1. (a) If the health care provider is dissatisfied with the insurance carrier's final action on a medical bill, the health care provider may request that the insurance carrier reconsider its action.
2. (b) The health care provider shall submit the request for reconsideration no later than eleven months from the date of service.

3. (c) A health care provider shall not submit a request for reconsideration until:

   1. (1) the insurance carrier has taken final action on a medical bill; or
   2. (2) the health care provider has not received an explanation of benefits within 50 days from submitting the medical bill to the insurance carrier.

4. (d) The request for reconsideration shall:

   1. (1) reference the original bill and include the same billing codes, date(s) of service, and dollar amounts as the original bill;
   2. (2) include a copy of the original explanation of benefits, if received, or documentation that a request for an explanation of benefits was submitted to the insurance carrier;
   3. (3) include any necessary and related documentation not submitted with the original medical bill to support the health care provider's position; and
   4. (4) include a bill-specific, substantive explanation in accordance with §133.3 of this chapter (relating to Communication Between Health Care Providers and Insurance Carriers) that provides a rational basis to modify the previous denial or payment.
5. (e) An insurance carrier shall review all reconsideration requests for completeness in accordance with subsection (d) of this section and may return an incomplete reconsideration request no later than seven days from the date of receipt. A health care provider may complete and resubmit its request to the insurance carrier.
6. (f) The insurance carrier shall take final action on a reconsideration request within 21 days of receiving the request for reconsideration. The insurance carrier shall provide an explanation of benefits for all items included in a reconsideration request in the form and format prescribed by the Division.
7. (g) A health care provider shall not resubmit a request for reconsideration earlier than 26 days from the date the insurance carrier received the original request for reconsideration or after the insurance carrier has taken final action on the reconsideration request.
8. (h) If the health care provider is dissatisfied with the insurance carrier's final action on a medical bill after reconsideration, the health care provider may request medical dispute resolution in accordance with §133.305 of this chapter (relating to Medical Dispute Resolution - General).

Source Note:The provisions of this §133.250 adopted to be effective May 2, 2006, 31 TexReg 3544.