Insurance Commissioner to Health Plans: Be Proactive on New Surprise Billing Law
By Joey Berlin


Texas Insurance Commissioner Kent Sullivan is reminding insurers of their obligations under the state’s new baseball-style arbitration law to resolve disputes on many out-of-network medical bills.

In a letter Tuesday addressed to “the health plans of Texas,” Mr. Sullivan said the Texas Department of Insurance (TDI) will monitor how health plans implement Senate Bill 1264, passed during last year’s session of the Texas Legislature and now in effect.

“We expect you to be proactive to meet both the letter and spirit of SB 1264,” Mr. Sullivan said. “Review your policies and procedures and address potential issues quickly.”

The letter highlighted several of the plans’ responsibilities in relation to the law. The commissioner’s letter noted that:

  • State law requires plans to cover medical screenings necessary to rule out the presence of an emergency condition;
  • For emergency care, claim denials based on failure to meet the prudent-layperson standard must be based on the patient’s presenting symptoms, not on the later diagnosis code;
  • Plans must meet required deadlines to promptly adjudicate clean claims; and
  • Plans must be ready to provide accurate information about the new law, including required notices about mediation and arbitration, on explanations of benefits. The plans must be able to quickly respond to questions from policyholders and practitioners.

Mr. Sullivan’s letter noted that TDI has set up an SB 1264 page on its website, which includes a link to the state’s new portal for mediation and arbitration requests.

The Texas Medical Association has published a brief overview of the new law for physicians.

Last Updated On

February 10, 2023

Originally Published On

January 09, 2020