Source: https://www.oag.state.tx.us/opinions/opinions/49cornyn/op/2002/htm/jc0502.htm
Timestamp: 2015-03-27 08:17:46
Document Index: 440550527

Matched Legal Cases: ['art. 3', 'art. 20', 'art. 3', 'art. 20', 'art. 3', 'art. 3', 'art. 20', 'art. 3', 'art. 20', 'art. 3', 'art. 20', 'art. 3', 'art. 3', 'art. 20', 'art. 3', 'art. 20', 'art. 3', 'art. 20', 'art. 3', 'art. 20', 'art. 3', 'art. 20', 'art. 3', 'art. 3', 'art. 20', 'art. 21', 'art. 3', 'art. 20', 'art. 3', 'art. 3', 'art. 3', 'art. 20', 'art. 3', 'art. 3', 'art. 3', 'art. 3', 'art. 20', 'art. 3', 'art. 3']

�� 1-2, 76th Leg., R.S. (1999), Act of May 29, 1999, 76th Leg., R.S., ch. 1343, �� 1-2, 1999 Tex.
Gen. Laws 4556, 4556-59 (enacting Tex. Ins. Code art. 3.70-3C, � 3A(a), (c) and art. 20A.18B(a),
rules, see id. (enacting Tex. Ins. Code art. 3.70-3C, � 3A(a) and art. 20A.18B(a)). Significantly for
implementing rules. See id. (enacting Tex. Ins. Code art. 3.70-3C, � 3A(i), (n) and art.
bundling, or downcoding policies. See 28 Tex. Admin. Code �� 21.2801-.2816 (2001) (Submission of Clean Claims). It appears,
It is the department's position that Article 20A.18B(i) and Article 3.70-3C � 3A(i), relating
Tex. Ins. Code Ann. art. 3.70-3C, � 3A(a); id. art. 20A.18B(a) (Vernon Supp. 2002). The prompt
Id. art. 3.70-3C, � 3A(c); id. art. 20A.18B(c). If the PPO or HMO acknowledges coverage
the claim from the . . . provider." Id. art. 3.70-3C, � 3A(e); id. art. 20A.18B(e). A PPO or an HMO that fails to pay a provider in accordance with these requirements "is
that is not covered by" the health insurance policy or health care plan, id. art. 3.70-3C, � 3A(f); id.
Code, id. art. 3.70-3C, � 3A(h); id. art. 20A.18B(h). "The administrative penalty imposed under that
or (e) of this section." Id. art. 3.70-3C, � 3A(h); id. art. 20A.18B(h). The prompt payment provisions also require a PPO or an HMO to "provide a . . . provider
including required data elements and claim formats." Id. art. 3.70-3C, � 3A(i); id. art. 20A.18B(i).
be submitted with the . . . provider claim." Id. art. 3.70-3C, � 3A(j); id. art. 20A.18B(j). "Not later
each . . . provider." Id. art. 3.70-3C, � 3A(k); id. art. 20A.18B(k). Finally, both prompt payment
3.70-3C, � 3A(n) ("The commissioner of insurance may adopt rules as necessary to implement this
or procedures, including required data elements and claim formats," id. art. 3.70-3C, � 3A(i);
�� 21.2802(4) (2001) (defining clean claim), .2803(b) (required data elements), (c) (necessary
accordingly. See Tex. Gov't Code Ann. � 311.011(b) (Vernon 1998). Otherwise, words and
Id. � 311.011(a). When a statute does not define a term, we apply the term's ordinary meaning. See
data elements and claim formats." Tex. Ins. Code Ann. art. 3.70-3C, � 3A(i); id. art. 20A.18B(i)
clarification of coverage." Id. art. 21.58A, � 2(20). It is not clear to us that fee schedules or
understood meaning of those terms. See Tex. Gov't Code Ann. � 311.011 (Vernon 1998) (words
art. 3.70-3C, � 3A(i); id. art. 20A.18B(i) (Vernon Supp. 2002), are clearly intended, at a minimum, to ensure that providers will
of the statute. See Tex. Gov't Code Ann. � 311.023 (Vernon 1998); see also id. � 311.021 (in enacting a statute, it is presumed
Code Ann. art. 3.70-3C, � 3A(a), (h), (n) (Vernon Supp. 2002) ("The commissioner of insurance
including required data elements and claim formats." Tex. Ins. Code Ann. art. 3.70-3C, � 3A(i);
provisions. See id. art. 3.70-3C, � 3A(a), (h), (n) ("The commissioner of insurance may adopt rules
a presumption that components not expressed are excluded." Tex. Gov't Code Ann. � 311.005(13)
expertise in this matter. See Tex. Gov't Code Ann. � 311.011(b) (Vernon 1998) (words and
� 3A(c)(1); id. art. 20A.18B(c)(1) (Vernon Supp. 2002) (emphasis added). And, if the PPO or HMO
[PPO or HMO] receives the claim from the . . . provider." Id. art. 3.70-3C, � 3A(e); id. art.
Code Ann. art. 3.70-3C, � 3A(n) (Vernon Supp. 2002) ("The commissioner of insurance may adopt
Tex. Ins. Code Ann. art. 3.70-3C, � 3(n)(1)-(2) (Vernon Supp. 2002) (emphasis added), as amended
art. 3.70-3C, � 3A(i); id. art. 20A.18B(i) (Vernon Supp. 2002), to require disclosure of fee schedules
and claim formats," Tex. Ins. Code Ann. art. 3.70-3C, � 3A(i); id.
7. Under article 3.70-3C, a "preferred provider" is "a physician, practitioner, hospital, institutional provider, or health care provider, or an organization of physicians or health care providers, who contracts with an insurer to provide medical care or health care to insureds covered by a health insurance policy, certificate, or contract." Tex. Ins. Code Ann. art. 3.70-3C, � 1(10) (Vernon Supp. 2002). Article 3.70-3C applies to "any preferred provider benefit plan in which an insurer provides, through its health insurance policy, for the payment of a level of coverage which is different from the basic level of coverage provided by the health insurance policy if the insured uses a preferred provider." Id. � 2 ("This article does not apply to provisions for dental care benefits in any health insurance policy.").