A Texas HMO determines that a claim from a non-network physician or provider is payable and pays it at a rate that the physician or provider did not agree to. Under 28 TAC 11.1611, what must the HMO send the enrollee?
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Answer & full 3-part explanation (select an option above, or peek)
Why D is correct
Under 28 TAC 11.1611, after determining that a claim from a non-network physician or provider is payable, the HMO must issue payment to that physician or provider at the usual and customary rate or at a rate agreed to between them; if the rate was not agreed to by the physician or provider, the HMO must provide an explanation of benefits to the enrollee that includes a statement that the payment is at least equal to the usual and customary rate, that the enrollee should notify the HMO if the physician or provider bills beyond the amount paid, the procedures for contacting the HMO on receipt of such a bill, and the number for the department's toll-free consumer information help line for complaints regarding payment. The explanation of benefits is the enrollee's early-warning document: it states what was paid, asks the enrollee to report any balance bill, and gives a place to complain.
Why the other options are wrong
- A) Physician and provider contracts are not part of the required enrollee explanation of benefits, which is limited to payment and complaint information.
- B) The rule requires the opposite: the explanation of benefits must state that the HMO's payment is at least the usual and customary rate and instruct the enrollee to report any billing beyond that amount.
- C) No forfeiture of coverage arises from a non-network balance bill, and the rule requires the HMO to invite the enrollee to report the billing rather than to threaten the coverage.
Memory hook
Rate not agreed to means an EOB that warns, explains, and gives TDI's help line.