28 TAC §§21.2801 - 21.2809
The Texas Department of Insurance proposes new §§21.2801
- 21.2809, concerning submission of clean claims to health maintenance organizations
(HMOs) and insurers who issue preferred provider benefit plans. These sections
are the result of the passage of House Bill 610 during the 76th Legislative
Session. House Bill 610 provides for claims payment decisions on claims submitted
by contracted providers to HMOs and preferred provider carriers within 45
days of the submission of a "clean claim." It also provides that department
rules shall determine when a claim is complete, thus constituting a clean
claim.
Proposed §21.2801 sets forth the scope of these proposed sections,
namely their applicability to claims submitted by contracted physicians or
providers of HMOs and preferred provider carriers. Nothing in these sections
should be construed as obviating the duty of health care plans to promptly
and efficiently process claims submitted by insureds, enrollees, and non-contracted
physicians or providers. The department anticipates that HMOs and preferred
provider carriers will bring physician or provider contracts, and/or physician
or provider manuals or other documents that set forth the procedure for filing
claims with the HMO or preferred provider carrier, into compliance with these
rules by December 15, 1999. This compliance date will allow HMOs and plans
sufficient time to notify physicians and providers of any attachments or additional
clean claim requirements without requiring immediate revision of contracts
or provider manuals. Proposed §21.2802 defines terms used in these rules.
Where possible, existing definitions of terms were incorporated by reference
to their statutory or regulatory origin. Since "clean claim," had not previously
been defined, a new definition was developed.
Proposed §21.2803 further develops the elements of a clean claim.
A clean claim consists of specified data elements utilized on Health Care
Financing Administration (HCFA) claim forms, attachments specified by contract
or proper notice, additional elements that are identified by contract or proper
notice, and in coordination of benefit or patient eligibility situations,
if specified by contract, the amount of the claim paid by the primary plan.
Electronic claims submissions are in no way precluded by these proposed sections.
After the 1997 Legislative Session, HMOs and preferred provider carriers were
required to pay claims submitted by physicians or providers within 45 days.
The "trigger" for the running of the prompt payment period was the receipt
of a claim for payment "with the documentation reasonably necessary to process
the claim." In practice, the issue of what documentation was reasonably necessary
to process a claim resulted in numerous disputes between HMOs and preferred
provider carriers and the physicians or providers submitting claims. These
sections are designed to diminish the frequency of such disputes, by requiring
prior notification to physicians and providers of documentation considered
reasonably necessary to process a claim (i.e., what constitutes a clean claim).
These sections are not intended to address the validity or the viability
of a submitted claim. Instead, these sections are meant to put physicians,
providers, HMOs and preferred provider carriers all on the same page with
regard to documentation considered reasonably necessary to process a claim.
Any question as to the completeness of a claim should be able to be answered
by reference to the physician or provider contract, manual and/or other document
that sets forth the procedure for filing claims, and pertinent notifications.
If coordination of benefits or patient eligibility for coverage is an issue,
information regarding these situations may be contractually required as clean
claim elements. The patient eligibility scenario may arise in an instance
where a preferred provider carrier questions whether an insured has a preexisting
condition, but that insured's current physician does not have the insured's
past medical records or other information from which a preexisting condition
determination could be made. From the point that a clean claim is received,
an HMO or preferred provider carrier has 45 days in which to make the claim
payment decision.
Proposed §21.2804 requires that, if attachments beyond those identified
in the physician or provider contracts, or in the physician or provider manual
or other document that sets forth the procedure for filing claims with the
HMO or preferred provider carrier, are to be required, then the HMO or preferred
provider carrier must give 60-day prior written notice to the affected physicians
or providers. Proposed §21.2805 provides that, if additional elements
beyond those identified in the physician or provider contracts, or in the
physician or provider manual or other document that sets forth the procedure
for filing claims with the HMO or preferred provider carrier, are to be required,
then the HMO or preferred provider carrier must give 60-day prior written
notice to the affected physicians or providers. Proposed §21.2806 specifies
that filing of a clean claim starts the running of the 45-day prompt payment
of claims decision period.
A clean claim is considered filed when received at the address designated
by the HMO or preferred provider carrier.
Proposed §21.2807 identifies the administrative claim filing information
that must be disclosed by HMOs and preferred provider carriers in their physician
or provider contracts or in the physician or provider manual or other document
that sets forth the procedure for filing claims with the HMO or preferred
provider carrier. If the administrative claims filing information is revised,
the HMO or preferred provider carrier must give its physicians or providers
60-day written notice prior to the change. Proposed §21.2808 prohibits
the denial of a claim based upon a physician's or provider's filing of the
claim at an incorrect address, unless the 60-day prior written notice has
been provided. Finally, proposed §21.2809 requires that an HMO or preferred
provider carrier that delegates its claims processing functions include in
its delegation agreement a provision requiring the delegated claims processor
to comply with the clean claims requirements. Claims that are delegated for
processing remain subject to the statutory 45-day claims processing period.
The department will consider the adoption of new §§21.2801 -
21.2809 concerning submission of clean claims to HMOs and preferred provider
carriers in a public hearing under Docket No. 2415, scheduled for September
xx, 1999 in Room 100 of the William P. Hobby Jr. State Office Building, 333
Guadalupe Street in Austin, Texas. The department encourages any interested
party to provide the department with any comments prior to the hearing or
at the hearing.
Kim Stokes, Associate Commissioner, Life/Health and Managed Care, Regulation
and Safety, has determined that for each year of the first five years the
proposal is in effect, there will be no fiscal implications for state or local
government as a result of enforcing or administering the proposed sections.
There will be no adverse effects on local employment or the local economy.
Ms. Stokes has determined that for each year of the first five years the
proposal is in effect the public benefits anticipated as a result of the adoption
of the proposal will be a reduction in claim payment disputes between physicians
or providers and HMOs or preferred provider carriers. By providing clear and
specific notice of the elements of a clean claim to physicians and providers,
the beginning point of the statutory claim payment period is more clearly
defined. By reducing the number of disputes regarding claim payment issues,
these sections allow physicians, providers, HMOs, preferred provider carriers,
and regulators to devote their energies to enrollee issues.
The economic cost to comply with these proposed sections is the result
of the legislative enactment of House Bill 610. These proposed sections do
not mandate any action not contemplated by HB610, and therefore impose no
costs other than those imposed by the new legislation.
Ms. Stokes has determined that there is no economic costs or adverse impact
for each year of the first five years on any small or micro-business HMOs
or preferred provider carriers that are a result of these proposed new sections.
The determining factor in the costs that would be incurred by an HMO or a
preferred provider carrier is the number of physicians or providers with whom
that HMO or preferred provider carrier contracts, and not upon the size of
the HMO or preferred provider carrier. The size of the business thus has no
bearing upon the applicability of these proposed sections. Under these proposed
sections, an HMO or preferred provider organization may incorporate the clean
claim elements into physician or provider contracts, physician or provider
manuals or other document that sets forth claim processing procedures, or
provide 60-day notice of clean claim element revisions. Thus, by allowing
an HMO or preferred provider carrier to select the form of notification, these
proposed sections allow an HMO or preferred provider carrier of any size to
determine costs that it will incur as a result of HB610. Moreover, it is neither
legal nor feasible to exempt small or micro-business HMOs or preferred provider
carriers from the requirements of these proposed sections. The requirements
of these proposed sections should not be waived.
Comments on the proposal must be submitted within 30 days after publication
of the proposed sections in the
Texas Register
to Lynda H. Nesenholtz, General Counsel and Chief Clerk, Mail Code 113-2A,
Texas Department of Insurance, P. O. Box 149104, Austin, Texas, 78714-9104.
Additional copies of the comment are to be submitted to Kim Stokes, Associate
Commissioner, Life/Health and Managed Care, Regulation and Safety, Mail Code
103-6A, Texas Department of Insurance, P. O. Box 149104, Austin, Texas, 78714-9104.
These new sections are proposed under the Insurance Code Articles
3.70-3C, §§3(m) and 9; 20A.09(j); 20A.22 and 1.03A. Insurance Code
Article 3.70-3C, §3(m) specifies that a preferred provider contract must
provide for prompt payment to a physician or provider for covered services
rendered not later than the 45th day after the date a claim for payment is
received "with the documentation reasonably necessary to process the claim."
Insurance Code Article 3.70-3C, §9 grants the commissioner rulemaking
authority to implement the provisions of Article 3.70-3C dealing with preferred
provider benefit plans. Insurance Code Article 20A.09(j) specifies that HMOs
shall make prompt payment to a physician or provider for covered services
rendered not later than the 45th day after the date a claim for payment is
received "with documentation reasonably necessary for the HMO to process the
claim." Article 20A.22(a) grants the commissioner rulemaking authority to
carry out the provisions of the HMO Act. Furthermore, House Bill 610, passed
by the 76th Legislature, created new Insurance Code Articles 3.70-3C, §3A(a)
and 20A.18B(a), which are effective September 1, 1999. These Articles provide
that a clean claim is a "completed claim, as determined under Texas Department
of Insurance rules." Article 1.03A provides that the Commissioner of Insurance
may adopt rules and regulations to execute the duties and functions of the
Texas Department of Insurance only as authorized by statute.
The following articles are affected by this proposal: Insurance Code Articles
3.70-3C, §§3(m) and 3A, 20A.09(j) and 20A.18B.
§21.2801.Scope and Applicability.
This subchapter applies to claims submitted by physicians or providers
for covered services or benefits provided to insureds of preferred provider
carriers and enrollees of HMOs, for the purpose of determining the starting
point for the claims payment period set forth in Insurance Code Article 3.70-3C,
§§3(m) and 3A, Article 20A.09(j) and Article 20A.18B.
§21.2802.Definitions.
The following words and terms, when used in this subchapter shall have
the following meanings, unless the context clearly indicates otherwise:
(1)
Clean claim -- A physician's or provider's claim for payment
with documentation reasonably necessary for the HMO or preferred provider
carrier to process the claim, which contains:
(A)
the required data elements set forth in §21.2803(b)
of this title (relating to Elements of a Clean Claim);
(B)
the attachments of which the physician or provider has
been properly notified as necessary for processing pursuant to §§21.2803(c)
and 21.2804 of this title (relating to Disclosure of Necessary Attachments);
(C)
any additional elements of which the physician or provider
has been properly notified pursuant to §21.2805 of this title (relating
to Disclosure of Additional Clean Claim Elements) , and
(D)
the amount paid by the primary plan pursuant to §21.2803(e)
of this title, if applicable.
(2)
Condition code - The code utilized by HCFA to
identify conditions that may affect processing of the claim.
(3)
Diagnosis code - The ICD-9-CM code number. Narrative
diagnoses for non-physician specialties must be submitted on an attachment.
(4)
HMO - A health maintenance organization as defined
by Insurance Code Article 20A.02(n).
(5)
HMO delivery network - As defined by Insurance Code
Article 20A.02(w).
(6)
Occurrence span code - The code utilized by HCFA to
define a specific event relating to the billing period.
(7)
Patient control number - A unique alphanumeric number
assigned by the provider to facilitate retrieval of individual financial records
and posting of payment.
(8)
Patient-status-at-discharge code - The code utilized
by HCFA to indicate the patient's status at time of discharge or billing.
(9)
Physician or provider -
(A)
with regard to a preferred provider carrier, a preferred
provider as defined by Insurance Code Article 3.70-3C, Section 1(10) (Preferred
Provider Benefit Plans).
(B)
with regard to an HMO,
(i)
a physician, as defined by Insurance Code Article 20A.02(r),
who is a member of that HMO's delivery network; or
(ii)
a provider, as defined by Insurance Code Article 20A.02(t),
who is a member of that HMO's delivery network.
(10)
Place of service code - The codes utilized
by HCFA that identifies the place at which the service was rendered.
(11)
Preferred provider carrier - An insurer that issues
a preferred provider benefit plan as provided for by Insurance Code Article
3.70-3C, Section 2.
(12)
Primary Plan - As defined in §3.3506 of this
title (relating to Use of the Terms "Plan," "Primary Plan," "Secondary Plan,"
and "This Plan" in Policies, Certificates and Contracts).
(13)
Procedure Code - The HCFA Common Procedure Coding
System (HCPCS) number.
(14)
Revenue code - The code assigned by HCFA to each
cost center for which a separate charge is billed.
(15)
Secondary Plan - As defined in §3.3506 of this
title.
(16)
Source of admission code - The code utilized by HCFA
to indicate the source of an inpatient admission.
(17)
Subscriber - If individual coverage, the individual
who is the contract holder and is responsible for payment of premiums to the
HMO or preferred provider carrier; or if group coverage, the individual who
is the certificate holder and whose employment or other membership status,
except for family dependency, is the basis for eligibility for enrollment
in the HMO or coverage by the preferred provider carrier.
(18)
Type of bill code - The three-digit alphanumeric
code utilized by HCFA to identify type of facility, type of care, and sequence
of bill in a particular episode of care.
§21.2803.Elements of a Clean Claim.
(a)
Required claim elements. A physician or provider submits
a clean claim by providing the required data elements specified in subsection
(b) of this section to an HMO or a preferred provider carrier, along with
any attachments and additional elements of which the physician or provider
has been properly notified as necessary pursuant to subsections (c) and (d)
of this section, and §§21.2804 (relating to Disclosure of Necessary
Attachments), and 21.2805 of this title (relating to Disclosure of Additional
Clean Claim Elements), and any coordination of benefits or patient eligibility
information contracted for pursuant to subsection (e) of this section, if
applicable. Electronic claims submissions remain permissible under this subchapter.
(b)
Required data elements. The Health Care Financing Administration
(HCFA) of the U.S. Department of Health and Human Services has developed claim
forms which provide much of the information necessary to process claims. Two
of these forms, HCFA-1500 (12-90) and UB-92 HCFA-1450, and their successor
forms, have been identified by Insurance Code Article 21.52C as required for
the submission of certain claims. The terms used in paragraphs (1), (2) and
(3) of this subsection are based upon the terms used by HCFA on the HCFA-1500
(12-90) and UB-92 HCFA-1450 claim forms. The parenthetical information following
each term is a reference to the applicable HCFA claim form, and the field
number to which that term corresponds on the HCFA claim form.
(1)
Necessary data elements for individual physicians or providers.
The information in this paragraph is necessary for claims filed by physicians
and providers that utilize the HCFA-1500 (12-90) claim form.
(A)
subscriber's/patient's plan ID number (HCFA 1500, field
1a);
(B)
patient's name (HCFA 1500, field 2);
(C)
patient's date of birth and gender (HCFA 1500, field 3);
(D)
patient's address (street or P.O. Box, city, zip) (HCFA
1500, field 5);
(E)
whether patient's condition is related to employment, auto
accident, or other accident (HCFA 1500, field 10);
(F)
subscriber's birth date and gender (HCFA 1500, field 11a);
(G)
subscriber's plan name (employer, school, etc.) (HCFA 1500,
field 11b);
(H)
HMO or insurer name (HCFA 1500, field 11c);
(I)
disclosure of any other health benefit plans (HCFA 1500,
field 11d);
(J)
patient's or authorized person's signature (HCFA 1500,
field 12);
(K)
subscriber's or authorized person's signature (HCFA 1500,
field 13);
(L)
date of current illness, injury, or pregnancy (HCFA 1500,
field 14);
(M)
list of all diagnosis codes upon claim form (HCFA 1500,
field 21);
(N)
date(s) of service (HCFA 1500, field 24A);
(O)
place of service codes (HCFA 1500, field 24B);
(P)
type of service (HCFA 1500, field 24C);
(Q)
procedure code (HCFA 1500, field 24D);
(R)
diagnosis code by specific service (HCFA 1500, field 24E);
(S)
charge for each listed service (HCFA 1500, field 24F);
(T)
number of days or units (HCFA 1500, field 24G);
(U)
physician's or provider's federal tax ID number (social
security number or employer identification number) (HCFA 1500, field 25);
(V)
whether assignment was accepted (HCFA 1500, field 27);
(W)
total charge (HCFA 1500, field 28);
(X)
signature of physician or supplier (HCFA 1500, field 31);
(Y)
name and address of facility where services rendered (if
other than home office) (HCFA 1500, field 32); and
(Z)
physician's or provider's billing name and address (HCFA
1500, field 33).
(2)
Necessary data elements for institutional providers.
The information in this paragraph is necessary for claims filed by institutional
providers that utilize the UB-92 HCFA-1450 claim form.
(A)
provider name, address and telephone number (UB-92, field
1);
(B)
patient control number (UB-92, field 3);
(C)
type of bill code (UB-92, field 4);
(D)
provider's federal tax ID number (UB-92, field 5);
(E)
statement covers period (beginning and ending date of claim
period) (UB-92, field 6);
(F)
covered days (UB-92, field 7);
(G)
noncovered days (UB-92, field 8);
(H)
coinsurance days (UB-92, field 9);
(I)
lifetime reserve days (inpatient only) (UB-92, field 10);
(J)
patient's name (UB-92, field 12);
(K)
patient's address ((UB-92, field 13);
(L)
patient's date of birth (UB-92, field 14);
(M)
patient's gender (UB-92, field 15);
(N)
date of admission (UB-92, field 17);
(O)
hours of admission (UB-92, field 18);
(P)
type of admission (e.g. emergency, urgent, elective, newborn)
(UB-92, field 19);
(Q)
source of admission code (UB-92, field 20);
(R)
discharge hour (UB-92, field 21);
(S)
patient's status at discharge code (UB-92, field 22);
(T)
condition codes (UB-92, fields 24-30);
(U)
occurrence span code, from and through dates (UB-92, field
36);
(V)
revenue code (UB-92, field 42);
(W)
HCPCS/Rates (UB-92, field 44);
(X)
units of service (UB-92, field 46);
(Y)
total charge (UB-92, field 47);
(Z)
noncovered charges (UB-92, field 48);
(AA)
payor name (UB-92, field 50);
(BB)
provider number (UB-92, field 51);
(CC)
prior payments - payor and patient (UB-92, field 54);
(DD)
patient's/subscriber's certificate number, social security
number, health claim number, ID number (UB-92, field 60);
(EE)
treatment authorization codes (UB-92, field 63);
(FF)
principle diagnosis code (UB-92, field 67);
(GG)
admission diagnosis code (inpatient only) (UB-92, field
76); and
(HH)
signature of provider representative (UB-92, field 85).
(3)
Conditional data elements. The Information in
this paragraph is necessary only on those claims in which these data elements
are present.
(A)
other insured's or enrollee's name (HCFA 1500, field 9);
(B)
other insured's or enrollee's policy/group number (HCFA
1500, field 9a);
(C)
other insured's or enrollee's date of birth (HCFA 1500,
field 9c);
(D)
other insured's or enrollee's plan name (employer, school,
etc.) (HCFA 1500, field 9c);
(E)
other insured's or enrollee's HMO or insurer name (HCFA
1500, field 9d);
(F)
prior authorization number (HCFA 1500, field 23);
(G)
amount paid (HCFA 1500, field 29);
(H)
balance due (HCFA 1500, field 30);
(I)
diagnoses codes other than principle diagnosis code ((UB-92,
fields 68-75);
(J)
procedure coding methods used (UB-92, field 79);
(K)
principle procedure code (UB-92, field 80); or
(L)
other procedure codes (UB-92, field 81).
(c)
Attachments. In addition to the required data elements
set forth in subsection (b) of this section, HCFA has developed a variety
of manuals that identify various attachments required of different physicians
or providers for specific services. An HMO or a preferred provider carrier
may use the appropriate Medicare standards for attachments in order to properly
process claims for certain types of services. Before any attachments may be
required, the HMO or preferred provider carrier must satisfy the notification
procedures set forth in §21.2804 of this title (relating to Disclosure
of Necessary Attachments).
(d)
Additional clean claim elements. Additional elements beyond
the required data elements and attachments identified in subsections (b) and
(c) of this section may be required. Before any additional clean claim elements
may be required, the HMO or the preferred provider carrier must satisfy the
notification procedures set forth in §21.2805 of this title (relating
to Disclosure of Additional Clean Claim Elements).
(e)
Coordination of benefits and patient eligibility clean
claim requirements.
(1)
If a claim is submitted for covered services or benefits
in which coordination of benefits pursuant to §§3.3501 - 3.3511
of this title (relating to Group Coordination of Benefits) is necessary, the
secondary plan may by contract require as an element of a clean claim, from
the physician or provider, the amount paid by the primary plan.
(2)
If an HMO or preferred provider carrier establishes
a good-faith, reasonable doubt that the claim submitted involved treatment
or services provided to a patient that was not eligible for coverage for those
services from the HMO or preferred provider carrier, the HMO or preferred
provider carrier may by contract require as an element of a clean claim the
information necessary to determine the eligibility of the patient for coverage.
In such a situation, the HMO or preferred provider must make a reasonable
effort to resolve all questions of eligibility within their control. Upon
request, the HMO or preferred provider carrier must timely submit for review
by the physician or provider all specific information that casts doubt on
the patient's eligibility under the claim.
(f)
Format of elements. The required elements of a clean claim
set forth in subsections (b), (c), (d) and (e), if applicable, of this section
must be complete, legible and accurate.
(g)
Signature on file. The original signatures of patients,
subscribers, physicians and providers, or their authorized representatives,
required by subparagraphs (J), (K), and (X) of subsection (b)(1) of this section
and subparagraph (HH) of subsection (b)(2) of this section are not necessary
if original signatures are on file with the physician or provider.
§21.2804.Disclosure of Necessary Attachments.
For attachments described in §21.2803(b) of this title (relating
to Elements of a Clean Claim) to be required as part of a clean claim, the
HMO or preferred provider carrier must provide advance written notice to all
affected physicians or providers that such attachments are necessary. Such
notice must identify with specificity the attachment(s) required and must
be received by the physician or provider at least 60 days before requiring
such attachment as an element of a clean claim. If an attachment is identified
as a required element of a clean claim in the contract between the HMO or
preferred provider carrier and the physician or provider, or in the physician
or provider manual or other document that sets forth the procedure for filing
claims with the HMO or preferred provider carrier, then additional written
notice is not required. If an HMO or preferred provider carrier requests an
attachment not identified in the contract between the HMO or preferred provider
carrier and the physician or provider, or in the physician or provider manual
or other document that sets forth the procedure for filing claims with the
HMO or preferred provider carrier, or for which written notice has not been
provided as required by this section, the request will not extend the claim
payment period.
§21.2805.Disclosure of Additional Clean Claim Elements.
An HMO or preferred provider carrier may include in its contracts
with physicians or providers a provision to require additional elements for
clean claims. To require such additional elements as part of a clean claim,
the HMO or preferred provider carrier must provide advance written notice
to all affected physicians or providers that such additional elements are
necessary. Such notice must identify with specificity the additional elements
required, and must be received by the physician or provider at least 60 days
before requiring such additional elements as a requirement of a clean claim.
If an element beyond the required data elements and attachments identified
in §21.2803(b) and (c) of this title (relating to Elements of a Clean
Claim) is identified as a required element of a clean claim in the contract
between the HMO or preferred provider carrier and the physician or provider,
or in the physician or provider manual or other document that sets forth the
procedure for filing claims with the HMO or preferred provider carrier, then
additional written notice is not required. If an HMO or preferred provider
carrier requires resubmission of a claim with additional clean claim elements
not identified in the contract between the HMO or preferred provider carrier
and the physician or provider, or in the physician or provider manual or other
document that sets forth the procedure for filing claims with the HMO or preferred
provider carrier, or for which written notice has not been provided as required
by this section, the request will not extend the claim payment period.
§21.2806.Effect of Filing a Clean Claim.
The claims payment period begins to run upon receipt of a clean claim
from a physician or provider at the address designated by the HMO or preferred
provider carrier, whether it be the address of the HMO, preferred provider
carrier, or a delegated claims processor.
§21.2807.Disclosure of Processing Procedures.
(a)
In contracts with physicians or providers, or in the physician
or provider manual or other document that sets forth the procedure for filing
claims, an HMO or preferred provider carrier must disclose to its physicians
and providers:
(1)
the address where claims should be sent for processing;
(2)
the phone number at which physicians' and providers'
questions and concerns regarding claims may be addressed;
(3)
any entity to which the HMO or preferred provider
carrier has delegated claim payment functions, if applicable; and
(4)
the address of any separate claims processing centers
for specific types of services, if applicable.
(b)
An HMO or preferred provider carrier shall provide no less
than 60 days prior written notice of any changes of address for submission
of claims, and of any changes of delegation of claims payment functions, to
all affected physicians and providers with whom the HMO or preferred provider
carrier has contracts.
§21.2808.Denial of Claims Prohibited for Change of Address or Administrator.
After a change of claims payment address or a change in delegation
of claims payment functions, an HMO or preferred provider carrier may not
premise the denial of a claim upon a physician's or provider's failure to
file a claim within any contracted time period for claim filing, unless timely
written notice as required by §21.2807(b) of this title (relating to
Disclosure of Processing Procedures) has been given.
§21.2809.Requirements Applicable to Delegated Claims Processors.
If an HMO or preferred provider carrier has delegated its claims processing
functions to a third party, the delegation agreement must provide that the
claims processing entity will comply with the requirements of this subchapter.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of the Secretary of State, on
July 26, 1999.
TRD-9904478
Gene C. Jarmon
Assistant General Counsel
Texas Department of Insurance
Earliest possible date of adoption: September 5, 1999
For further information, please call: (512) 463-6327