reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter R - DIABETES › Section 21.2601 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
					 subchapter, have the following meanings, unless the context clearly indicates
					 otherwise.
(1) Basic benefit--Health
				  care service or coverage, which is included in the evidence of coverage,
				  policy, or certificate, without additional premium.
(2) Caretaker--A family member or significant
				  other responsible for ensuring that an insured not able to manage his or her
				  illness (due to age or infirmity) is properly managed, including overseeing
				  diet, administration of medications, and use of equipment and
				  supplies.
(3) Diabetes--Diabetes
				  mellitus. A chronic disorder of glucose metabolism that can be characterized by
				  an elevated blood glucose level. The terms "diabetes" and "diabetes mellitus"
				  are synonymous.
(4) Diabetes
				  equipment--The term "diabetes equipment" includes items defined in Insurance
				  Code §
										1358.051 and §
										1358.056,
				  and §
										21.2605
				  of this title (relating to Diabetes Equipment and Supplies).
(5) Diabetes supplies--The term "diabetes
				  supplies" includes items defined in Insurance Code §
										1358.051 and §
										1358.056,
				  and §
										21.2605
				  of this title.
(6) Diabetes
				  self-management training--Instruction enabling an insured and/or his or her
				  caretaker to understand the care and management of diabetes, including
				  nutritional counseling and proper use of diabetes equipment and
				  supplies.
(7) Health benefit
				  plan--A health benefit plan, for purposes of this subchapter, means:
(A) a plan that provides benefits for medical
				  or surgical expenses incurred as a result of a health condition, accident, or
				  sickness, including:
(i) an individual, group,
				  blanket, or franchise insurance policy or insurance agreement; a group hospital
				  service contract; or an individual or group evidence of coverage that is
				  offered by:
(I) an insurance
				  company;
(II) a group hospital
				  service corporation operating under Insurance Code Chapter 842;
(III) a fraternal benefit society operating
				  under Insurance Code Chapter 885;
(IV) a stipulated premium insurance company
				  operating under Insurance Code Chapter 884;
(V) a reciprocal exchange operating under
				  Texas Insurance Code Chapter 942; or
(VI) a health maintenance organization (HMO)
				  operating under Insurance Code Chapter 843;
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter R - DIABETES › Section 21.2602 - Required Benefits for Persons with Diabetes

Current through Reg. 49, No. 28; July 12, 2024
(a) Notwithstanding §
										172.014,
				  Local Government Code, or any other law, health plans provided by a risk pool
				  created under Chapter 172, Local Government Code, delivered, issued for
				  delivery, or renewed on or after January 1, 1998, that provide benefits for the
				  treatment of diabetes and associated conditions must provide coverage to an
				  insured for diabetes equipment, diabetes supplies, and diabetes self-management
				  training programs, in accordance with §
										21.2603 of
				  this title (relating to Out of Pocket Expenses), §
										21.2605
				  of this title (relating to Diabetes Equipment and Supplies) and §
										21.2606
				  of this title (relating to Diabetes Self-Management Training).
(b) Health benefit plans (other than
				  reciprocal exchanges operating under Chapter 942 of the Texas Insurance Code)
				  delivered, issued for delivery, or renewed on or after January 1, 1999, must
				  provide coverage to each insured in accordance with §
										21.2603 of
				  this title and §
										21.2604
				  of this title (relating to Minimum Standards for Benefits for Persons with
				  Diabetes).
(c) Health benefits
				  plans delivered, issued for delivery, or renewed on or after January 1, 1998,
				  by an entity other than an HMO, which provide coverage limited to
				  hospitalization expenses, shall provide coverage to each insured for diabetes
				  equipment, diabetes supplies, and diabetes self-management training programs,
				  in accordance with §§
										21.2603,
				  21.2605
				  and
				  21.2606
				  of this title, during hospitalization of the insured.
(d) A determination of medical necessity may
				  be applied to benefits required under this subchapter provided it complies with
				  all applicable laws and regulations.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter R - DIABETES › Section 21.2603 - Out of Pocket Expenses

Current through Reg. 49, No. 28; July 12, 2024
(a) The basic
				  benefits required under this subchapter shall not be subject to a deductible,
				  coinsurance, or copayment requirement that exceeds the applicable deductible,
				  coinsurance, or copayment applicable to other analogous chronic medical
				  conditions or other similar benefits provided under the plan.
(b) No more than one copayment shall be
				  charged for a thirty-day supply of any item of diabetes supplies listed in
				  §
										21.2605
				  of this title (relating to Diabetes Equipment and Supplies). The amount of
				  supplies that constitutes a thirty-day supply for an insured is the amount
				  prescribed as a thirty-day supply by the physician or practitioner of the
				  insured.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter R - DIABETES › Section 21.2604 - Minimum Standards for Benefits for Persons with Diabetes, Requirement for Periodic Assessment of Physician and Organizational Compliance

Current through Reg. 49, No. 28; July 12, 2024
(a) Health benefit plans provided by HMOs
				  must provide coverage for the services in paragraphs (1) through (7) of this
				  subsection and must contract with providers that agree to comply with the
				  minimum practice standards outlined in subsection (b) of this section. Services
				  to be covered include:
(1) office visits and
				  consultations with physicians and practitioners for monitoring and treatment of
				  diabetes, including office visits and consultations with appropriate
				  specialists;
(2) immunizations
				  required by Insurance Code Chapter 1367, Subchapter B, Coverage for Childhood
				  Immunizations;
(3) immunizations
				  for influenza and pneumococcus;
(4)
				  inpatient services, and physician and practitioner services when the insured is
				  confined to:
(A) a hospital;
(B) a rehabilitation facility; or
(C) a skilled nursing facility;
(5) inpatient and outpatient
				  laboratory and diagnostic imaging services;
(6) diabetes equipment and supplies in
				  accordance with §
											21.2605
				  of this title (relating to Diabetes Equipment and Supplies); and
(7) diabetes self-management training, in
				  accordance with subsection (b)(1)(A)(iii) of this section and §
											21.2606
				  of this title (relating to Diabetes Self-Management Training);
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter R - DIABETES › Section 21.2605 - Diabetes Equipment and Supplies

Current through Reg. 49, No. 28; July 12, 2024
(a) A
				  health benefit plan shall provide coverage for equipment and supplies for the
				  treatment of diabetes for which a physician or practitioner has written an
				  order, including:
(1) blood glucose monitors,
				  including those designed to be used by or adapted for the legally
				  blind;
(2) test strips specified
				  for use with a corresponding glucose monitor;
(3) lancets and lancet devices;
(4) visual reading strips and urine testing
				  strips and tablets which test for glucose, ketones and protein;
(5) insulin and insulin analog
				  preparations;
(6) injection aids,
				  including devices used to assist with insulin injection and needleless
				  systems;
(7) insulin
				  syringes;
(8) biohazard disposal
				  containers;
(9) insulin pumps, both
				  external and implantable, and associated appurtenances, which include:
(A) insulin infusion devices;
(B) batteries;
(C) skin preparation items;
(D) adhesive supplies;
(E) infusion sets;
(F) insulin cartridges;
(G) durable and disposable devices to assist
				  in the injection of insulin; and
(H) other required disposable
				  supplies;
(10) repairs
				  and necessary maintenance of insulin pumps not otherwise provided for under a
				  manufacturer's warranty or purchase agreement, and rental fees for pumps during
				  the repair and necessary maintenance of insulin pumps, neither of which shall
				  exceed the purchase price of a similar replacement pump;
(11) prescription medications which bear the
				  legend "Caution: Federal Law prohibits dispensing without a prescription" and
				  medications available without a prescription for controlling the blood sugar
				  level;
(12) podiatric appliances,
				  including up to two pairs of therapeutic footwear per year, for the prevention
				  of complications associated with diabetes; and
(13) glucagon emergency kits.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter R - DIABETES › Section 21.2606 - Diabetes Self-Management Training

Current through Reg. 49, No. 28; July 12, 2024
(a) A
				  health benefit plan must provide diabetes self-management training or coverage
				  for diabetes self-management training for which a physician or practitioner has
				  written an order, including a written order of a practitioner practicing under
				  protocols jointly developed with a physician, to each insured or the caretaker
				  of the insured in accordance with the standards contained in Insurance Code
				  §
										1358.054.
(b) A person may not provide a component of
				  diabetes self-management training under subsection (a) of this section unless
				  the subject matter of the component is within the scope of the person's
				  practice and the person meets the education requirements as determined by the
				  person's licensing agency in consultation with the Commissioner of Public
				  Health .
(c) Self-management
				  training should include the development of an individualized management plan
				  that is created for and in collaboration with the insured and that meets the
				  requirements of the minimum standards for benefits in accordance with §
										21.2604
				  of this title (relating to Minimum Standards for Benefits for Persons with
				  Diabetes).
(d) Nutrition counseling
				  and instructions on the proper use of diabetes equipment and supplies must be
				  provided or covered as part of the training.
(e) Diabetes self-management training must be
				  provided, or coverage for diabetes self-management training must be provided to
				  an insured or a caretaker, upon the following occurrences relating to an
				  insured, provided that any training involving the administration of medications
				  must comply with the applicable delegation rules from the appropriate licensing
				  agency:
(1) the initial diagnosis of
				  diabetes;
(2) the written order of
				  a physician or practitioner indicating that a significant change in the
				  symptoms or condition of the insured requires changes in the insured's
				  self-management regime;
(3) the
				  written order of a physician or practitioner that periodic or episodic
				  continuing education is warranted by the development of new techniques and
				  treatment for diabetes.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter S - ASSOCIATION PLANS › Section 21.2701 - Scope

Current through Reg. 49, No. 28; July 12, 2024
Unless otherwise specified, this subchapter applies to all
					 health carriers that issue health benefit plans to associations or bona fide
					 associations. This subchapter does not apply to coverage issued to employer
					 associations.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter S - ASSOCIATION PLANS › Section 21.2702 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms when used in this subchapter
					 have the following meanings, unless the context clearly indicates otherwise.
(1) Association--An association
				  (other than an employer association), including but not limited to a labor
				  union or organizations of such unions, membership corporations organized or
				  holding a certificate of authority under the Texas Non-profit Corporation Act,
				  and cooperatives and corporations subject to the supervision and control of the
				  Farm Credit Administration of the United States of America, that:
(A) has a constitution and bylaws;
(B) has been actively in existence for at
				  least 2 years; and
(C) has been
				  formed and maintained in good faith for purposes other than obtaining coverage
				  under a health benefit plan to cover members for the benefit of persons other
				  than the association or its officers or trustees.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter S - ASSOCIATION PLANS › Section 21.2703 - Health Care Plans Issued to Associations and Bona Fide Associations

Current through Reg. 49, No. 28; July 12, 2024
A health benefit plan issued to an association or a bona
					 fide association is considered a group product, and shall comply with the
					 statutes and regulations applicable to coverages and benefits relating to group
					 products. Notwithstanding any other provisions of this subchapter to the
					 contrary, health carriers other than HMOs that offer health benefit plans to
					 associations that are not bona fide associations may decline, restrict, limit,
					 exclude or rate-up coverage based upon a member's health status-related
					 factors.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter S - ASSOCIATION PLANS › Section 21.2704 - Mandatory Guaranteed Renewability Provisions for Health Benefit Plans Issued to Members of an Association or Bona Fide Association

Current through Reg. 49, No. 28; July 12, 2024
(a) Except as provided by subsection (d) of
				  this section, a health carrier shall renew a health benefit plan issued to an
				  association, or a bona fide association, at the option of the association or
				  bona fide association, unless:
(1) the
				  association or bona fide association has failed to pay premiums or
				  contributions in accordance with the terms of the health benefit plan,
				  including any timeliness requirements;
(2) the association or bona fide association
				  has performed an act or practice that constitutes fraud, or has made an
				  intentional misrepresentation of material fact, relating in any way to the
				  health benefit plan, including claims for benefits under the health benefit
				  plan;
(3) in regards only to a
				  health benefit plan offered by an HMO or a group hospital service plan issued
				  under the Insurance Code Chapter 20, the association or bona fide association
				  ceases to have any covered members who reside, live, or work in the service
				  area of the HMO or group hospital service plan, but only if coverage is
				  terminated uniformly without regard to any health status-related factor of
				  covered members or dependents of covered members, if dependent coverage is
				  offered; or
(4) the health carrier
				  is ceasing to offer health benefit plan coverage in the association market in
				  accordance with subsection (d) of this section.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter S - ASSOCIATION PLANS › Section 21.2705 - Certification of Creditable Coverage

Current through Reg. 49, No. 28; July 12, 2024
Each health carrier that issues a health benefit plan to
					 members of an association or bona fide association shall provide a
					 certification of coverage in accordance with §§
										21.1103-21.1107
					 of this title (relating to Notification of Creditable
					 Coverage).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter S - ASSOCIATION PLANS › Section 21.2706 - Coverage and Issuance Requirements to Bona Fide Associations

Current through Reg. 49, No. 28; July 12, 2024
(a) A health carrier that issues a health
				  benefit plan to a bona fide association may refuse to provide coverage to all
				  members, and dependents of members if dependent coverage is offered, of a bona
				  fide association in accordance with the health carrier's underwriting standards
				  and criteria. However, on issuance to a bona fide association, each carrier
				  shall provide coverage to each member without regard to the member's health
				  status-related factors.
(b) A
				  health carrier that issues a health benefit plan to members of a bona fide
				  association shall accept or reject all members who apply for coverage and may
				  exclude only those members who have not applied for coverage.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter T - SUBMISSION OF CLEAN CLAIMS › Section 21.2801 - Purpose and Scope

Current through Reg. 49, No. 28; July 12, 2024
The purpose of this subchapter is to specify the
					 definitions and procedures necessary to implement Insurance Code Chapters 843
					 and 1301 relating to clean claims and prompt payment of physician and provider
					 claims. This subchapter applies to all nonelectronic and electronic claims
					 submitted by contracted physicians or providers for services or benefits
					 provided to insureds of preferred provider carriers, insureds of exclusive
					 provider carriers, and enrollees of health maintenance organizations. The
					 subchapter also has limited applicability to noncontracted physicians and
					 providers. This subchapter does not apply to an exclusive provider benefit plan
					 regulated under Chapter 3, Subchapter KK of this title (relating to Exclusive
					 Provider Benefit Plan) written by an insurer under a contract with the Health
					 and Human Services Commission to provide services under the Texas Children's
					 Health Insurance Program or Medicaid.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter T - SUBMISSION OF CLEAN CLAIMS › Section 21.2802 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms when used in this subchapter
					 have the following meanings unless the context clearly indicates
					 otherwise:
(1) Audit--A procedure
				  authorized by and described in §
										21.2809 of this
				  title (relating to Audit Procedures) under which a managed care carrier (MCC)
				  may investigate a claim beyond the statutory claims payment period without
				  incurring penalties under §
										21.2815
				  of this title (relating to Failure to Meet the Statutory Claims Payment
				  Period).
(2) Batch submission--A
				  group of electronic claims submitted for processing at the same time within a
				  HIPAA standard ASC X12N 837 Transaction Set and identified by a batch control
				  number.
(3) Billed charges--The
				  charges for medical care or health care services included on a claim submitted
				  by a physician or a provider. For purposes of this subchapter, billed charges
				  must comply with all other applicable requirements of law, including Health and
				  Safety Code §
										311.0025,
				  Occupations Code §
										105.002,
				  and Insurance Code Chapter 552.
(4)
				  CMS--The Centers for Medicare and Medicaid Services of the U.S. Department of
				  Health and Human Services.
(5)
				  Catastrophic event--An event, including an act of God, civil or military
				  authority, or public enemy; war, accident, fire, explosion, earthquake,
				  windstorm, flood, or organized labor stoppage, that cannot reasonably be
				  controlled or avoided and that causes an interruption in the claims submission
				  or processing activities of an entity for more than two consecutive business
				  days.
(6) Clean claim--
(A) For nonelectronic claims, a claim
				  submitted by a physician or a provider for medical care or health care services
				  rendered to an enrollee under a health care plan or to an insured under a
				  health insurance policy that includes:
(i)
				  the required data elements set out in §
												21.2803(b) or
				  (c) of this title (relating to Elements of a
				  Clean Claim); and
(ii) if
				  applicable, the amount paid by the primary plan or other valid coverage under
				  §
												21.2803(d)
				  of this title;
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter T - SUBMISSION OF CLEAN CLAIMS › Section 21.2803 - Elements of a Clean Claim

Current through Reg. 49, No. 28; July 12, 2024
(a) Filing a clean
				  claim. A physician or a provider submits a clean claim by providing to an MCC
				  or any other entity designated for receipt of claims under §
										21.2811
				  of this title (related to Disclosure of Processing Procedures):
(1) for nonelectronic claims other than
				  dental claims, the required data elements specified in subsection (b) of this
				  section;
(2) for nonelectronic
				  dental claims filed with an HMO, the required data elements specified in
				  subsection (c) of this section;
(3)
				  for electronic claims and for electronic dental claims filed with an HMO, the
				  required data elements specified in subsections (e) and (f) of this section;
				  and
(4) if applicable, any
				  coordination of benefits or nonduplication of benefits information under
				  subsection (d) of this section.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter T - SUBMISSION OF CLEAN CLAIMS › Section 21.2804 - Requests for Additional Information from Treating Preferred Provider

Current through Reg. 49, No. 28; July 12, 2024
(a) If necessary to determine whether a claim
				  is payable, an MCC may, within 30 days of receipt of a clean claim, request
				  additional information from the treating preferred provider. The time to
				  request additional information may be extended as allowed by §
										21.2819(c)
				  of this title (relating to Catastrophic Event). An MCC may make only one
				  request to the submitting treating preferred provider for information under
				  this section.
(b) A request for
				  information under this section must:
(1) be in
				  writing;
(2) be specific to the
				  claim or the claim's related episode of care;
(3) describe with specificity the clinical
				  and other information to be included in the response;
(4) be relevant and necessary for the
				  resolution of the claim; and
(5) be
				  for information that is contained in or in the process of being incorporated
				  into the patient's medical or billing record maintained by the preferred
				  provider.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter T - SUBMISSION OF CLEAN CLAIMS › Section 21.2805 - Requests for Additional Information from Other Sources

Current through Reg. 49, No. 28; July 12, 2024
(a) If an MCC requests additional information
				  from a person other than the preferred provider who submitted the claim, the
				  MCC must provide to the preferred provider who submitted the claim a notice
				  containing the name of the physician, the provider, or the other entity from
				  which the MCC is requesting information. The MCC may not withhold payment
				  beyond the applicable statutory claims payment period pending receipt of
				  information requested under subsection (b) of this section. If, on receiving
				  information requested under this subsection the MCC determines that there was
				  an error in payment of the claim, the MCC may recover any overpayment under
				  §
										21.2818 of
				  this title (relating to Overpayment of Claims).
(b) An MCC must request that the entity
				  responding to a request made under this section attach a copy of the request to
				  the response. If the request for additional information was submitted
				  electronically in compliance with applicable federal requirements concerning
				  electronic transactions, the responding entity must submit the response in
				  compliance with those requirements, if applicable.
(c) Receipt of a request or a response to a
				  request under this section is subject to the provisions of §
										21.2816 of this
				  title (relating to Date of Receipt).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter T - SUBMISSION OF CLEAN CLAIMS › Section 21.2807 - Effect of Filing a Clean Claim

Current through Reg. 49, No. 28; July 12, 2024
(a) The
				  statutory claims payment period begins to run on receipt of a clean claim,
				  including a corrected claim that is a clean claim, from a preferred provider,
				  under §
										21.2816 of this
				  title (relating to Date of Receipt), at the address designated by the MCC, in
				  compliance with §
										21.2811
				  of this title (relating to Disclosure of Processing Procedures), whether it be
				  the address of the MCC or any other entity, including a clearinghouse or a
				  repricing company, designated by the MCC 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 before
				  the expiration of the applicable statutory claims payment period specified in
				  §
										21.2802 of
				  this title (relating to Definitions), an MCC must:
(1) pay the total amount of the clean claim
				  as specified in the contract between the preferred provider and the
				  MCC;
(2) deny the clean claim in
				  its entirety after a determination that the MCC 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 of the contracted rate on the claim to the preferred provider;
				  or
(4) pay the portion of the clean
				  claim for which the MCC acknowledges liability as specified in the contract
				  between the preferred provider and the MCC, and:
(A) deny the remainder of the clean claim
				  after a determination that the MCC 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 remainder of the clean claim will be audited and pay 100 percent of
				  the contracted rate on the unpaid portion of the clean claim to the preferred
				  provider.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter T - SUBMISSION OF CLEAN CLAIMS › Section 21.2808 - Effect of Filing Deficient Claim

Current through Reg. 49, No. 28; July 12, 2024
If an MCC determines that a submitted claim is deficient,
					 the MCC must notify the preferred provider submitting the claim that the claim
					 is deficient within 45 calendar days of the MCC's receipt of the nonelectronic
					 claim, or within 30 days of receipt of an electronic claim. If an MCC
					 determines that a claim for a prescription benefit is deficient, the MCC must
					 notify the provider that the claim is deficient within 21 calendar days of the
					 MCC's receipt of the nonelectronic claim, or within 18 days of receipt of an
					 electronic claim.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter T - SUBMISSION OF CLEAN CLAIMS › Section 21.2810 - Date of Claim Payment

Current through Reg. 49, No. 28; July 12, 2024
For purposes of determining compliance with the statutory
					 claims payment period, payment is considered to have been paid on the date
					 of:
(1) the postmark, if a claim
				  payment is delivered by the United States Postal Service;
(2) electronic transmission, if a claim
				  payment is made electronically;
(3)
				  delivery of the claim payment to a commercial carrier, such as UPS or Federal
				  Express; or
(4) receipt by the
				  physician or provider, if a claim payment is made other than as provided in
				  paragraph (1), (2), or (3) of this section.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter T - SUBMISSION OF CLEAN CLAIMS › Section 21.2811 - Disclosure of Processing Procedures

Current through Reg. 49, No. 28; July 12, 2024
(a) In
				  contracts with preferred providers, or in the physician or the provider manual
				  or other document that sets forth the procedure for filing claims, or by any
				  other method mutually agreed on by the contracting parties, an MCC must
				  disclose to its preferred providers:
(1) the
				  address, including a physical address, where claims are to be sent for
				  processing;
(2) the telephone
				  number to which preferred providers' questions and concerns regarding claims
				  may be directed;
(3) any entity,
				  along with its address, including physical address and telephone number, to
				  which the MCC has delegated claim payment functions; and
(4) the mailing address, physical address,
				  and telephone number of any separate claims processing centers for specific
				  types of services.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter T - SUBMISSION OF CLEAN CLAIMS › Section 21.2812 - Denial of Clean Claim Prohibited for Change of Address

Current through Reg. 49, No. 28; July 12, 2024
After a change of claims payment address or a change in
					 delegation of claims payment functions, an MCC may not premise the denial of a
					 clean claim on a preferred provider's failure to file a claim within the claim
					 filing deadline set out in §
										21.2806 of
					 this title (relating to Claim Filing Deadline), unless the MCC has given timely
					 written notice as required by §
										21.2811(b)
					 of this title (relating to Disclosure of Processing
					 Procedures).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter T - SUBMISSION OF CLEAN CLAIMS › Section 21.2813 - Requirements Applicable to Other Contracting Entities

Current through Reg. 49, No. 28; July 12, 2024
Any contract or delegation agreement between an MCC and an
					 entity that processes or pays claims, obtains the services of physicians and
					 providers to provide health care services, or issues verifications or
					 preauthorizations may not limit the MCC's authority or responsibility to comply
					 with all applicable statutory and regulatory requirements.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter T - SUBMISSION OF CLEAN CLAIMS › Section 21.2814 - Electronic Adjudication of Prescription Benefits

Current through Reg. 49, No. 28; July 12, 2024
If a prescription benefit does not require authorization by
					 an MCC, the statutory claims payment period must begin on the date of
					 affirmative adjudication of the claim for a prescription
					 benefit.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter T - SUBMISSION OF CLEAN CLAIMS › Section 21.2815 - Failure to Meet the Statutory Claims Payment Period

Current through Reg. 49, No. 28; July 12, 2024
(a) An MCC that determines under §
										21.2807
				  of this title (relating to Effect of Filing a Clean Claim) that a claim is
				  payable must pay the contracted rate owed on the claim; and:
(1) if the claim is paid on or before the
				  45th day after the end of the applicable statutory claims payment period, pay
				  to a noninstitutional preferred provider a penalty in the amount of the lesser
				  of:
(A) 50 percent of the difference between
				  the billed charges and the contracted rate; or
(B) $100,000;
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter T - SUBMISSION OF CLEAN CLAIMS › Section 21.2816 - Date of Receipt

Current through Reg. 49, No. 28; July 12, 2024
(a) A written
				  communication, including a claim, referenced under this subchapter is subject
				  to and must comply with this section unless otherwise stated in this
				  subchapter.
(b) An entity subject
				  to these rules may deliver written communications as follows:
(1) submit the communication by United States
				  mail, first class; by United States mail, return receipt requested; or by
				  overnight delivery;
(2) submit the
				  communication electronically and maintain proof of the electronically submitted
				  communication;
(3) if the entity
				  accepts facsimile transmissions for the type of communication being sent, fax
				  the communication and maintain proof of facsimile transmission; or
(4) hand deliver the communication and
				  maintain a copy of the signed receipt acknowledging the hand
				  delivery.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter T - SUBMISSION OF CLEAN CLAIMS › Section 21.2817 - Terms of Contracts

Current through Reg. 49, No. 28; July 12, 2024
Unless otherwise provided in this subchapter, contracts
					 between MCCs and preferred providers may not include terms that:
(1) extend the statutory or regulatory time
				  frames; or
(2) waive the preferred
				  provider's right to recover reasonable attorney's fees and court costs under
				  Insurance Code §
										1301.108 and
				  §
										843.343.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter T - SUBMISSION OF CLEAN CLAIMS › Section 21.2818 - Overpayment of Claims

Current through Reg. 49, No. 28; July 12, 2024
(a) An MCC may
				  recover a refund due to overpayment or completion of an audit if:
(1) the MCC notifies the physician or the
				  provider of the overpayment not later than the 180th day after the date of
				  receipt of the overpayment; or
(2)
				  the MCC notifies the physician or the provider of the completion of an audit
				  under §
											21.2809 of this
				  title (relating to Audit Procedures).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter T - SUBMISSION OF CLEAN CLAIMS › Section 21.2819 - Catastrophic Event

Current through Reg. 49, No. 28; July 12, 2024
(a) An MCC, a
				  physician, or a provider must notify the Texas Department of Insurance (TDI)
				  if, due to a catastrophic event, it is unable to meet the deadlines in §
										21.2804 of this title (relating to
				  Requests for Additional Information from Treating Preferred Provider), §
										21.2806 of this title (relating to
				  Claims Filing Deadline), §
										21.2807 of this title (relating to
				  Effect of Filing a Clean Claim), §
										21.2808 of this title (relating to
				  Effect of Filing Deficient Claim), §
										21.2809 of this title (relating to
				  Audit Procedures), and §
										21.2815 of this title (relating to
				  Failure to Meet the Statutory Claims Payment Period), as applicable. The entity
				  must send a request required under this section to TDI within five days of the
				  date the catastrophic event began substantially interfering with the normal
				  business operations of the entity, or as specified in a notice published by the
				  commissioner regarding the catastrophic event.
(b) An entity must send the request required
				  under this section to TDI by email to PromptPay@tdi.texas.gov, unless an
				  alternative electronic method is provided by TDI for a specified event. The
				  request must:
(1) be from:
(A) if for a physician or a provider, the
				  physician, provider, office manager, administrator, or their designee;
				  or
(B) if for an MCC, a corporate
				  officer or a corporate officer's designee;
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter T - SUBMISSION OF CLEAN CLAIMS › Section 21.2820 - Identification Cards

Current through Reg. 49, No. 28; July 12, 2024
(a) An
				  identification card, or other similar document that includes information
				  necessary to allow enrollees and insureds to access services or coverage under
				  an HMO evidence of coverage, a preferred provider benefit plan, or an exclusive
				  provider benefit plan that is issued by an MCC subject to this subchapter must
				  comply with the requirements of this section.
(b) An identification card or other similar
				  document issued to enrollees or to insureds must include the following
				  information:
(1) the name of the enrollee or
				  the insured;
(2) the first date on
				  which the enrollee or the insured became eligible for benefits under the plan
				  or a toll-free number that a preferred provider may use to obtain such
				  information;
(3) for an exclusive
				  provider benefit plan, the acronym "EPO" or the phrase "Exclusive Provider
				  Organization"; and
(4) the letters
				  "TDI" or "DOI" prominently displayed on the front of the card or the
				  document.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter T - SUBMISSION OF CLEAN CLAIMS › Section 21.2821 - Reporting Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) An MCC must
				  submit to the department quarterly claims payment and related penalty and
				  interest payment information, and information regarding complaints, in
				  compliance with the requirements of this section.
(b) The MCC must submit the report required
				  by subsection (a) of this section to the department on or before:
(1) May 15th for the months of January,
				  February, and March of each year;
(2) August 15th for the months of April, May,
				  and June of each year;
(3) November
				  15th for the months of July, August, and September of each year; and
(4) February 15th for the months of October,
				  November, and December of each preceding calendar year.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter T - SUBMISSION OF CLEAN CLAIMS › Section 21.2822 - Administrative Penalties

Current through Reg. 49, No. 28; July 12, 2024
(a) An MCC that
				  fails to comply with §
										21.2807
				  of this title (relating to Effect of Filing a Clean Claim) for more than 2
				  percent of clean claims submitted to the MCC is subject to an administrative
				  penalty under Insurance Code §
										843.342(k)
				  or §
										1301.137(k),
				  as applicable.
(b) The percentage
				  of the MCC's compliance with §
										21.2807
				  of this title must be determined on a quarterly basis and must be separated
				  into a compliance percentage for noninstitutional preferred provider claims and
				  institutional preferred provider claims. Claims paid in compliance with §
										21.2809 of this
				  title (relating to Audit Procedures) are not included in calculating the
				  compliance percentage under this section.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter T - SUBMISSION OF CLEAN CLAIMS › Section 21.2823 - Applicability to Certain Noncontracting Physicians and Providers

Current through Reg. 49, No. 28; July 12, 2024
The provisions of §
										19.1719
					 of this title (relating to Verification for Health Maintenance Organizations
					 and Preferred Provider Benefit Plans) and §
										21.2807
					 of this title (relating to Effect of Filing a Clean Claim) apply to a physician
					 or a provider that provides to an enrollee or an insured of an MCC:
(1) care related to an emergency or its
				  attendant episode of care as required by state or federal law; or
(2) specialty or other medical care or health
				  care services at the request of the MCC, the physician, or the provider because
				  the services are not reasonably available from a physician or a provider who is
				  included in the MCC's network.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter T - SUBMISSION OF CLEAN CLAIMS › Section 21.2824 - Applicability

Current through Reg. 49, No. 28; July 12, 2024
The amendments to §§21.2801 - 21.2803, 21.2807 -
					 21.2809, and 21.2811 - 21.2817 of this title (relating to Scope, Definitions,
					 Elements of a Clean Claim, Effect of Filing a Clean Claim, Effect of Filing
					 Deficient Claim, Audit Procedures, Disclosure of Processing Procedures, Denial
					 of Clean Claim Prohibited for Change of Address, Requirements Applicable to
					 Other Contracting Entities, Electronic Adjudication of Prescription Benefits,
					 Failure to Meet the Statutory Claims Payment Period, Date of Receipt, and Terms
					 of Contracts), and new §§21.2804 - 21.2806, 21.2818, 21.2819, and
					 21.2821 - 21.2825 of this title (relating to Requests for Additional
					 Information from Treating Preferred Provider, Requests for Additional
					 Information from Other Sources, Claims Filing Deadline, Overpayment of Claims,
					 Catastrophic Event, Reporting Requirements, Administrative Penalties,
					 Applicability to Certain Non-Contracting Physicians and Providers,
					 Applicability, and Severability) apply to services provided, or inpatient
					 services beginning, under contracts entered into or renewed between an MCC and
					 a preferred provider after October 4, 2003, and to services provided or
					 hospital confinements beginning after October 4, 2003, by physicians and
					 providers that do not have a contract with an MCC.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter T - SUBMISSION OF CLEAN CLAIMS › Section 21.2825 - Severability

Current through Reg. 49, No. 28; July 12, 2024
If a court of competent jurisdiction holds that any
					 provision of this subchapter or its application to any person or circumstance
					 is invalid for any reason, the invalidity does not affect other provisions or
					 applications of this subchapter that can be given effect without the invalid
					 provision or application, and to this end the provisions of this subchapter are
					 severable.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter T - SUBMISSION OF CLEAN CLAIMS › Section 21.2826 - Waiver

Current through Reg. 49, No. 28; July 12, 2024
In compliance with Insurance Code §
										1211.001,
					 the provisions in Insurance Code Chapter 1301, § 1301.069, §
					 1301.162, and Subchapters C and C-1; Chapter 1213; Chapter 843, § 843.209,
					 § 843.319, and Subchapter J; as well as this subchapter and §§
					 3.3703(a)(20), 11.901(a)(11), 19.1718, and 19.1719 of this title (relating to
					 Contracting Requirements, Required Provisions, Preauthorization for Health
					 Maintenance Organizations and Preferred Provider Benefit Plans, and
					 Verification for Health Maintenance Organizations and Preferred Provider
					 Benefit Plans, respectively) are not applicable to Medicaid and Children's
					 Health Insurance Program plans provided by an MCC to persons enrolled in the
					 medical assistance program established under Human Resources Code Chapter 32 or
					 the child health plan established under Health and Safety Code Chapter
					 62.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter V - PHARMACY BENEFITS › Division 1 - GENERAL PROVISIONS › Section 21.3001 - Applicability and Severability

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Applicability. This subchapter implements the provisions of Insurance Code
					 Chapter 1369 as follows:
(1) Division 2 of
					 this subchapter applies to a health benefit plan that is subject to Insurance
					 Code Chapter 1369, Subchapter D, and relates to pharmacy identification
					 cards.
(2) Division 3 of this
					 subchapter applies to a health benefit plan that is subject to Insurance Code
					 Chapter 1369, Subchapter A, and relates to coverage of off-label
					 drugs.
(3) Division 4 of this
					 subchapter applies to a health benefit plan that is subject to Insurance Code
					 Chapter 1369, Subchapter B, and relates to the use of a drug formulary by a
					 health benefit plan. Consistent with Insurance Code §
												1369.077,
					 §§21.3031 - 21.3033 apply only to an individual health benefit
					 plan.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter V - PHARMACY BENEFITS › Division 2 - IDENTIFICATION CARDS › Section 21.3003 - Standard Identification Cards

Current through Reg. 49, No. 28; July 12, 2024
(a) The
					 issuer of a health benefit plan that provides pharmacy benefits, or a pharmacy
					 benefit manager or administrator issuing standard identification cards to
					 enrollees must issue standard identification cards as follows:
(1) For a subscriber who is an enrollee, and
					 who has no enrolled dependents, a single card must be issued to the subscriber,
					 with additional cards available on request.
(2) For a subscriber who is an enrollee, and
					 who has enrolled dependents, either:
(A) a
					 card must be issued to the subscriber and to each of the enrolled dependents,
					 with additional cards available on request; or
(B) two cards must be issued to the
					 subscriber for use by the subscriber and all enrolled dependents, with
					 additional cards available on request.
(3) For coverage under an individual health
					 benefit plan in which the subscriber is not an enrollee, or for coverage under
					 a health benefit plan that is continued by an enrollee under Insurance Code
					 Chapter 1251, Subchapter E , either:
(A) a
					 card must be issued to each enrollee, with additional cards available on
					 request; or
(B) two cards must be
					 issued for use by all enrollees, with additional cards available on
					 request.