Mediation for a health insurance claim
Read these instructions if you got medical services, supplies, or emergency care on or after January 1, 2018.
We can help you with your surprise bill if:
- You have health coverage through one of the following:
- An insured preferred provider benefit organization (PPO).
- The Employees Retirement System of Texas.
- the Teacher Retirement System of Texas.
- The amount of the bill is more than $500, not including copays, deductibles, and coinsurance.
- You didn’t sign an estimate that shows a cost of services that is the same or less than your bill.
- You were billed for:
- Emergency care by a doctor, hospital, clinic, or other health care provider that isn’t in your health plan’s network.
or - Medical services or supplies:
- By a facility-based doctor or other health care provider who isn’t part of your health plan’s network.
and - At one of the following places in your health plan’s network:
- Hospital.
- Ambulatory surgical center.
- Birthing center.
- Freestanding emergency medical care facility.
- By a facility-based doctor or other health care provider who isn’t part of your health plan’s network.
- Emergency care by a doctor, hospital, clinic, or other health care provider that isn’t in your health plan’s network.
If you meet the above rules:
- Get these three documents together:
- A copy of the front of your health insurance ID card.
- A copy of your Explanation of Benefits (EOB) form. Your insurance company sends this form to you after you get health care services.
- A copy of the doctor or provider’s bill.
- Fill out the form and attach the documents listed in step A:
Learn more about how this process works:
Visit our How Mediation Works web page.
If you aren’t able to get help with a surprise bill:
You can file a complaint about your health insurance. To learn more, go to our Insurance Complaint Process web page.