Texas Administrative Code
Title 25 - HEALTH SERVICES
Part 1 - DEPARTMENT OF STATE HEALTH SERVICES
Chapter 133 - HOSPITAL LICENSING
Subchapter C - OPERATIONAL REQUIREMENTS
Section 133.46 - Billing Requirements
Universal Citation: 25 TX Admin Code ยง 133.46
Current through Reg. 49, No. 38; September 20, 2024
(a) Itemized statements.
(1) A hospital shall adopt,
implement, and enforce a policy to ensure that the hospital complies with Texas
Health and Safety Code (HSC) §311.002.
(2) A hospital shall comply with the itemized
bill requirements under HSC §185.002.
(b) Audits of billing. A hospital shall adopt, implement, and enforce a policy to ensure that the hospital complies with HSC §311.0025(a).
(c) Balance billing.
(1) A hospital may not
violate a law that prohibits the hospital from billing a patient who is an
insured, participant, or enrollee in a managed care plan an amount greater than
an applicable copayment, coinsurance, and deductible under the insured's,
participant's, or enrollee's managed care plan or that imposes a requirement
related to that prohibition.
(2) A
hospital shall comply with Senate Bill 1264, 86th Legislature, Regular Session,
2019, and with related Texas Department of Insurance rules at 28 TAC Chapter
21, Subchapter OO, §§21.4901 - 21.4904 (relating to Disclosures by
Out-of-Network Providers) to the extent this subchapter applies to the
hospital.
(d) Complaint investigation procedures.
(1) A complaint
submitted to the Texas Health and Human Services Commission's Complaint and
Incident Intake relating to billing must specify the patient for whom the bill
was submitted.
(2) Upon receiving a
complaint warranting an investigation, Texas Health and Human Services
Commission (HHSC) shall send the complaint to the hospital requesting the
hospital to conduct an internal investigation. Within 30 days of the hospital's
receipt of the complaint, the hospital shall submit to HHSC:
(A) a report outlining the hospital's
investigative process;
(B) the
resolution or conclusions reached by the hospital with the patient, third party
payor or complainant; and
(C)
corrections, if any, in the hospital's policies or protocols which were made as
a result of its investigative findings.
(3) In addition to the hospital's internal
investigation, HHSC may also conduct an investigation to audit any billing and
patient records of the hospital.
(4) HHSC shall inform in writing a
complainant who identifies himself by name and address:
(A) of the receipt of the
complaint;
(B) if the complainant's
allegations are potential violations of the Act or this chapter warranting an
investigation;
(C) whether the
complaint will be investigated by HHSC;
(D) if the complaint was referred to the
hospital for internal investigation;
(E) whether and to whom the complaint will be
referred;
(F) of the results of the
hospital's investigation and the hospital's resolution with the complainant;
and
(G) of HHSC's findings if an
on-site audit investigation was conducted.
(5) HHSC shall refer investigative reports of
billing by health care professionals who have provided improper, unreasonable,
or medically or clinically unnecessary treatments or billed for treatments
which were not provided to the appropriate licensing agency.
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