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Physician/Provider FAQs

Information & Advice for Physicians and Providers

HB 610 Provider FAQs

Q: To whom do the clean claims rules apply?
A: Contracted physicians, contracted providers, insurers who issue preferred provider benefit plans, and HMOs are covered under the clean claims rules.

Q: Do prompt payment laws apply to self-funded plans?
A: The prompt payment laws and the clean claims rules do not apply to valid self-funded plans. These plans are subject to the federal Employee Retirement Income Security Act of 1974 (ERISA) and Department of Labor regulations. Seek assistance from the U.S. Department of Labor at:

U. S. Department of Labor
Division of Technical Assistance and Inquiries
200 Constitution Ave. NW Room N-5619
Washington, DC 20210
Phone: (202) 219-8776

Q: What other types of claims are excluded?
A: Medicare, Medicaid, Worker´s Compensation, TriCare, and indemnity policies are excluded.

Q: When must a physician or provider comply with a notice regarding additional clean claim elements and attachments from a health insurance carrier or an HMO?
A: An appropriate notice is effective 60 calendar days from the date of receipt. A physician or provider is not required to include the noticed additional elements or attachments during the 60-day period. The insurance carrier or HMO may not treat a claim as deficient because it does not contain the noticed additional elements and attachments during the 60-day period. On the 61st day from the date of receipt of the notice, the physician or provider must include the additional elements and attachments that are available. Failure to do so will render the claim deficient.

Q: Is a physician or provider required to conduct additional research to generate materials in response to a notice of additional clean claim elements and attachments?
A: No. The clean claims rules provide that additional elements and attachments are limited to items contained in or in the process of being contained in the medical or billing record of the physician or provider.

Q: Can a carrier list additional clean claim elements or attachments that "may" be required in order to consider a claim "clean"?
A: A carrier cannot list information that it may require as additional clean claim elements or attachments and then deny the claim as deficient for failing to include a "potential" attachment or additional clean claim element. Disclosures are intended to put the physician and provider on notice of exactly what information is required in order to submit a clean claim. A laundry list of "potential" additional clean claim elements or attachments is inappropriate. The department will view a claim as clean if it does not include the information on the list of documents that "may" be required. In addition to the clean claim elements defined by rule, only appropriately noticed additional clean claim elements and attachments may be considered in establishing a clean claim.

Q: How do I complete Blocks 14, 15, 24C, and 32 on the HCFA 1500 form?
A: Block 14 - Date of Current Illness, Injury, or Pregnancy
Block 15 - First Date of Previous Same or Similar Illness

Blocks 14 and 15 must be completed unless the contract between the provider and health carrier states otherwise. Even when (1) patients receive preventative services absent any symptoms or signs of illness; (2) patients present with multiple diagnoses that may have begun on different dates; and (3) patients with whom physicians or their staff do not have direct contact, these required fields must be completed. It is essential that physicians ascertain whether their contracts, claims filing manuals, claims filing instructions, or clean claim element notices provide instructions regarding the completion of these fields in the event of one of the example scenarios. Absent such direction, the information that is presented to the provider at the time of the visit is paramount. When preventative care is provided and no illness is discerned, the provider may list the date of the service to complete Blocks 14 and 15. When a patient presents with multiple diagnoses that may have begun on different dates, the physician may list the onset date of the primary diagnosis that initiated the visit or treatment. Physicians who do not have direct access to the patient may use information from medical records to complete Blocks 14 and 15. For example, the cardiologist reading the EKG should have access to the chart and be able to obtain the necessary information. Alternatively, the technician performing the EKG could ask the patient for this information and note it in the patient´s medical record. In those rare situations when a particular specialist or technician is unable to obtain this information and does not have direct contact with the patient or patient´s medical record, the physician or provider may enter the date the test or procedure was performed on the patient for which the specialist or technician is currently evaluating. Again, patient information at the time of the office visit, test, or treatment is critical.

Block 24C - Type of Service Code

For guidance as to the appropriate type of service code, the physician may need to examine the provider manual. The physician may also look to the HCFA Common Procedure Coding System, known as HCPCS, which provides a common coding structure for determining reimbursement. For further guidance, the physician can download a copy of the 2001 Texas Medicaid Provider Procedures Manual at http://www.tmhp.com/Providers/default.aspx.

The Department recognizes that many non-regulated plans are not requiring this information for claims filing. If a physician and a carrier agree that this element is no longer necessary, then they can enter into a contract which excludes Block 24C as a required element.

Block 32 - Name and Address of Facility Where Services Were Rendered (if other than home or office)

This information is a required field for TDI´s clean claims rules, as well as for Medicare and Medicaid. To complete this field the physician should specify the name and address of facility (repeat provider billing address or note the different address for the relevant facility) or when appropriate, insert the words "Same." CMS instructions permit the entry of the word "Same" to reference the information in Block 33. Medicare Part B Newsletter No. 00-006, June 1, 2000. Block 33 - Physician´s or provider´s billing name and address - is also a required field per TDI´s clean claim rules. The other primary users of the HCFA 1500 require completion of Block 32 for appropriate claim filing purposes. Also, the HCFA 1500 form includes a "Place of Service Code" in Block 24B.

Q: Under the clean claims rules the HMO or insurance company has 45 days to pay or deny a clean claim. When does the 45-day period start?
A: The 45-calendar-day period starts on the date the clean claim is received at the claims processing address that the HMO or insurance company designates in accordance with the claims processing notice procedures in the clean claims rules.

Q: Is a fax confirmation sheet sufficient documentation that a clean claim was received at the claims processing "address" for the HMO or insurance company?
A. Yes. It would be helpful to include information identifying the claims submitted on the fax cover sheet.

Q: Can insurance companies avoid paying claims by requesting accident information from the insured? Can the provider supply the information of the accident report rather than the patient?
A: Under the prompt payment law and the clean claims rules, HMOs and preferred provider carriers are required to process a clean claim within 45 days of receipt of the clean claim. If the HMO or preferred provider carrier requires more than 45 days to process the clean claim for whatever reason (including obtaining accident reports), the HMO or preferred provider carrier is required to notify the physician in writing within 45 days of the receipt of the claim that the claim is being audited. The HMO or preferred provider carrier is required to pay 85 percent of the contracted rate on the claim to the physician or provider. The physician or provider may obtain the accident report and provide it to the HMO or preferred provider carrier, but the HMO or preferred provider carrier cannot require the physician or provider to do so.

Q: What constitutes an "audit"?
A: An audit is the review of any part of a clean claim for a covered individual which an HMO or insurance company does not pay or deny within 45 calendar days of receipt. The HMO or insurance company must provide written notification of the audit and pay the audited portion at 85 percent of the contracted rate within the 45 calendar days. Any additional payment must be made within 30 calendar days of the completion of the audit.

Q: My patient´s HMO did not process my claim. Can I bill the patient?
A: No, physicians and providers who are contracted with HMOs are specially prohibited from billing HMO members for covered services. The patient is not responsible for paying the claim. Review your contractual requirements and contact the appropriate entity for payment. Your contract may require you to file claims with your IPA or the HMO depending on the services. If you cannot resolve the issues with the HMO, consider filing a complaint with TDI.

Q: I treated a patient for injuries resulting from an auto accident. The patient has both health insurance and an automobile insurance policy. Which insurer pays for the cost of treatment?
A: Both the PIP and Medical Pay coverages under the Personal Auto Policy contain assignment of benefits provisions which state that payments for medical expenses will be paid directly to a physician or other health care provider if the company receives a written assignment of benefits signed by the "covered person." If the patient assigns benefits to a provider, then the provider can submit medical expenses for payment directly to the auto insurer. However, in most cases when a person is injured in an auto accident, he or she seeks medical services from their primary health care provider under a health care policy. In this case, the health care provider should file a claim just as the provider would with any other health care claim for that patient.

Q: How long does an HMO have to pay a provider claim?
A: An HMO must make payment to a provider no later than the 45th day after the date the HMO receives the claim with documentation reasonably necessary for the HMO to process the claim. If the provider´s contract with the HMO specifies a shorter (can't be greater than 45 days) time frame for payment, the HMO must make payment within that time limit.

Q: My patient´s HMO did not process my claim in a timely manner. Can I bill the patient?
A: No, the patient is not responsible for this claim, and Texas law prohibits you from billing the patient. Contact the HMO about payment of the claim. If you cannot resolve the issues with the HMO, file a complaint with TDI.

Q: Can I bill my patients´ insurance companies or HMOs whenever I choose?
A: No. You must bill the insurance company or HMO within 10 months after providing services. If a provider is under contract with a health plan, then the billing deadline set by the contract prevails over the 10-month general deadline. Similarly, if a provider is required or allowed to directly bill a third-party payor or operating under federal or state law, including Medicare and Medicaid, the contract deadline prevails.

Q: My patient´s insurance company or HMO refuses to pay for a drug I prescribed that´s not on the health plan´s formulary? Can they do this?
A: Yes. For plans delivered, issued for delivery or renewed on or after January 1, 2000, however, an insurance company or HMO cannot refuse to pay for a drug not on their formulary that you prescribed to treat an enrollee for a covered chronic, disabling, or life-threatening illness. The drug must meet certain conditions, including being FDA-approved for at least one indication and recognized in a prescription drug reference book, approved by the Commissioner or in peer-reviewed medical literature for treatment of the patient´s illness. Not all plans are required to comply with the requirement of the new law, most notably small employer plans.

Q: An insurance company paid my patient instead of me. Now I can´t collect from either one. Can TDI help?
A: TDI may be able to help you, depending on the patient´s plan. File a complaint and explain the circumstances involved. Include a copy of the signed Assignment of Health Care Benefits, if any, with your complaint.

Q: Why was my claim denied after the company preauthorized treatment?
A: Preauthorization is not a guarantee of payment. It only means that coverage is in effect. A company decides whether it will pay a claim after receiving all the necessary documents and reviewing the claim against the patient´s benefit plan.

Q: I believe the HMO unfairly reduced my reimbursement. What recourse do I have?
A: Your contract with the company outlines your fee schedule. It´s important that you review and understand the contract before you sign it. Contracting parties must resolve disputes about contract terms among themselves. Work with the health care plan´s provider relations representative to resolve your problem.

Q: How long does an insurance company have to pay a claim from a non-contracted provider?
A: When there is no contractual relationship between the physician or provider and the insurer, the insured may make an assignment of benefits to the physician or provider. This includes instances in which an insured in a fee-for-service or indemnity plan makes an assignment of benefits to a physician or provider or if an insured in a preferred provider plan receives services from a non-network provider and makes an assignment of benefits. Under Article 3.51-6, §1(d)(2)(x) (group health plans) and Article 3.70-3, §(A)(8) (11) (individual policies) of the Texas Insurance Code, the insurer must pay all benefits payable under the policy within 60 days after receipt of proof of loss.

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Last updated: 10/03/2016

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