Texas / Provider field guide
Texas IDR, from claim to resolution.
Start with the plan. Match the claim to arbitration or mediation. Then protect the filing window and prepare for the details that make Texas different.
01 / Eligibility
First, confirm Texas applies.
A Texas service address or a familiar insurer name does not establish the dispute pathway. Check the plan, the service, and the provider that billed the claim.
Identify the actual plan
Look for TDI/DOI on the ID card and check the EOB and plan documents. Texas also covers applicable ERS and TRS plans. Confirm the product and administrator rather than routing solely by the insurance company’s name.
Source: TDI: provider FAQ
Check the ERISA exception
Self-funded employer plans can elect Texas IDR. Match the employer or plan sponsor and applicable plan year against TDI’s opt-in list. If Texas does not govern, evaluate federal eligibility separately.
Sources: TDI: participating ERISA plansTDI: Texas IDR overview
Match the protected service
Eligible professional claims can include emergency care, facility-based services at an in-network facility, and out-of-network lab or imaging services connected to care by an in-network provider. Facility mediation has its own claim criteria.
Source: TDI: adopted process rules (PDF)
Separate payment from coverage
An underpayment dispute is different from a coverage denial. Arbitration generally cannot decide whether a service is covered unless both parties agree. Confirm covered-service status and the applicable balance-billing protections before choosing IDR.
Source: TDI: adopted process rules (PDF)
What if Texas does not apply?
Check CMS’s eligibility requirements for federal IDR. Being outside Texas IDR does not itself make a claim eligible for the federal process. Keep the federal service, plan, and filing requirements separate.
Source: CMS: federal payment disputes
How are ambulance services different?
Air ambulance services fall outside the Texas process; evaluate federal protections and IDR eligibility. Texas ground ambulance and EMS claims follow separate statutory payment rules. Do not route a ground ambulance claim through this professional/facility workflow based only on its out-of-network status.
Sources: TDI: Texas IDR overviewTexas Register: February 2026 amendments
02 / Choose a pathway
One encounter. Two possible processes.
Classify the billing provider and the claim independently. A hospital’s facility bill and an emergency physician’s professional bill can take different paths.
| Question | Arbitration | Mediation |
|---|---|---|
| Who uses it? | Out-of-network providers that are not facilities. | Out-of-network facilities. |
| What does it do? | An arbitrator selects the party’s final amount closest to the reasonable amount. | A mediator helps the parties reach an agreed payment. |
| What care can qualify? | Emergency care; qualifying in-network facility services; connected lab or imaging services. | Emergency care; qualifying lab or imaging services connected to an in-network provider’s care. |
| When can you request it? | After 20 days and no later than day 90 following initial-payment receipt. | After 20 days and no later than day 180 following initial-payment receipt for services on/after June 20, 2025. |
| Can claims be combined? | Same provider and same plan issuer/administrator; total amount in controversy no more than $5,000. | Parties may agree to aggregate claims for the same facility and same plan issuer/administrator. |
| Who pays the neutral? | The provider and health plan each pay half. | The facility and health plan each pay half. |
Sources: TDI: adopted process rules (PDF)TDI: process and portal FAQTDI: mediation deadline update
03 / Filing windows
Protect the first clock.
Record when the provider received the initial payment. The date of service determines which mediation rule applies; it is not the event that starts the payment-based filing window.
Arbitration
Clock starts: initial payment received
Payment received
Save the receipt date
Keep the EOB or remittance and evidence of receipt. Identify the unpaid amount after patient cost-sharing.
First 20 days
Review and try to resolve
Use this time to verify eligibility and pursue the plan’s internal appeal process if appropriate.
After 20 days → day 90
Submit the request
TDI summarizes this as the 20–90 day filing window. The rule requires filing after 20 days, and no later than the 90th day after initial-payment receipt.
Mediation
Clock starts: initial payment received
Check the service date
Apply the correct rule
The 180-day filing limit applies to services on or after June 20, 2025.
First 20 days
Review and try to resolve
Confirm the facility claim meets mediation criteria and organize the payment history.
After 20 days → day 180
Submit the request
File after the initial 20-day period and no later than 180 days after receipt of initial payment.
Sources: TDI: adopted process rules (PDF)TDI: process and portal FAQTDI: mediation deadline updateTexas Register: February 2026 amendments
Track the initial-payment receipt date even while pursuing an internal appeal. The filing rules use that initial payment as the trigger; do not assume a later appeal response or revised payment gives the claim a fresh window.
Source: TDI: adopted process rules (PDF)
04 / After you file
A new clock starts at filing.
These are TDI’s standard post-request milestones. An agreed extension changes the schedule; use the dates shown in the portal for the actual dispute.
Arbitration
Clock starts: arbitration requested
Request day
File and notify
Submit in the TDI portal and send written notice to the other party that same day.
First 30 days
Informal settlement
Participate in the settlement teleconference. Record offers, any agreement, and the next deadline.
Day 31 or later
Neutral assignment
TDI assigns an arbitrator if the parties have not settled, agreed on a neutral, or extended the schedule. Fees become due at assignment.
By day 51
Decision and report
Under the standard schedule, the arbitrator decides the dispute, notifies the parties, and reports the result to TDI.
Mediation
Clock starts: mediation requested
Request day
File and notify
Submit in the TDI portal and send written notice to the other party that same day.
First 30 days
Informal settlement
Try to settle with the plan. If unresolved, agree on a mediator or track the assignment deadline.
Day 31 or later
Neutral assignment
TDI assigns a mediator if the parties have not resolved the case, selected a mediator, or extended the schedule.
By day 180
Hold the mediation
This is the post-request mediation milestone, separate from the 180-day limit to file after payment. The mediator reports within 45 days after mediation concludes.
Sources: TDI: adopted process rules (PDF)TDI: process and portal FAQ
How do neutral selection and conflicts work?
The portal presents five potential neutrals; each party may remove up to two. The parties can also agree on another neutral and notify TDI. Review conflicts promptly: the process rules require parties to notify TDI within 10 days of the request about conflicts on the list.
Sources: TDI: process and portal FAQTDI: adopted process rules (PDF)
Can the settlement period be extended?
TDI’s portal allows an extension request before the assignment deadline. The other party must approve it. Save the approval and updated dates; a submitted request alone is not an agreed extension and does not reset the original eligibility-to-file deadline.
Sources: TDI: process and portal FAQTDI: adopted process rules (PDF)
Who records an informal settlement?
Only the health plan can enter the informal teleconference information in the portal. TDI then emails both parties a settlement confirmation. Follow up with the plan and retain that confirmation alongside the settlement terms.
Source: TDI: process and portal FAQ
What happens after a result?
For arbitration, TDI’s payment guidance states that payment is due within 30 days of the decision under Insurance Code §1467.089(d). For mediation, document the payment terms in the agreement. Reconcile the result against the original payment and patient cost-sharing. A separate 45-day civil-action window runs after the arbitration decision, or after the mediator’s report is filed; escalate a contested result promptly for legal review.
Sources: TDI: batching, notices & payment FAQ (PDF)TDI: process and portal FAQ
05 / Batching & fees
Check the economics before assignment.
The size of the dispute, the ability to combine claims, and the neutral’s fee all matter when deciding how to pursue a claim.
$5,000 limits a batch
Multiple arbitration claims must involve the same provider and plan issuer or administrator, with no more than $5,000 total in controversy. A single arbitration claim can exceed $5,000. Use the disputed amount when evaluating a batch.
Sources: TDI: adopted process rules (PDF)TDI: batching, notices & payment FAQ (PDF)
Assignment creates a fee obligation
Each party pays half of the neutral’s fixed fee. Once assigned, the fee is payable even if the parties settle before the neutral performs services. Check the current fee before that milestone.
Sources: TDI: process and portal FAQTDI: mediators and arbitrators
Mediation aggregation is by agreement between the parties for claims involving the same facility and plan issuer or administrator. Do not apply the arbitration batching rule to a mediation without checking its separate requirements.
Source: TDI: adopted process rules (PDF)
06 / The Texas evidence
Build the argument around the Texas factors.
The arbitrator evaluates a reasonable amount and selects whichever party’s final amount is closer. Organize the evidence around the statutory factors and the final positions recorded during the appeal or informal settlement process.
1–3 · Payment comparisons and provider qualifications
Address any gross disparity between the bill and payments to the same provider for comparable out-of-network services, or to similarly qualified out-of-network providers in the region. Include the provider’s training, education and experience, and usual charges for comparable services.
Source: TDI: process and portal FAQ
4–5 · The specific care provided
Explain case complexity, the circumstances of care, its time and place, and the individual patient characteristics relevant to the service. Tie the narrative to the claim rather than relying on a generic specialty description.
Source: TDI: process and portal FAQ
6–7 · The two FAIR Health benchmarks
Identify the 80th-percentile billed-charge benchmark and 50th-percentile participating-provider rate benchmark for the service, specialty, and geozip. Keep the benchmark context with the supporting material.
Source: TDI: process and portal FAQ
8–10 · Contracting, historical data, and offers
Include the parties’ network-contracting history, historical information for the two benchmark percentiles, and offers made in the informal settlement teleconference. Preserve the final amounts and supporting correspondence.
Source: TDI: process and portal FAQ
The arbitrator sets the evidence-submission schedule and must allow the parties to review and respond to each other’s written information. Missing a request for information can result in a decision on the available record without an opportunity for reconsideration.
Source: TDI: adopted process rules (PDF)
07 / Filing checklist
A file that is ready to move.
Use this operational checklist to prepare the request and keep ownership clear through settlement or decision.
Confirm the plan and service
Retain the ID card or equivalent, plan and group numbers, plan type, applicable ERISA election if any, and the facts supporting eligibility. Classify the billing entity as a facility or nonfacility provider.
Sources: TDI: adopted process rules (PDF)TDI: participating ERISA plansTexas Register: February 2026 amendments
Document the payment and deadline
Collect the EOB/remittance, proof of initial-payment receipt, date of service, billed amount, payment, patient cost-sharing, and disputed balance. Check for a deductible-only $0 payment.
Sources: TDI: adopted process rules (PDF)Texas Register: February 2026 amendments
Prepare the request and any batch
Have the claim number, service details, provider or facility information, and representative contacts ready. For arbitration batches, verify the provider, plan issuer/administrator, and total amount in controversy.
Source: TDI: adopted process rules (PDF)
Submit and send the same-day notice
Complete the TDI portal request. Send the required notice to the plan’s EOB-designated email address that day. Save the request ID, receipt, notice, recipient, and timestamp.
Calendar settlement, selection, and evidence
Track conflict review, the informal teleconference, the assignment deadline, approved extensions, the neutral’s fee, and all evidence requests. Do not treat a pending extension as approved.
Sources: TDI: adopted process rules (PDF)TDI: process and portal FAQ
Close the loop on reporting and payment
For informal settlement, confirm the plan entered the result and that both parties received TDI’s confirmation. Keep the agreement or award, reconcile any additional payment, and escalate discrepancies or contested outcomes promptly.
Source: TDI: process and portal FAQ
Reference desk
Sources & updates
This review incorporates SB 2544 and the February 2026 rule amendments. Where older TDI FAQs omit newer rules, the later statute, adopted rule, and implementation bulletin control the explanation here.
- TDI: Texas IDR overview ↗
State and federal pathways, ERISA opt-in, and ambulance distinctions.
- TDI: adopted process rules (PDF) ↗
28 TAC §§21.5010–21.5021: eligibility, notices, submission, fees, conflicts, and batching. Read with the later amendments below.
- TDI: process and portal FAQ ↗
Settlement, neutral selection, arbitration factors, and post-filing timelines. Its older mediation filing summary must be read with SB 2544.
- TDI: mediation deadline update ↗
August 21, 2025 bulletin: the June 20, 2025 service-date cutoff and October 20, 2025 transition deadline.
- SB 2544: enacted text ↗
Amends Insurance Code §1467.054 with the 180-day mediation filing limit and transition provisions.
- Texas Register: February 2026 amendments ↗
Chapter 21 amendments effective February 19, 2026: mediation deadlines, deductible-only payments, and Higher Ed Plans.
- TDI: participating ERISA plans ↗
Check the sponsor, administrator, and applicable plan year; participation is plan-specific.
- TDI: provider FAQ ↗
ERS/TRS coverage, protected services, and shared arbitration costs. Its older ERISA exclusion must be read with the opt-in guidance.
- TDI: batching, notices & payment FAQ (PDF) ↗
Clarifies the $5,000 multiple-claim limit, same-day notices, reporting, and payment within 30 days of an arbitration decision.
- TDI: mediators and arbitrators ↗
Access TDI’s current neutral directory and fee information.
- CMS: federal payment disputes ↗
Federal eligibility and dispute instructions for claims outside the Texas pathway.
- TDI: filing portal ↗
Submit a request, retain its ID, and monitor the dispute and assignment deadlines.
General information, not legal advice. Verify current agency instructions and the facts of the claim before filing.