# 28 Tex. Admin. Code § 21.5020: 28 TAC § 21.5020. Qualified Arbitration Claim Criteria, DIVISION 3. ARBITRATION PROCESS

> Texas · Regulations · In force

URL: https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C21_S21_5020

## Section

- **Citation:** 28 Tex. Admin. Code § 21.5020
- **Heading:** 28 TAC § 21.5020. Qualified Arbitration Claim Criteria, DIVISION 3. ARBITRATION 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 § 21.5020

## Text

(a) Required criteria. An out-of-network provider that
 is not a facility or a health benefit plan issuer or administrator
 may request mandatory binding arbitration of an out-of-network claim
 under §21.5021 of this title (relating to Arbitration Request
 Procedure) if the claim complies with the criteria specified in this
 section. An out-of-network claim that complies with those criteria
 is referred to as a "qualified arbitration claim" in this subchapter.
(1) The health benefit claim must be for:
(A) emergency care;
(B) a health care or medical service or supply provided
 by a facility-based provider in a facility that is a participating
 provider;
(C) an out-of-network laboratory service provided in
 connection with a health care or medical service or supply provided
 by a participating provider; or
(D) an out-of-network diagnostic imaging service provided
 in connection with a health care or medical service or supply provided
 by a participating provider; and
(2) The health benefit claim must be for a charge billed
 by the provider and unpaid by the health benefit plan issuer or administrator
 after copayments, coinsurance, and deductibles for which an enrollee
 may not be billed.
(b) Availability. Not later than the 90th day after
 the date an out-of-network provider receives the initial payment for
 a health care or medical service or supply, the out-of-network provider
 or the health benefit plan issuer or administrator may request arbitration
 of a settlement of an out-of-network health benefit claim. The initial
 payment could be zero dollars if the allowable amount was applied
 to an enrollee's deductible.
(c) Ineligible claims. Unless otherwise agreed to by
 the parties, an arbitrator may not determine whether a health benefit
 plan covers a particular health care or medical service or supply.

## Nearby sections

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Source: Frix Law Library, https://www.frixlaw.com/law-library/statutes/STATE_TX_TAC_T28_P1_C21_S21_5020. Check the current official text before relying on it. Not legal advice.