Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 351 - CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM › Section 351.10 - Payment of Services

Current through Reg. 49, No. 28; July 12, 2024
The program reimburses providers for covered services for
				  clients. Payment may be made only after the delivery of the service, with the
				  exception of meals, transportation, lodging, and insurance premium payments.
				  Excluding allowable insurance or health maintenance organization co-payments,
				  the client or client's family must not be billed for the service or be required
				  to make a preadmission or pretreatment payment or deposit. Providers may not
				  request or accept payment from the client or the client's family for completing
				  any program forms. Providers must agree to accept established fees as payment
				  in full. The program may negotiate reimbursement alternatives to reduce costs
				  through requests for proposals, contract purchases, or incentive
				  programs.
(1) Payment or denial of
				claims. Payments made on behalf of a client will be for claims received by the
				program or its payment contractor within 95 days of the date of service, within
				95 days from the date of discharge from inpatient hospital and inpatient
				rehabilitation facilities, within 95 days from the date the client's
				eligibility is added to program automation systems, or within the submission
				deadlines listed in paragraphs (1)(B)(ii) and (2) of this section, whichever is
				later. Claims for family support services, drug co-payments, and insurance
				premium payment assistance must be submitted within 95 days of the last day of
				the month in which services were provided. If the 95th day for receipt of a
				claim falls on a weekend or holiday, the deadline shall be extended to the next
				business day following the weekend or holiday. The program must process the
				claims of eligible providers within a period not to exceed 30 days of receipt
				and determination of proper evidence establishing the validity of claims,
				invoices, and statements. In cases where the program determines that a basis
				exists for further review, suspension, or other irregularity, extended
				processing time may be required. The manager of the department unit having
				responsibility for oversight of the program or his or her designee(s) may waive
				the filing deadlines according to the conditions and circumstances specified in
				paragraphs (3) - (5) of this section. A claim must be processed and paid within
				24 months of the date of service. Claims received by the program or its payment
				contractor after this time frame will not be considered for payment by the
				program.
(A) Claims will be paid if submitted
				on claim forms approved by the program (including electronic claims submission
				systems) and if the required documentation is received with the
				claim.
(B) Denied claims are claims
				which are incomplete, submitted on the wrong form, lack necessary
				documentation, contain inaccurate information, fail to meet the filing
				deadline, are for ineligible persons, services, or providers, or are for
				clients who do not qualify for the health care benefit claimed.
(i) Corrected claims must be submitted on
				claim forms approved by the program along with required documentation within
				the filing deadline established in clause (ii) of this subparagraph.
(ii) Denied claims may be corrected and
				resubmitted for reconsideration if received within 120 days of the last denial
				or adjustment to the original claim. If the results of the reconsideration
				process are unsatisfactory, denied claims may be appealed according to §
				351.13 of this title (relating to Right of Appeal).