"section of the website and apply to day.
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