Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter T - SUBMISSION OF CLEAN CLAIMS › Section 21.2809 - Audit Procedures

Current through Reg. 49, No. 28; July 12, 2024
(a) Notice and
				  payment required. If an MCC is unable to pay or deny a clean claim, in whole or
				  in part, within the applicable statutory claims payment period specified in
				  §
										21.2802 of
				  this title (relating to Definitions) and intends to audit the claim to
				  determine whether the claim is payable, the MCC must notify the preferred
				  provider that the claim is being audited and pay 100 percent of the contracted
				  rate within the applicable statutory claims payment period.
(b) Failure to provide notice and payment. An
				  MCC that fails to provide notice of the decision to audit the claim and pay 100
				  percent of the applicable contracted rate subject to copayments and deductibles
				  within the applicable statutory claims payment period, or, if applicable, the
				  extended periods allowed for by §
										21.2804(c)
				  of this title (relating to Requests for Additional Information from Treating
				  Preferred Provider) or §
										21.2819(c)
				  of this title (relating to Catastrophic Event), may not make use of the audit
				  procedures set out in this section. A preferred provider that receives less
				  than 100 percent of the contracted rate with a notice of intent to audit has
				  received an underpayment and must notify the MCC within 270 days in compliance
				  with the provisions of §
										21.2815(f)(2)
				  of this title (relating to Failure to Meet the Statutory Claims Payment Period)
				  to qualify to receive a penalty for the underpaid amount.
(c) Explanation of payment. The MCC must
				  clearly indicate on the explanation of payment that the claim is being audited
				  and that the preferred provider is being paid 100 percent of the contracted
				  rate, subject to completion of the audit. A nonelectronic explanation of
				  payment complies with this requirement if the notice of the audit is clearly
				  and prominently identified.
(d)
				  Audit deadline and requirements. The MCC must complete the audit within 180
				  calendar days from receipt of the clean claim. The HMO or preferred provider
				  carrier must provide written notice of the results of the audit. The MCC must
				  include in the notice a listing of the specific claims paid and not paid under
				  the audit, as well as a listing of specific claims and amounts for which a
				  refund is due and, for each claim, the basis and specific reasons for
				  requesting a refund. An MCC seeking recovery of any refund under this section
				  must comply with the procedures set out in §
										21.2818 of
				  this title (relating to Overpayment of Claims).
(e) Requests for information. An MCC may
				  recover the total amount paid on the claim under subsection (a) of this section
				  if a physician or a provider fails to timely provide additional information
				  requested under the requirements of Insurance Code §
										1301.105 or §
										843.340(c).
				  Section
				  21.2816 of this
				  title (relating to Date of Receipt) applies to the submission and receipt of a
				  request for information under this subsection.
(f) Opportunity for appeal. Before seeking a
				  refund for a payment made under this section, an MCC must provide a preferred
				  provider with the opportunity to appeal the request for a refund in compliance
				  with §
										21.2818 of
				  this title. An MCC may not seek to recover the refund until all of the
				  preferred provider's internal appeal rights under §
										21.2818 of
				  this title have been exhausted.
(g)
				  No admission of liability. Payments made under this section on a clean claim
				  are not an admission that the MCC acknowledges liability on that
				  claim.