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COMMISSIONER'S BULLETIN # B-0015-13

July 11, 2013


To: All Health Maintenance Organizations (HMOs) and Preferred Provider Carriers


Re: Mandatory Data Call for Claims Processing Reports

DUE: August 15, 2013 - Second Quarter (April - June) 2013 and 2012 Annual Reports

Pursuant to Title 28 Texas Administrative Code Section 21.2821, TDI issues this mandatory data call for HMOs and preferred provider carriers doing business in Texas (collectively "carriers").

TDI requires this data call to determine carriers' compliance with prompt pay requirements on claims submitted by providers under Texas Insurance Code Chapter 1301, Subchapters C and C-1; Texas Insurance Code Chapter 843, Subchapter J; and 28 TAC Chapter 21, Subchapter T.

The reports due are -

  • House Bill (HB) 610, 76th Legislature, Regular Session, quarterly report; and
  • Senate Bill (SB) 418, 78th Legislature, Regular Session, quarterly report; and
  • Senate Bill (SB) 418, Annual Report

The reports are due on August 15, 2013, as required by 28 TAC ยง21.2821. The reporting database will be unavailable for report submission after 11:59 p.m., Central time on the date the report is due.

The HB 610 quarterly report applies to provider claims paid under provider contracts issued or renewed before August 16, 2003.

The SB 418 quarterly report applies to provider claims paid under provider contracts issued or renewed on or after August 16, 2003.

The SB 418 Annual Report of Reasons for Declinations: Carriers are required to report annually the reasons for declining to verify a claim. Carriers should report declination data from July 1, 2012 through June 30, 2013. Carriers must also submit separate reports about declinations issued by each delegated entity that processes that carrier's insureds' or enrollees' claims.

Exemptions

Some carriers may no longer have claims subject to these reporting requirements. Carriers should submit exemption requests as follows:

  • A carrier must enter an exemption request for the HB 610 report if it no longer has provider contracts last issued or renewed before August 16, 2003.
  • A carrier may submit all zeros only if it has provider contracts within the HB 610 or SB 418 criteria, but paid no claims in the quarter.
  • Entering a one-time exemption request for the HB 610 report does not affect the ability to enter data for the SB 418 report.
  • A carrier must enter an exemption request for the SB 418 report if it no longer has provider contracts last issued or renewed on or after August 16, 2003.
  • A one-time exemption request for the SB 418 quarterly report will automatically extend to the SB 418 annual report of reasons for declinations of verifications.

Once a carrier submits an exemption form for a report, it no longer needs to respond to the data call for that particular report. However, if a carrier only submits one exemption form, the carrier is still required to submit the other report on a quarterly or annual basis, as applicable.

Delegated Entity Data

If a carrier uses delegated entities to pay claims, the carrier must submit data for each delegated entity on a separate reporting form under the carrier's TDI number. A carrier may submit multiple reporting forms to accommodate data for all delegated entities in addition to data for claims the carrier processes. Both the carrier and its delegated entity must meet the statutory claims payment deadlines, and must comply with the 98 percent timely claims payment requirement.

Reporting

The online claims data reporting application and forms are available on the TDI website at https://apps.tdi.state.tx.us/SB418company/Login.do.

A tips guide with detailed additional information on reporting is available at http://www.tdi.texas.gov/hprovider/documents/provclaimstips.pdf.

If you have questions about this bulletin, please contact TDI via email at promptpay@tdi.texas.gov.

Julia Rathgeber
Commissioner of Insurance



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Last updated: 09/07/2014

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