Texas Register, Volume 38, Number 46, Pages 8023-8312, November 15, 2013 Page: 8,123
8023-8312 p. ; 28 cm.View a full description of this periodical.
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carrier] may not withhold payment beyond the applicable [2-, 3-0- or
45-day] statutory claims payment period pending receipt of informa-
tion requested under subsection (b) of this section. If, on receiving in-
formation requested under this subsection the MCC [HMO or preferred
provider carrier] determines that there was an error in payment of the
claim, the MCC [MO or preferred provider carrier] may recover any
overpayment under 21.2818 of this title (relating to Overpayment of
Claims).
(b) An MCC must [HMO er p r .efered pyovier easier s1ll]
request that the entity responding to a request made under this section
[to] attach a copy of the request to the response. If the request for ad-
ditional information was submitted electronically in compliance with
[in aeeordance with] applicable federal requirements concerning elec-
tronic transactions, the responding entity must submit the response in
compliance with [shall be submitted in accordance with] those require-
ments, if applicable.
(c) (No change.)
21.2806. Claim f[laims] Filing Deadline.
(a) Claim submission deadline. A physician or a provider must
submit a claim to an MCC [HMO r preferred provider caier] not later
than the 95th day after the date the physician or the provider delivers
[provides] the medical care or health care services for which the claim
is made. An MCC [HMO or preferred provider carier] and a physician
or a provider may agree, by contract, to extend the period for submitting
a claim. For a claim submitted by an institutional provider, the 95-day
period does not begin until the date of discharge. For a claim for which
coordination of benefits applies, the 95-day period does not begin for
submission of the claim to the secondary payor until the physician or
the provider receives notice of the payment or the denial from the pri-
mary payor.
(b) Failure to meet claim submission deadline. If a physician
or a provider fails to submit a claim in compliance with this section,
the physician or the provider forfeits the right to payment unless the
physician or the provider has certified that the failure to timely submit
the claim is a result of a catastrophic event in compliance [accordance]
with 21.2819 of this title (relating to Catastrophic Event).
(c) Manner of claim submission. A physician or a provider
may submit claims via United States mail, first class; United States
mail, return receipt requested;[;] overnight delivery service;[;] elec-
tronic transmission;,;] hand delivery[;l] facsimile, if the MCC [HIMO
or preferred provider earier] accepts claims submitted by facsimile; [,]
or as otherwise agreed to by the physician or the provider and the MCC
[M r preferred provider earier]. An MCC must [HMO or pre-
ferred provider carrier shall] accept as proof of timely filing a claim
filed in compliance with this subsection or information from another
MCC [MO or preferred provider carrier] showing that the physician
or the provider submitted the claim to the other MCC [HMO or pre-
ferred provider carrier] in compliance with this subsection.
(d) Determining date of submission. Section 21.2816
[421 2816] of this title (relating to Date of Receipt) determines the
date an MCC LMO r preferred p provider carrier] receives a claim.
(e) Duplicate claims.
(1) A physician or a provider may not submit a duplicate
claim prior to the 46th day, or the 31st day if filed electronically, [or the
22nd day ifa claim for prescription benefits-] after the date the original
claim is received according to the provisions of 21.2816 of this title,
except as provided in paragraph (2) of this subsection for prescription
benefit claims.
(2) A physician or a provider may not submit a duplicate
claim for prescription benefits prior to the 22nd day, or the 19th day iffiled electronically, after the date the original claim is received accord-
ing to the provisions of 21.2816 of this title.
(3) An MCC [MO er preferred provider carrier] that re-
ceives a duplicate claim prior to the applicable date specified in para-
graphs (1) and (2) of this subsection [46th day after reeipt of the origi-
nal e1aim- a duplicate eleetronie elaim prior to the 3-1st day after reeipt
of the origina elaim or a duplicate el-im for prescription benefi ts prior
to the 22nd day after receipt of the original elaim] is not subject to the
provisions of 21.2807 [ 21.2807] of this title (relating to Effect of
Filing a Clean Claim) or 21.2815 [2-.2815] of this title (relating to
Failure to Meet the Statutory Claims Payment Period) with respect to
the duplicate claim.
21.2807. Effect of Filing a Clean Claim.
(a) The statutory claims payment period begins to run upon re-
ceipt of a clean claim, including a corrected claim that is a clean claim,
from a preferred provider, under [pursuant to] 21.2816 of this title
(relating to Date of Receipt), at the address designated by the MCC
[HMO or preferred proider carrier], in compliance [accordance] with
21.2811 of this title (relating to Disclosure of Processing Procedures),
whether it be the address of the MCC [HMO, preferred proida ear-
rier] or any other entity, including a clearinghouse or a repricing com-
pany, designated by the MCC [HMO or preferred provider caier] to
receive claims. The date of claim payment is determined in 21.2810
of this title (relating to Date of Claim Payment).
(b) After receipt of a clean claim and[,] prior to the expiration
of the applicable statutory claims payment period specified in 21.2802
of this title (relating to Definitions), an MCC must [HMO or preferred
.r.. er carrier sha]:
(1) pay the total amount of the clean claim as specified in
[in accordance with] the contract between the preferred provider and
the MCC [HMG or preferred provider carier];
(2) deny the clean claim in its entirety after a determination
that the MCC [HM or preferred provider carrier] is not liable for the
clean claim and notify the preferred provider in writing why the clean
claim will not be paid;
(3) notify the preferred provider in writing that the entire
clean claim will be audited and pay 100 percent [40%] of the con-
tracted rate on the claim to the preferred provider; or
(4) pay the portion of the clean claim for which the MCC
[1M or preferred provier earlier] acknowledges liability as specified
in n accordance with] the contract between the preferred provider and
the MCC [MG or preferred provider carrier], and:
(A) deny the remainder of the clean claim after a deter-
mination that the MCC [HMO r preferred provider carrier] is not liable
for the remainder of the clean claim and notify the preferred provider
in writing why the remainder of the clean claim will not be paid; or
(B) notify the preferred provider in writing that the re-
mainder of the clean claim will be audited and pay 100 percent [400%]
of the contracted rate on the unpaid portion of the clean claim to the
preferred provider.
(c) With regard to a clean claim for a prescription benefit
subject to the statutory claims payment period specified in 21.2802
of this title, an HMO or preferred provider carrier shall, after receipt
of an electronically submitted clean claim for a prescription benefit
that is affirmatively adjudicated pursuant to Insurance Code Article
3.70-3C, 3A(f) (Preferred Provider Benefit Plans) and Insurance
Code 843.339, pay the prescription benefit claim within 21 calendar
days after the clean claim is adjudicated.PROPOSED RULES November 15, 2013 38 TexReg 8123
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Texas. Secretary of State. Texas Register, Volume 38, Number 46, Pages 8023-8312, November 15, 2013, periodical, November 15, 2013; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth379973/m1/101/: accessed July 18, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu.; crediting UNT Libraries Government Documents Department.