reglab/housing_qa huggingface dataset:
TX Ins Code § 1301.104 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter C. Prompt Payment of Claims|Section 1301.104. Deadline for Action on Pharmacy Claims; Payment

Sec. 1301.104.  DEADLINE FOR ACTION ON PHARMACY CLAIMS; PAYMENT.  (a) An  insurer, or a pharmacy benefit manager that administers pharmacy claims for the insurer under a preferred provider benefit plan, that affirmatively adjudicates a pharmacy claim that is electronically submitted shall pay the total amount of the claim through electronic funds transfer not later than the 18th day after the date on which the claim was affirmatively adjudicated.(b)  An insurer, or a pharmacy benefit manager that administers pharmacy claims for the insurer under a preferred provider benefit plan, that affirmatively adjudicates a pharmacy claim that is not electronically submitted shall pay the total amount of the claim not later than the 21st day after the date on which the claim was affirmatively adjudicated.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(a), eff. September 1, 2005.Acts 2011, 82nd Leg., R.S., Ch. 798 (H.B. 2292), Sec. 9, eff. September 1, 2011.|
TX Ins Code § 1301.105 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter C. Prompt Payment of Claims|Section 1301.105. Audited Claims

Sec. 1301.105.  AUDITED CLAIMS.  (a)  Except as provided by Section 1301.1054, an insurer that intends to audit a claim submitted by a preferred provider shall pay the charges submitted at 100 percent of the contracted rate on the claim not later than:(1)  the 30th day after the date the insurer receives the clean claim from the preferred provider if the claim is submitted electronically; or(2)  the 45th day after the date the insurer receives the clean claim from the preferred provider if the claim is submitted nonelectronically.(b)  The insurer shall clearly indicate on the explanation of payment statement in the manner prescribed by the commissioner by rule that the clean claim is being paid at 100 percent of the contracted rate, subject to completion of the audit.(c)  If the insurer requests additional information to complete the audit, the request must describe with specificity the clinical information requested and relate only to information the insurer in good faith can demonstrate is specific to the claim or episode of care.  The insurer may not request as a part of the audit information that is not contained in, or is not in the process of being incorporated into, the patient's medical or billing record maintained by a preferred provider.(d)  If the preferred provider does not supply information reasonably requested by the insurer in connection with the audit, the insurer may:(1)  notify the provider in writing that the provider must provide the information not later than the 45th day after the date of the notice or forfeit the amount of the claim; and(2)  if the provider does not provide the information required by this section, recover the amount of the claim.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(a), eff. September 1, 2005.|
TX Ins Code § 1301.1051 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter C. Prompt Payment of Claims|Section 1301.1051. Completion of Audit

Sec. 1301.1051.  COMPLETION OF AUDIT.  The insurer must complete an audit under Section 1301.105 on or before the 180th day after the date the clean claim is received by the insurer, and any additional payment due a preferred provider or any refund due the insurer shall be made not later than the 30th day after the completion of the audit.|Amended by: Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(a), eff. September 1, 2005.|
TX Ins Code § 1301.1052 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter C. Prompt Payment of Claims|Section 1301.1052. Preferred Provider Appeal After Audit

Sec. 1301.1052.  PREFERRED PROVIDER APPEAL AFTER AUDIT.  If a preferred provider disagrees with a refund request made by an insurer based on an audit under Section 1301.105, the insurer shall provide the provider with an opportunity to appeal, and the insurer may not attempt to recover the payment until all appeal rights are exhausted.|Amended by: Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(a), eff. September 1, 2005.|
TX Ins Code § 1301.1053 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter C. Prompt Payment of Claims|Section 1301.1053. Deadlines Not Extended

Sec. 1301.1053.  DEADLINES NOT EXTENDED.  The investigation and determination of payment, including any coordination of other payments, does not extend the period for determining whether a claim is payable under Section 1301.103 or 1301.104 or for auditing a claim under Section 1301.105.|Amended by: Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(a), eff. September 1, 2005.|
TX Ins Code § 1301.1054 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter C. Prompt Payment of Claims|Section 1301.1054. Requests for Additional Information

Sec. 1301.1054.  REQUESTS FOR ADDITIONAL INFORMATION.  (a)  If an insurer needs additional information from a treating preferred provider to determine payment, the insurer, not later than the 30th calendar day after the date the insurer receives a clean claim, shall request in writing that the preferred provider provide an attachment to the claim that is relevant and necessary for clarification of the claim.  The request must describe with specificity the clinical information requested and relate only to information the insurer can demonstrate is specific to the claim or the claim's related episode of care.  The preferred provider is not required to provide an attachment that is not contained in, or is not in the process of being incorporated into, the patient's medical or billing record maintained by a preferred provider.(b)  An insurer that requests an attachment under Subsection (a) shall determine whether the claim is payable on or before the later of the 15th day after the date the insurer receives the requested attachment or the latest date for determining whether the claim is payable under Section 1301.103 or 1301.104.(c)  An insurer may not make more than one request under Subsection (a) in connection with a claim.  Sections 1301.102(b) and 1301.1021 apply to a request for and submission of an attachment under Subsection (a).(d)  If an insurer requests an attachment or other information from a person other than the preferred provider who submitted the claim, the insurer shall provide notice containing the name of the physician or health care provider from whom the insurer is requesting information to the preferred provider who submitted the claim.  The insurer may not withhold payment pending receipt of an attachment or information requested under this subsection. If on receiving an attachment or information requested under this subsection the insurer determines that there was an error in payment of the claim, the insurer may recover any overpayment under Section 1301.132.(e)  The commissioner shall adopt rules under which an insurer can easily identify attachments or other information submitted by a physician or health care provider under this section.|Amended by: Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(a), eff. September 1, 2005.|
TX Ins Code § 1301.106 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter C. Prompt Payment of Claims|Section 1301.106. Claims Processing Procedures and Claims Payment Processes

Sec. 1301.106.  CLAIMS PROCESSING PROCEDURES AND CLAIMS PAYMENT PROCESSES.  (a)  An insurer shall provide a preferred provider with copies of all applicable utilization review policies and claim processing policies or procedures.(b)  An insurer's claims payment processes shall:(1)  use nationally recognized, generally accepted Current Procedural Terminology codes, notes, and guidelines, including all relevant modifiers; and(2)  be consistent with nationally recognized, generally accepted bundling edits and logic.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(a), eff. September 1, 2005.|
TX Ins Code § 1301.107 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter C. Prompt Payment of Claims|Section 1301.107. Contractual Waiver and Other Actions Prohibited

Sec. 1301.107.  CONTRACTUAL WAIVER AND OTHER ACTIONS PROHIBITED.  Except as provided by Section 1301.102(e), the provisions of this subchapter may not be waived, voided, or nullified by contract.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(a), eff. September 1, 2005.|
TX Ins Code § 1301.108 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter C. Prompt Payment of Claims|Section 1301.108. Attorney's Fees

Sec. 1301.108.  ATTORNEY'S FEES.  A preferred provider may recover reasonable attorney's fees and court costs in an action to recover payment under this subchapter.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(a), eff. September 1, 2005.|
TX Ins Code § 1301.109 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter C. Prompt Payment of Claims|Section 1301.109. Applicability to Entities Contracting With Insurer

Sec. 1301.109.  APPLICABILITY TO ENTITIES CONTRACTING WITH INSURER.  This subchapter applies to a person, including a pharmacy benefit manager, with whom an insurer contracts to:(1)  process or pay claims;(2)  obtain the services of physicians and health care providers to provide health care services to insureds; or(3)  issue verifications or preauthorizations.|Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.Amended by: Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(a), eff. September 1, 2005.Acts 2011, 82nd Leg., R.S., Ch. 798 (H.B. 2292), Sec. 11, eff. September 1, 2011.|
TX Ins Code § 1301.131 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter C. -1. Other Provisions Relating to Payment of Claims|Section 1301.131. Elements of Clean Claim

Sec. 1301.131.  ELEMENTS OF CLEAN CLAIM.  (a)  A nonelectronic claim by a physician or health care provider, other than an institutional provider, is a "clean claim" if the claim is submitted using the Centers for Medicare and Medicaid Services Form 1500 or, if adopted by the commissioner by rule, a successor to that form developed by the National Uniform Claim Committee or the committee's successor.  An electronic claim by a physician or provider, other than an institutional provider, is a "clean claim" if the claim is submitted using the Professional 837 (ASC X12N 837) format or, if adopted by the commissioner by rule, a successor to that format adopted by the Centers for Medicare and Medicaid Services or the center's successor.(b)  A nonelectronic claim by an institutional provider is a "clean claim" if the claim is submitted using the Centers for Medicare and Medicaid Services Form UB-92 or, if adopted by the commissioner by rule, a successor to that form developed by the National Uniform Billing Committee or the committee's successor.  An electronic claim by an institutional provider is a "clean claim" if the claim is submitted using the Institutional 837 (ASC X12N 837) format or, if adopted by the commissioner by rule, a successor to that format adopted by the Centers for Medicare and Medicaid Services or the centers' successor.(c)  The commissioner may adopt rules that specify the information that must be entered into the appropriate fields on the applicable claim form for a claim to be a clean claim.(d)  The commissioner may not require any data element for an electronic claim that is not required in an electronic transaction set needed to comply with federal law.(e)  An insurer and a preferred provider may agree by contract to use fewer data elements than are required in an electronic transaction set needed to comply with federal law.(f)  An otherwise clean claim submitted by a physician or health care provider that includes additional fields, data elements, attachments, or other information not required under this section is considered to be a clean claim for the purposes of this chapter.(g)  Except as provided by Subsection (e), the provisions of this section may not be waived, voided, or nullified by contract.|Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(b), eff. September 1, 2005.|
TX Ins Code § 1301.132 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter C. -1. Other Provisions Relating to Payment of Claims|Section 1301.132. Overpayment

Sec. 1301.132.  OVERPAYMENT.  (a)  An insurer may recover an overpayment to a physician or health care provider if:(1)  not later than the 180th day after the date the physician or provider receives the payment, the insurer provides written notice of the overpayment to the physician or provider that includes the basis and specific reasons for the request for recovery of funds; and(2)  the physician or provider does not make arrangements for repayment of the requested funds on or before the 45th day after the date the physician or provider receives the notice.(b)  If a physician or health care provider disagrees with a request for recovery of an overpayment, the insurer shall provide the physician or provider with an opportunity to appeal, and the insurer may not attempt to recover the overpayment until all appeal rights are exhausted.|Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(b), eff. September 1, 2005.|
TX Ins Code § 1301.133 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter C. -1. Other Provisions Relating to Payment of Claims|Section 1301.133. Verification

Sec. 1301.133.  VERIFICATION.  (a)  In this section, "verification" includes preauthorization only when preauthorization is a condition for the verification.(b)  On the request of a preferred provider for verification of a particular medical care or health care service the preferred provider proposes to provide to a particular patient, the insurer shall inform the preferred provider without delay whether the service, if provided to that patient, will be paid by the insurer and shall specify any deductibles, copayments, or coinsurance for which the insured is responsible.(c)  An insurer shall have appropriate personnel reasonably available at a toll-free telephone number to provide a verification under this section between 6 a.m. and 6 p.m. central time Monday through Friday on each day that is not a legal holiday and between 9 a.m. and noon central time on Saturday, Sunday, and legal holidays.  An insurer must have a telephone system capable of accepting or recording incoming phone calls for verifications after 6 p.m. central time Monday through Friday and after noon central time on Saturday, Sunday, and legal holidays and responding to each of those calls on or before the second calendar day after the date the call is received.(d)  An insurer may decline to determine eligibility for payment if the insurer notifies the physician or preferred provider who requested the verification of the specific reason the determination was not made.(e)  An insurer may establish a specific period during which the verification is valid of not less than 30 days.(f)  An insurer that declines to provide a verification shall notify the physician or provider who requested the verification of the specific reason the verification was not provided.(g)  If an insurer has provided a verification for proposed medical care or health care services, the insurer may not deny or reduce payment to the physician or provider for those medical care or health care services if provided to the insured on or before the 30th day after the date the verification was provided unless the physician or provider has materially misrepresented the proposed medical care or health care services or has substantially failed to perform the proposed medical care or health care services.(h)  The provisions of this section may not be waived, voided, or nullified by contract.|Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(b), eff. September 1, 2005.|
TX Ins Code § 1301.134 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter C. -1. Other Provisions Relating to Payment of Claims|Section 1301.134. Coordination of Payment

Sec. 1301.134.  COORDINATION OF PAYMENT.  (a)  An insurer may require a physician or health care provider to retain in the physician's or provider's records updated information concerning other health benefit plan coverage and to provide the information to the insurer on the applicable form described by Section 1301.131.  Except as provided by this subsection, an insurer may not require a physician or provider to investigate coordination of other health benefit plan coverage.(b)  Coordination of payment under this section does not extend the period for determining whether a service is eligible for payment under Section 1301.103 or 1301.104 or for auditing a claim under Section 1301.105.(c)  A physician or health care provider who submits a claim for particular medical care or health care services to more than one health maintenance organization or insurer shall provide written notice on the claim submitted to each health maintenance organization or insurer of the identity of each other health maintenance organization or insurer with which the same claim is being filed.(d)  On receipt of notice under Subsection (c), an insurer shall coordinate and determine the appropriate payment for each health maintenance organization or insurer to make to the physician or health care provider.(e)  Except as provided by Subsection (f), if an insurer is a secondary payor and pays a portion of a claim that should have been paid by the insurer or health maintenance organization that is the primary payor, the overpayment may only be recovered from the health maintenance organization or insurer that is primarily responsible for that amount.(f)  If the portion of the claim overpaid by the secondary insurer was also paid by the primary health maintenance organization or insurer, the secondary insurer may recover the amount of overpayment under Section 1301.132 from the physician or health care provider who received the payment.  An insurer processing an electronic claim as a secondary payor shall rely on the primary payor information submitted on the claim by the physician or provider.  Primary payor information may be submitted electronically by the primary payor to the secondary payor.(g)  An insurer may share information with a health maintenance organization or another insurer to the extent necessary to coordinate appropriate payment obligations on a specific claim.(h)  The provisions of this section may not be waived, voided, or nullified by contract.|Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(b), eff. September 1, 2005.|
TX Ins Code § 1301.1353 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter C. -1. Other Provisions Relating to Payment of Claims|Section 1301.1353. Remedy for Noncompliance

Sec. 1301.1353.  REMEDY FOR NONCOMPLIANCE.  (a)  In addition to any other penalty or remedy provided by law, an insurer that uses a preauthorization process for medical care or health care services that violates this subchapter with respect to a required publication, notice, or response regarding its preauthorization requirements, including by failing to comply with any applicable deadline for the publication, notice, or response, must provide an expedited appeal under Section 4201.357 for any medical care or health care service affected by the violation.(b)  The provisions of this section may not be waived, voided, or nullified by contract.|Added by Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 2.04, eff. September 1, 2019.|
TX Ins Code § 1301.136 (2021)
2021 Texas Statutes|Insurance Code|Title 8 - Health Insurance and Other Health Coverages|Subtitle D - Provider Plans|Chapter 1301 - Preferred Provider Benefit Plans|Subchapter C. -1. Other Provisions Relating to Payment of Claims|Section 1301.136. Availability of Coding Guidelines

Sec. 1301.136.  AVAILABILITY OF CODING GUIDELINES.  (a)  A contract between an insurer and a preferred provider must provide that:(1)  the preferred provider may request a description and copy of the coding guidelines, including any underlying bundling, recoding, or other payment process and fee schedules applicable to specific procedures that the preferred provider will receive under the contract;(2)  the insurer or the insurer's agent will provide the coding guidelines and fee schedules not later than the 30th day after the date the insurer receives the request;(3)  the insurer or the insurer's agent will provide notice of changes to the coding guidelines and fee schedules that will result in a change of payment to the preferred provider not later than the 90th day before the date the changes take effect and will not make retroactive revisions to the coding guidelines and fee schedules; and(4)  the contract may be terminated by the preferred provider on or before the 30th day after the date the preferred provider receives information requested under this subsection without penalty or discrimination in participation in other health care products or plans.(b)  A preferred provider who receives information under Subsection (a) may only:(1)  use or disclose the information for the purpose of practice management, billing activities, and other business operations; and(2)  disclose the information to a governmental agency involved in the regulation of health care or insurance.(c)  The insurer shall, on request of the preferred provider, provide the name, edition, and model version of the software that the insurer uses to determine bundling and unbundling of claims.(d)  The provisions of this section may not be waived, voided, or nullified by contract.|Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(b), eff. September 1, 2005.|