Texas Register, Volume 38, Number 46, Pages 8023-8312, November 15, 2013 Page: 8,106
8023-8312 p. ; 28 cm.View a full description of this periodical.
Extracted Text
The following text was automatically extracted from the image on this page using optical character recognition software:
non-Medicare claims beginning January 6, 2014, with manda-
tory use by April 1, 2014. These rules are being proposed and
will be adopted on an expedited basis so that all affected parties
can phase in their use of the new form before its mandatory use
date.
House Bill 1772, 82nd Legislature, Regular Session (2011)
amended Insurance Code Chapter 1301, 1301.0041 to add
exclusive provider benefit plans to the entities regulated by the
chapter. Under 28 TAC 3.3701, a provision that applies to a
preferred provider benefit plan in the Administrative Code also
applies to an exclusive provider benefit plan. The proposed
amendments clarify that these rules apply to an exclusive
provider benefit plan carrier unless specifically excepted. For
this reason, the term "managed care carrier" (MCC) is sub-
stituted for the phrase "HMO or preferred provider carrier"
throughout this proposal and throughout the proposed rule to
more easily identify the three types of entities regulated by
Subchapter T.
House Bill 2292, 82nd Legislature, Regular Session (2011)
amended Insurance Code Chapter 843, 843.339, and Chapter
1301, 1301.104 to provide that a pharmacy claim submitted
electronically to a managed care carrier must be paid by elec-
tronic funds transfer not later than 18 days after its affirmative
adjudication, and a pharmacy claim submitted nonelectronically
must be paid not later than 21 days after its affirmative adjudi-
cation. The proposed amendments are needed to incorporate
those timelines into these rules.
The proposed amendments do not establish clean claim data el-
ements for pharmacy claims because Insurance Code 843.339
and 1301.104, which establish the payment deadlines for such
claims, reference the date a claim is affirmatively adjudicated,
rather than the receipt of a clean claim.
House Bill 2064, 81st Legislature, Regular Session (2009)
amended Insurance Code Chapter 843, 843.342, and Chapter
1301, 1301.137 to provide that a portion of certain penalty
payments and interest payments that are statutorily paid by
managed care carriers for late payment and underpayment
of clean claims would be paid to the Texas Health Insurance
Risk Pool (Pool). The proposed amendments are needed to
incorporate those payments into the rule.
Senate Bill 1367, 83rd Legislature, Regular Session (2013) abol-
ishes the Pool and reallocates payments made to the Pool under
the clean claims rules to the department upon the Pool's disso-
lution. The proposed amendments are needed to add that real-
location to the rule.
Throughout the proposed rule nonsubstantive amendments are
made to conform the subchapter to the current codification and
language of the Insurance and Administrative Codes, to update
the rule's internal references, and to make minor language,
punctuation, and grammatical changes to make the rules easier
to read, understand, and use. These proposed nonsubstantive
amendments will be noted in the explanatory text below, but will
not be described in detail.
BRIEF EXPLANATION OF THE PROPOSED AMENDMENTS.
21.2801. Purpose and Scope. The proposed amendment to
21.2801 reflects the recodification of repealed Insurance Code
Article 3.70-3C as Chapter 1301. The amendment also adds
exclusive provider carriers to the entities governed by the rules,
but excludes from the rule's coverage an exclusive provider ben-
efit plan regulated under Chapter 3, Subchapter KK (ExclusiveProvider Benefit Plan) of this title, that provides services un-
der the Texas Children's Health Insurance Program or with the
Statewide Rural Healthcare Program.
21.2802. Definitions. Throughout this section, the rule sub-
stitutes the term "managed care carrier" (MCC) for the phrase
"HMO or preferred provider carrier" to more easily identify the
three types of entities governed by this subchapter (HMO, pre-
ferred provider carrier, and exclusive provider carrier). There are
also nonsubstantive amendments made throughout the section
to conform its language to the current codification and language
of the Insurance and Administrative Codes, to update the rule's
internal references, and to make minor language, punctuation,
and grammatical changes to make the rules easier to read, un-
derstand, and use. All other amendments are described below.
21.2802(2), (4), (7), (9), (11), (13), (14), (15), (18), (21), (27),
and (28) (Batch submission; CMS; Condition code; Corrected
claim; Diagnosis code; HMO; HMO delivery network; Institu-
tional provider; Patient control number; Physician; Provider; and
Revenue code). These definitions are either unchanged or are
amended only to update their paragraph number.
21.2802(3), (5), (10), (16), (17), (19), (20), (22), (26), and (33)
(Billed charges; Catastrophic event; Deficient claim; NPI num-
ber; Occurrence span code; Patient financial responsibility; Pa-
tient-status-at-discharge code; Place of service code; Procedure
code; and Type of bill code). These definitions are amended only
to make minor language, punctuation, and grammatical changes
intended to make the rules easier to read, understand, and use.
21.2802(1) Audit. This definition is amended to introduce the
term "managed care carrier" (MCC) to replace the rule's existing
language of "HMO or preferred provider carrier."
Existing 21.2802(8), (12), (26), and (32) (Contracted rate;
Duplicate claim; Procedure code; and Subscriber). These defi-
nitions are amended to substitute "MCC" for "HMO or preferred
provider carrier" because they now also apply to exclusive
provider carriers.
Proposed 21.2802(13) Exclusive provider carrier. The
amended rule adds a definition of "exclusive provider carrier"
because Insurance Code Chapter 1301 and these rules now
apply to exclusive provider plans as set forth in Insurance Code
1301.0041 and 1301.0042.
Proposed 21.2802(17) MCC or managed care carrier. The
amended rule creates the term "managed care carrier" (MCC)
to more easily identify the three types of entities governed by
Subchapter T (HMO, preferred provider carrier, and exclusive
provider carrier). The term "MCC" is then substituted for the
phrase "HMO or preferred provider carrier" throughout the
balance of the rule.
Existing 21.2802(23) Preferred provider. The definition is
amended to reflect that the term includes providers in both
preferred provider plans and exclusive provider plans. Para-
graph numbers are removed from two cites to Insurance Code
843.002 (Definitions) so that, should the statute's definitions
change, the rule need not be amended to reflect a renumbering
of those paragraphs.
Existing 21.2802(24) Preferred provider carrier The definition
is amended to reflect that the term does not include a carrier that
issues exclusive provider benefit plans.
Existing 21.2802(25) Primary plan. The definition is amended
to add language anticipating a successor rule to existing 28 TAC38 TexReg 8106 November 15, 2013 Texas Register
Upcoming Pages
Here’s what’s next.
Search Inside
This issue can be searched. Note: Results may vary based on the legibility of text within the document.
Tools / Downloads
Get a copy of this page or view the extracted text.
Citing and Sharing
Basic information for referencing this web page. We also provide extended guidance on usage rights, references, copying or embedding.
Reference the current page of this Periodical.
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/m1/84/: accessed July 17, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu.; crediting UNT Libraries Government Documents Department.