# 28 Tex. Admin. Code § 21.5010: 28 TAC § 21.5010. Qualified Mediation Claim Criteria, DIVISION 2. MEDIATION PROCESS

> Texas · Regulations · In force

URL: https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C21_S21_5010

## Section

- **Citation:** 28 Tex. Admin. Code § 21.5010
- **Heading:** 28 TAC § 21.5010. Qualified Mediation Claim Criteria, DIVISION 2. MEDIATION PROCESS
- **Jurisdiction:** Texas
- **Kind:** Regulations
- **Status:** In force
- **Text as of:** August 14, 2026
- **Source:** Compiled text
- **Location:** Texas Administrative Code / Title 28 INSURANCE / Part 1 TEXAS DEPARTMENT OF INSURANCE / Chapter 21 TRADE PRACTICES / 28 TAC § 21.5010

## Text

(a) Required criteria. An out-of-network provider that
 is a facility or a health benefit plan issuer or administrator may
 request mandatory mediation of an out-of-network claim under §21.5011
 of this title (relating to Mediation Request Procedure) if the claim
 complies with the criteria specified in this subsection. An out-of-network
 claim that complies with those criteria is referred to as a "qualified
 mediation claim" in this subchapter.
(1) The out-of-network health benefit claim must be
 for:
(A) emergency care;
(B) an out-of-network laboratory service provided in
 connection with a health care or medical service or supply provided
 by a participating provider; or
(C) an out-of-network diagnostic imaging service provided
 in connection with a health care or medical service or supply provided
 by a participating provider.
(2) There is an amount billed by the provider and unpaid
 by the health benefit plan issuer or administrator after copayments,
 deductibles, and coinsurance, for which an enrollee may not be billed.
(b) Submission of multiple claim forms. The use of
 more than one form in the submission of a claim, as defined in §21.5003
 of this title (relating to Definitions), does not prevent eligibility
 of a claim for mandatory mediation under this subchapter if the claim
 otherwise meets the requirements of this section.
(c) Ineligible claims. This division does not require
 a health benefit plan issuer or administrator to pay for an uncovered
 service or supply.

## Nearby sections

- [28 Tex. Admin. Code § 21.5001 28 TAC § 21.5001. Purpose, DIVISION 1. GENERAL PROVISIONS](https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C21_S21_5001.md)
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Source: Frix Law Library, https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C21_S21_5010. Check the current official text before relying on it. Not legal advice.