Texas Department of Insurance

Insurance & HMOs


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Pharmacists Resource Page

2012 Pharmacy Outreach Conference Calls
  • January 12, 2012
Purpose

 The Texas Department of Insurance (TDI) has created this web page to serve the needs of pharmacists and pharmacy staff.  This page represents one component of TDI's Pharmacy Outreach Initiative and provides information detailing how TDI can assist pharmacists in understanding insurance and HMO coverage, workers' compensation coverage, and requirements for claims processing and payment.

Complaints to TDI

TDI can assist pharmacists with complaints on a variety of issues including complaints regarding prompt and correct payment of health care claims. Note: Complaints concerning transaction or claim processing fees must include the name of the carrier; the patient's name, patient's group and ID numbers, and the name of the PBM, if any.

To file a complaint with TDI, pharmacists can use the online complaint form or pharmacists can send TDI an e-mail or letter that includes:

  • the pharmacist/pharmacy contact information;
  • the name of the health plan and/or PBMinvolved in the complaint;
  • the nature of the complaint; and
  • patient name(s), group and ID number(s), and date(s) of service.

Send the complaint and any supporting documents to TDI:

  • Via e-mail to ConsumerProtection@tdi.state.tx.us
  • Via fax to 512-475-1771
  • Via USPS to:
    Texas Department of Insurance
    Consumer Protection - MC 111-1A
    P.O. Box 149091
    Austin, Texas 78714-9091

Pharmacists who elect to use the online complaint form can complete the basic information section, provide details on Attachment A, and submit the form electronically via the following link: https://wwwapps.tdi.state.tx.us/inter/perlroot/consumer/complform/complform.html

Frequently Asked Questions

Q. I am a pharmacy provider and I received notice that the issuer of a health benefit plan intends to begin charging an adjudication fee for each electronic pharmacy claim that they process. Is this allowed?

A. No. The Texas prompt pay statute states that a health benefit plan issued by an insurer or a health maintenance organization may not directly or indirectly charge or hold a health care professional, health care facility, or person enrolled in a health benefit plan responsible for a fee for the adjudication of a claim.

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Last updated: 03/27/2012



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