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SUBCHAPTER T. SUBMISSION OF CLEAN CLAIMS 28 TAC §§21.2803, 21.2809, and 21.2810

The Commissioner of Insurance adopts amendments to §§21.2803, 21.2809, and 21.2810 concerning submission of clean claims to health maintenance organizations (HMOs) and insurers that issue preferred provider benefit plans (preferred provider carriers). Section 21.2809 is adopted with changes to the proposed text as published in the October 20, 2000 issue of the Texas Register (25 TexReg 10437). Sections 21.2803 and 21.2810 are adopted without changes and will not be republished.

These amendments are necessary to clarify and update the "clean claim" rules that apply to claims filed for non-confinement services, treatments, or supplies rendered on or after August 1, 2000, and to claims filed for services, treatments, or supplies for in-patient confinements in a hospital or other institution that began on or after August 1, 2000. The amendment to §21.2803(b)(1)(L)(ii) is necessary to facilitate the electronic claims filing process and is in response to petitions from numerous physicians and providers. The amendment to §21.2809(b) is necessary to clarify the essential information that is to be included in the notice of audit results and will assist physicians and providers in more efficient and accurate recordkeeping of audited claims as well as allow physicians and providers to suggest a refund method other than a chargeback. Articles 3.70-3C §3A(e) and 20A.18B(e) of the Insurance Code as enacted by House Bill 610 (Acts 1999, 76 th Leg., ch. 1343, p. 4556, eff. Sept. 1, 1999) require notice of the audit results to be provided to the physician or provider and require a refund to be made to the preferred provider carrier or HMO upon completion of the audit in the event of overpayment to the physician or provider. The amendment to §21.2810 is necessary to allow private metered postmarks to be an acceptable proof of postmark in those instances when the claim payment is delivered by the U.S. Postal Service. The amendment is in response to information received by the department from the U.S. Postal Service that private metered mail is checked by the post office to verify the correct date and is returned to the customer if incorrectly dated.

In response to comments, changes have been made to the proposed amendments to §21.2809(b) as published. For purposes of clarification, references to "notification" have been changed to "written notification."

Section 21.2803(b)(1) specifies the elements necessary for the submission of a clean claim by physicians and noninstitutional providers. The amendment to §21.2803(b)(1)(L)(ii) specifies the requirements relating to the element on disclosure of any other health care coverage when the response is "no." Section §21.2809(b) specifies procedures for refunds due to the HMO or preferred provider carrier upon completion of the audit. The amendment also provides that existing or future contractual arrangements that allow alternative reimbursement methods in the event of overpayment to the physician or provider are not affected by the rule. Under the amendment to §21.2810, private metered postmarks will be acceptable proof of postmark in those instances when the claim payment is delivered by the U.S. Postal Service.

§21.2803(b)(1)(L)(ii) Essential data elements for physicians and noninstitutional providers

Comment: Numerous commenters requested that proposed §21.2803(b)(1)(L)(ii) be revised to remove the requirement that the physician or provider keep on file a document signed within the past 12 months stating that there is no other health care coverage. One commenter stated that the proposed amendment will result in physician confusion as well as the potential for carriers to intentionally or inadvertently circumvent the law. Three commenters stated that the proposed amendment violates the intent of House Bill 610 to promulgate rules that promote prompt payment. One commenter stated that the proposed requirement gives health plans one more reason to deny or delay payment on a claim. One commenter stated that it is unclear as to the department's legal authority to place on physicians mandates that are separate from an "essential" insurance requirement. Several commenters stated that the proposed requirement will place additional burden and expense on the physician's office. Three commenters stated that the proposed amendment shifts a major business function of insurance onto the physicians because insurance companies are in the most appropriate position to address coordination of benefit issues, which are a function of the business of insurance; one of these commenters stated that this will impede the delivery of health care. Five commenters stated that the proposed amendment will have little or no effect on facilitating electronic claims filing. One of these commenters stated that the inability to use electronic submission of claims increases overhead expenses and delays payments. One commenter stated that the proposed amendment is confusing in light of HIPAA (Health Insurance Portability and Accountability Act of 1996), which promotes electronic filing of claims, and that it violates federal mandates within HIPAA because the proposed amendment continues to promote manual attachments. Several commenters stated that HCFA (Health Care Financing Administration) does not have this requirement, and that it is the responsibility of the payor to seek coordination of benefits from the patient. The commenters stated that the payor should accept the due diligence of the physician that answers "no" in box 11d of a HCFA 1500 form and process the claim accordingly. One commenter stated that these rules are based primarily on HCFA requirements. One commenter stated that the department has not given adequate justification of the need for this requirement. One commenter stated that many HMOs and preferred provider carriers do not want the "no other health coverage" documentation as it would be too burdensome. Several commenters stated that by requiring physicians or providers to allow open access to the additional documentation is an unnecessary compromise and further complicates the claims payment system.

Response: The department disagrees. Many of the comments seem to result from a misunderstanding of how the amendment will function. It is the department's understanding that, currently, most physicians and providers obtain or attempt to obtain health care coverage information from their patients (i.e., enrollees/insureds) as a standard business practice in order to submit claims to or to seek reimbursement from the responsible parties: an insurer, an HMO, a self-funded plan, Medicaid, Medicare, or the patient. This information is currently collected by physicians and providers at various times and through various means: in an initial or annual office visit questionnaire, in a sign-in sheet enrollees/insureds are requested to complete at office visits, or upon obtaining certain services, treatment or supplies from the physician or provider, or as part of the physician's or provider's routine record updating. Under the amendment, physicians and providers must retain in their files the form completed by the enrollee/insured and provide this form to the HMO or preferred provider carrier upon request. This form could be a copy of the initial or annual office visit questionnaire, sign-in sheets, or other similar document signed by the enrollee/insured within the last 12 months that there is no other health coverage. If the HMO or preferred provider carrier has reason to see such documentation, such as the HMO or preferred provider carrier having information that the enrollee/insured may have other coverage, they may request the physician or provider to submit a copy of the signed document. This request does not affect in any way the 45-day requirement under which the HMO or preferred provider carrier must process a clean claim in accordance with §21.2807 or audit a clean claim in accordance with §21.2809. Thus, an HMO or preferred provider carrier may not delay the processing of a clean claim if the physician or provider has responded "no" to the disclosure of health care coverage (HCFA 1500, field 11d), even if the carrier requests a copy of the signed document stating that there is no other health care coverage. For these reasons, the department disagrees that the amendment provides grounds for HMOs or preferred provider carriers to intentionally or inadvertently circumvent the law, that the amendment violates the intent of House Bill 610 to promote prompt payment, and that the amendment gives HMOs or preferred provider carriers one more reason to deny or delay payment on a clean claim. The amendment is a balanced and reasonable approach to address the coordination of benefit issues that arise in the processing of clean claims. The department disagrees that the amendment shifts a function that belongs to preferred provider carriers or HMOs onto the physicians or providers. Preferred provider carriers and HMOs that have coordination of benefit provisions in their insurance policies or health care plans are responsible for obtaining information if the patient has other health care coverage and the information is necessary for determining which coverage is primary or secondary pursuant to 28 TAC, Chapter 3, Subchapter V, and 28 TAC §11.511(1). The department believes that the adoption of the amendment is necessary to implement Articles 3.70-3C and 20A.18B. Under the amendment, the data elements relating to other health care coverage are not essential for a claim to be "clean" when the response is "no" to the disclosure of any other health benefit plans; therefore, it is necessary that HMOs and preferred provider carriers be able to obtain reliable information from the physician and provider that supports the "no" response. The rule does not specify when this information can be requested, but the department expects that HMOs and preferred provider carriers will have a good and valid reason to request the information. In addition, it is the department's understanding that physicians and providers routinely obtain information about other insurance in order to file claims for payment of health care services, treatment, and supplies. Therefore, the department disagrees that the amendment places additional burden and expense on the physician or provider. Physicians and providers need the information on other health care coverage to file claims properly and to receive proper payment for the services and treatment that they have rendered. Because the amendment is based on what the department understands to be the standard business practice of physicians and providers who routinely file claims for payment of health care services, treatment, and supplies, the department does not believe that there is any reason for physician or provider confusion. The department believes that the amendment will facilitate the filing of electronic claims because claims can be submitted electronically without providing a copy of a signed document stating that there is no other health care coverage; the signed document need only be provided in those instances in which the HMO or preferred provider carrier requests a copy of the document, and that request will be made after the claim is submitted electronically. Therefore, the amendment does not violate the HIPAA mandates on electronic claims and does not result in any increase in overhead expenses or delay in payments because of an inability to use electronic submission of claims. The department disagrees that it is appropriate or necessary for the clean claims elements to conform precisely to the HCFA requirements for Medicare claims with regard to the other health care coverage requirements when the response is "no" because Medicare is primary coverage for the majority of its claims, and thus coordination of benefits is not as significant an issue. Moreover, a recent Government Accounting Office report identified Medicare secondary payor debt as a major source of overpayment by HCFA for Medicare services, so the department does not believe that it is persuasive to rely upon Medicare practices as determinative with regard to this issue. The department disagrees that it has not given adequate justification of the need for the amendment; the rule proposal published in the October 20, 2000 issue of the Texas Register (25 TexReg 10437) explained that the amendment was being proposed to revise the requirements (adopted as part of the "clean claim" rules (28 TAC §§21.2801-21.2816)) relating to the element on disclosure of any other health care coverage when the response is "no"; that the amendment is necessary to facilitate the electronic claims filing process; and that the amendment was proposed in response to petitions from physicians and providers. Those HMOs or preferred provider carriers that do not want the "no other health coverage" documentation because it is too burdensome do not have to request it; the requesting of the documentation is optional for the HMO or preferred provider carrier. The department considers it inappropriate for an HMO or preferred provider carrier to seek the documentation indiscriminately, and the department will monitor complaints to identify any abuses. The amendment does not require open access to documentation that does not already exist for physicians and providers who routinely file claims for payment of health care services, treatment, and supplies; HMOs and preferred provider carriers routinely request physicians and providers to furnish this and other information as part of the claims handling process.

Comment: Two commenters objected to the requirement that the physician or provider keep on file a document signed within the past 12 months that there is no other health care coverage because the 12-month requirement is too long a period. The commenters stated that the document should be dated close to the date of service because such information may become outdated or incorrect in a shorter period of time. One commenter recommended requiring that the document on file be signed within either the past 30 days or within 30 days of the date of service for the claim being submitted. The other commenter recommended that the 12 months be reduced to six months as a balanced approach that is more efficient and reasonable.

Response: The department disagrees. Because many physicians and providers routinely obtain information from enrollees/insureds concerning coverage by other health benefit plans more frequently than every 12 months, depending upon the frequency of the visits (i.e., via sign-in sheets enrollees/insureds complete at office visits or upon obtaining certain services, treatment or supplies from the physician or provider or as part of the physician's or provider's routine record updating which may be more often than every 12 months), in many instances the physician or provider will have information that is provided close to the date of service or treatment. The rule does not require the physician or provider to follow-up with the patient/enrollee to determine the accuracy of the patient/enrollee statement; it only requires the physician/provider to provide a copy of the statement when requested. HMOs and preferred provider carriers that have coordination of benefit provisions in their contracts may request this information when they have information that the patient/enrollee may have other health care coverage. These HMOs and preferred provider carriers are responsible pursuant to coordination of benefit requirements (28 TAC, Chapter 3, Subchapter V, and 28 TAC §11.511(1)) to determine (a) if there was or was not actual coverage by other health benefit plans at the time the service or treatment was rendered and (b) if there was, determine what plan is primary and what plan is secondary.

Comment: One commenter recommended that the amendment be applicable only to electronically submitted claims and not to paper claims; the commenter stated that for paper claims there seems to be no reason not to attach the form.

Response: The department disagrees. To promote uniformity and to streamline the claims filing process, the department believes that paper claims and electronically filed claims should have the same requirements. Furthermore, the ability of an HMO or preferred provider carrier to request the documentation should not be abused by seeking the documentation in all instances or indiscriminately.

Comment: One commenter requested that a group of people familiar with the actual process of claims filing be included in the process for determining the requirements for clean claims. According to the commenter, each of the insurance companies have somewhat different requirements for clean claims but all avoid the 45 day payment requirement by requiring the physician to offer documentation that the patient has no other insurance as primary.

Response: The department appreciates the suggestion, and, in fact, the clean claims elements were developed with significant input from individuals directly involved in the claims payment process, including representatives of HMOs, preferred provider carriers, hospitals, physicians, and other providers. In addition, the department has made every attempt to ensure that the clean claims rules: properly implement House Bill 610; fairly balance the interest of all affected parties; and do not unduly burden any person or entity affected by the rules. Under the amendment, upon receipt of a clean claim for which the physician or provider has responded "no" to the disclosure of other health care coverage (HCFA 1500, field 11d), HMOs and preferred provider carriers must process the clean claim in accordance with §21.2807 or audit the clean claim in accordance with §21.2809. HMOs and preferred provider carriers may not delay the processing of such clean claims even if the HMO or preferred provider carrier requests from the physician or provider a copy of the signed document stating that there is no other health care coverage.

§21.2809(b) Audit Procedures

Comment: Numerous commenters requested that the proposed amendment to §21.2809(b) be revised to require that the notification be "written" and to provide that the HMO or preferred provider carrier may not make a chargeback sooner than the 45 th day after notice unless the physician or provider contacts the HMO or preferred provider carrier to arrange for reimbursement through an alternative method.

Response: The department agrees in part and disagrees in part. For purposes of clarification, the proposed amendment to §21.2809(b) is revised to change "notification" to "written notification." The commenter's recommendation that the HMO or preferred provider carrier may not make a chargeback sooner than the 45 th day after notice unless the physician or provider contacts the HMO or preferred provider carrier to arrange for reimbursement through an alternative method is inconsistent with House Bill 610. Articles 3.70-3C, §3A(e) and 20A.18B(e) of the Insurance Code, as enacted by House Bill 610, provide that following completion of the audit, any additional payment due a physician or provider or any refund due the HMO or preferred provider carrier is to be made not later than the 30 th day after the later of the date that the physician or provider receives notice of audit results or, if an appeal was filed before expiration of the 30-calendar-day refund period, any appeal rights of the insured or enrollee are exhausted.

Comment: One commenter recommended that the notification required in §21.2809(b) identify the relevant patient's name, the applicable date(s) of service(s), and on a service by service basis, either the additional percentage payment or the chargeback percentages as they affect the amounts already paid as determined by the results of the audit. The commenter stated that this change is needed to add more specificity to the chargeback notification and thus enhance the purpose behind the amendment.

Response: The department disagrees. The intent of the amendment is not to specify every single piece of information that must be included in the notice of audit results but rather to clarify the essential information that is to be included in the notice of audit results in the event that the HMO or preferred provider carrier intends to make a chargeback and to allow flexibility to HMOs and preferred provider carriers as to other information to be included in the notice of audit results. Additionally, to require the requested information in the notice of audit results could arguably impose requirements on HMOs and preferred provider carriers and other affected parties for which they have not received notice and an opportunity to comment. Therefore, the imposition of these additional requirements could be considered a substantive change in the proposed rule which would require republication of the amendment with another 30-day comment period before the rule could be considered for adoption.

Comment: One commenter recommended that the proposed language "unless otherwise agreed to by contract" in §21.2809(b) be deleted. According to the commenter, this is recommended because of the recognized disparity (as evidenced by the passage of SB 1468 relating to joint negotiations by physicians) in contractual bargaining power between the great majority of physicians and insurance companies that allow the clean claim rules to be circumvented by contract and thereby result in the deterioration or elimination of the intended purpose of the rule.

Response: The department disagrees. Articles 3.70-3C, §3A and 20A.18B recognize the right of physicians and providers and HMOs and preferred provider carriers to contract. Therefore, it is necessary to include the language "Unless otherwise agreed to by contract" because the physician or provider and the HMO or preferred provider carrier have the ability to agree to chargeback procedures by contract. If the parties do otherwise agree, there may not be a need for the HMO or preferred provider carrier to include the required statement in the notification of audit results.

Comment: One commenter recommended that the proposed amendment to §21.2809(b) be revised to remove the ability of the provider to "contact" the HMO or preferred provider carrier to arrange for an alternative reimbursement method and instead to provide that the HMO or preferred provider carrier will make a chargeback unless the HMO or preferred provider carrier agrees to accept reimbursement through an alternative method. The commenter stated that while they do not think that this language is intended to permit a physician or provider to deprive an HMO or preferred provider carrier of its right to make a chargeback merely by contacting the HMO or preferred provider carrier it would be easy to construe the proposed language as having that effect. The commenter believes that it is necessary that the HMO or preferred provider carrier "agrees" to such an alternative reimbursement method and that much more than a mere "contact" is necessary.

Response: The department disagrees with the requested change. The department agrees that the proper reading of the amendment is that the HMO or preferred provider carrier must agree to accept reimbursement through an alternative method, but the department interprets the language "arrange for reimbursement through an alternative method" to mean that there must be mutual agreement as to the method of reimbursement. Therefore, the department does not believe that any change is necessary because the rule as proposed contemplates agreement between the physician or provider and the HMO or preferred provider carrier.

Comment: One commenter recommended deletion of the proposed change to §21.2809(b). The commenter stated that the proposed change does not appear to be justified by practice or by House Bill 610. According to the commenter, neither House Bill 610 nor the rules define "alternative methods" and there is no explanation in the proposed rule changes for the new requirements.

Response: The department disagrees. It is the department's understanding, based on information received from physicians, providers, HMOs and preferred provider carriers and groups representing these parties, that it is an existing business practice for HMOs and preferred provider carriers to make chargebacks to recoup any overpayment to physicians and providers. While House Bill 610 does not specifically address "chargebacks," Articles 3.70-3C §3A(e) and 20A.18B(e) of the Insurance Code, as enacted by House Bill 610, require notice of the audit results to be provided to the physician or provider and require a refund to be made to the preferred provider carrier or HMO upon completion of the audit in the event of overpayment to the physician or provider. "Alternative methods" of reimbursement could be any means, other than chargebacks, by which the physician or provider may refund any overpayment to the HMO or preferred provider carrier, including check, cash, or installment plan. As explained in the rule proposal published in the October 20, 2000 issue of the Texas Register (25 TexReg 10437), the amendment is necessary to clarify the essential information that is to be included in the notice of audit results if, upon completion of the audit, a refund is due from the physician or provider and the HMO or preferred provider carrier intends to make a chargeback against the physician or provider. Also, as explained in the published rule proposal, the amendment is needed to assist physicians and providers in more efficient and accurate recordkeeping of audited claims and is needed to clarify that existing or future contractual arrangements that allow alternative reimbursement methods in the event of overpayment to the physician or provider are not affected by the rule. Additionally, the department received a petition from various groups to amend the clean claims rules to "ameliorate the accounting difficulties imposed on physicians and providers by chargeback arrangements. . . ." and to ensure "that all parties have a mutual understanding of what occurs when a claim has been incorrectly paid." The rule is similar to the amendment requested by the petitioners.

Comment: Several commenters objected to HMOs and preferred provider carriers being allowed to recover overpayments through chargebacks and recoupments. One commenter stated that in many instances chargebacks are inaccurate. Two commenters called chargebacks an "accounting nightmare." According to one commenter, if an insurance company has overpaid a claim, they need only send proper documentation of that payment, and a refund is issued in a timely manner. Three commenters stated that chargebacks and recoupments are extremely burdensome for physicians and that the regulations should allow flexibility regarding payment so that physicians can decide how best to deal with this as long as the repayment request is made within the appropriate time period and is justified. One commenter stated that carriers should be held to a deadline when asking for a payment back due to an error in processing. One commenter stated that a process of recoupment that allows insurers to recover overpayments without clearly relating the overpayment to an individual is unfair. According to this commenter, the deduction usually requires a call to the insurance company to determine where the money is being recouped from; the commenter recommended the more accurate and preferred method of refund requests and stated that physicians are willing to have reasonable time limits set for the refunds. One commenter objected to chargebacks and recoupments which do not give the physician's staff adequate time for research and response.

Response: Section 21.2809(b) recognizes that chargebacks are an existing business practice and one possible method by which HMOs and preferred provider carriers may recoup overpayment to physicians and providers; in some instances chargebacks may be the most efficient means of handling an overpayment. Section 21.2809(b) recognizes the various payment systems of the different types of physicians and providers and allows flexibility to both the physicians and providers and HMOs or preferred provider carriers to develop the most effective and efficient method of handling any overpayments. Neither the current rule nor the amendment imposes chargebacks on HMOs or preferred provider carriers or physicians or providers. The department does not have the authority under House Bill 610 to require or prohibit chargebacks.

§21.2810 Date of Claim Payment

Comment: One commenter expressed support for the amendment as published, and one commenter stated that the amendment posed no current concern.

Response: The department appreciates the commenters' support.

For with changes: Arlington Family Practice, Bent Tree Family Physicians, Blue Cross/Blue Shield of Texas, Dallas County Medical Society, The Diaz Clinic, Digestive Health Associates of Texas, Family Healthcare Center, Family Medicine Associates of Texas, Garland Medical Clinic, The Health Group, Heart Place, Jefferson Physician Group, Medical Clinic of North Texas, Orthopedic Associates of Dallas, Orthopedic Specialty Associates, Teen Care of Irving, Texas Association of Insurance Officials, Texas Medical Association, Texas Pulmonary Consultants, Urology Clinics of North Texas, and 17 individual physicians.

Against: None.

The amendments are adopted under the Insurance Code Articles 3.70-3C and 20A.18B and §36.001. Articles 3.70-3C, §3A(a) and 20A.18B(a) provide that under these sections, "clean claim" means a completed claim, as determined under department rules, submitted by a physician or provider for medical care or health care services under a health insurance policy or health care plan. Articles 3.70-3C, §3A(e) and 20A.18B(e) provide that following the completion of the audit of a clean claim, any additional payment due a physician or provider or any refund due the preferred provider carrier or HMO shall be made not later than the 30 th day after the later of the date that the physician or provider receives notice of the audit results or any appeal rights of the insured are exhausted. Articles 3.70-3C, §3A(c) and 20A.18B(c) specify actions that must be taken by an HMO or preferred provider carrier within 45 days after the date of receipt of a clean claim, including payment of the total amount of the claim in accordance with the contract between the physician or provider and the HMO or preferred provider carrier. Articles 3.70-3C, §3A(n) and 20A.18B(o) authorize the Commissioner to adopt rules as necessary to implement these articles. Section 36.001 provides that the Commissioner of Insurance may adopt rules for the conduct and execution of the powers and duties of the department only as authorized by statute.

§21.2803. Elements of a Clean Claim.

(a) Required clean 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, or revisions to data elements, 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 of this title (relating to Disclosure of Necessary Attachments), 21.2805 of this title (relating to Disclosure of Additional Clean Claim Elements), and 21.2806 of this title (relating to Disclosure of Revision of Data Elements, Attachments, or Additional Clean Claim Elements), and any coordination of benefits or non-duplication of benefits information pursuant to subsection (e) of this section, if applicable.

(b) Required data elements. HCFA has developed claim forms which provide much of the information needed to process claims. Two of these forms, HCFA-1500 and UB-82/HCFA, 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 successor forms 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) Essential data elements for physicians or noninstitutional providers. Unless otherwise agreed by contract, the data elements described in this paragraph are necessary for claims filed by physicians and noninstitutional providers.

(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) subscriber´s name (HCFA 1500, field 4);

(E) patient´s address (street or P.O. Box, city, zip) (HCFA 1500, field 5);

(F) patient´s relationship to subscriber (HCFA 1500, field 6);

(G) subscriber´s address (street or P.O. Box, city, zip) (HCFA 1500, field 7);

(H) whether patient´s condition is related to employment, auto accident, or other accident (HCFA 1500, field 10);

(I) subscriber´s policy number (HCFA 1500, field 11);

(J) subscriber´s birth date and gender (HCFA 1500, field 11a);

(K) HMO or preferred provider carrier name (HCFA 1500, field 11c);

(L) disclosure of any other health benefit plans (HCFA 1500, field 11d);

(i) if respond "yes", then

(I) data elements specified in paragraph (3)(A)-(E) of this subsection are essential unless the physician or provider submits with the claim documented proof to the HMO or preferred provider carrier that the physician or provider has made a good faith but unsuccessful attempt to obtain from the enrollee or insured any of the information needed to complete the data elements in paragraph (3)(A)-(E) of this subsection;

(II) the data element specified in paragraph (3)(I) of this subsection is essential when submitting claims to secondary payor HMOs or preferred provider carriers;

(ii) if respond "no," the data elements specified in paragraph 3(A)-(E) of this subsection are not applicable and therefore are not considered essential if the physician or provider has on file a document signed within the past 12 months by the patient or authorized person stating that there is no other health care coverage; although the submission of the signed document is not an essential data element, a copy of the signed document shall be provided to the HMO or preferred provider carrier upon request.

(M) patient´s or authorized person´s signature or notation that the signature is on file with the physician or provider (HCFA 1500, field 12);

(N) subscriber´s or authorized person´s signature or notation that the signature is on file with the physician or provider (HCFA 1500, field 13);

(O) date of current illness, injury, or pregnancy (HCFA 1500, field 14);

(P) first date of previous same or similar illness (HCFA 1500, field 15);

(Q) diagnosis codes or nature of illness or injury (HCFA 1500, field 21);

(R) date(s) of service (HCFA 1500, field 24A);

(S) place of service codes (HCFA 1500, field 24B);

(T) type of service code (HCFA 1500, field 24C);

(U) procedure /modifier code (HCFA 1500, field 24D);

(V) diagnosis code by specific service (HCFA 1500, field 24E);

(W) charge for each listed service (HCFA 1500, field 24F);

(X) number of days or units (HCFA 1500, field 24G);

(Y) physician´s or provider´s federal tax ID number (HCFA 1500, field 25);

(Z) total charge (HCFA 1500, field 28);

(AA) signature of physician or provider or notation that the signature is on file with the HMO or preferred provider carrier (HCFA 1500, field 31);

(BB) name and address of facility where services rendered (if other than home or office) (HCFA 1500, field 32); and

(CC) physician´s or provider´s billing name and address (HCFA 1500, field 33).

(2) Essential data elements for institutional providers. Unless otherwise agreed by contract, the data elements described in this paragraph are necessary for claims filed by institutional providers.

(A) provider's 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 period (beginning and ending date of claim period) (UB-92, field 6);

(F) patient's name (UB-92, field 12);

(G) patient's address (UB-92, field 13);

(H) patient's date of birth (UB-92, field 14);

(I) patient's gender (UB-92, field 15);

(J) patient's marital status (UB-92, field 16);

(K) date of admission (UB-92, field 17);

(L) admission hour (UB-92, field 18);

(M) type of admission (e.g. emergency, urgent, elective, newborn) (UB-92, field 19);

(N) source of admission code (UB-92, field 20);

(O) patient-status-at-discharge code (UB-92, field 22);

(P) value code and amounts (UB-92, fields 39-41);

(Q) revenue code (UB-92, field 42);

(R) revenue description (UB-92, field 43);

(S) units of service (UB-92, field 46);

(T) total charge (UB-92, field 47);

(U) HMO or preferred provider carrier name (UB-92, field 50);

(V) subscriber's name (UB-92, field 58);

(W) patient's relationship to subscriber (UB-92, field 59);

(X) patient's/subscriber's certificate number, health claim number, ID number (UB-92, field 60);

(Y) principal diagnosis code (UB-92, field 67);

(Z) attending physician ID (UB-92, field 82);

(AA) signature of provider representative or notation that the signature is on file with the HMO or preferred provider carrier (UB-92, field 85); and

(BB) date bill submitted (UB-92, field 86).

(3) Data elements that are necessary, if applicable. Unless otherwise agreed by contract, the data elements contained in this paragraph are necessary for claims filed by physicians or providers if circumstances exist which render the data elements applicable to the specific claim being filed. The applicability of any given data element contained in this paragraph is determined by the situation from which the claim arose.

(A) other insured's or enrollee's name (HCFA 1500, field 9), is applicable if patient is covered by more than one health benefit plan, generally in situations described in subsection (e) of this section. If the essential data element specified in paragraph (1)(L) of this subsection, "disclosure of any other health benefit plans", is answered yes, this is applicable unless the physician or provider submits with the claim documented proof to the HMO or preferred provider carrier that the physician or provider has made a good faith but unsuccessful attempt to obtain from the enrollee or insured any of the information needed to complete this data element;

(B) other insured's or enrollee's policy/group number (HCFA 1500, field 9a), is applicable if patient is covered by more than one health benefit plan, generally in situations described in subsection (e) of this section. If the essential data element specified in paragraph (1)(L) of this subsection, "disclosure of any other health benefit plans," is answered yes, this is applicable unless the physician or provider submits with the claim documented proof to the HMO or preferred provider carrier that the physician or provider has made a good faith but unsuccessful attempt to obtain from the enrollee or insured any of the information needed to complete this data element;

(C) other insured's or enrollee's date of birth (HCFA 1500, field 9b), is applicable if patient is covered by more than one health benefit plan, generally in situations described in subsection (e) of this section. If the essential data element specified in paragraph (1)(L) of this subsection, "disclosure of any other health benefit plans," is answered yes, this is applicable unless the physician or provider submits with the claim documented proof to the HMO or preferred provider carrier that the physician or provider has made a good faith but unsuccessful attempt to obtain from the enrollee or insured any of the information needed to complete this data element;

(D) other insured's or enrollee's plan name (employer, school, etc.) (HCFA 1500, field 9c), is applicable if patient is covered by more than one health benefit plan, generally in situations described in subsection (e) of this section. If the essential data element specified in paragraph (1)(L) of this subsection, "disclosure of any other health benefit plans", is answered yes, this is applicable unless the physician or provider submits with the claim documented proof to the HMO or preferred provider carrier that the physician or provider has made a good faith but unsuccessful attempt to obtain from the enrollee or insured any of the information needed to complete this data element;

(E) other insured's or enrollee's HMO or insurer name (HCFA 1500, field 9d), is applicable if patient is covered by more than one health benefit plan, generally in situations described in subsection (e) of this section. If the essential data element specified in paragraph (1)(L) of this subsection, "disclosure of any other health benefit plans," is answered yes, this is applicable unless the physician or provider submits with the claim documented proof to the HMO or preferred provider carrier that the physician or provider has made a good faith but unsuccessful attempt to obtain from the enrollee or insured any of the information needed to complete this data element;

(F) subscriber's plan name (employer, school, etc.) (HCFA 1500, field 11b) is applicable if the health benefit plan is a group plan;

(G) prior authorization number (HCFA 1500, field 23), is applicable when prior authorization is required;

(H) whether assignment was accepted (HCFA 1500, field 27), is applicable when assignment under Medicare has been accepted;

(I) amount paid (HCFA 1500, field 29), is applicable if an amount has been paid to the physician or provider submitting the claim by the patient or subscriber, or on behalf of the patient or subscriber or by a primary plan in accordance with paragraph (1)(L) of this subsection and as required by subsection (e) of this section;

(J) balance due (HCFA 1500, field 30), is applicable if an amount has been paid to the physician or provider submitting the claim by the patient or subscriber, or on behalf of the patient or subscriber;

(K) covered days (UB-92, field 7), is applicable if Medicare is a primary or secondary payor;

(L) noncovered days (UB-92, field 8), is applicable if Medicare is a primary or secondary payor;

(M) coinsurance days (UB-92, field 9), is applicable if Medicare is a primary or secondary payor;

(N) lifetime reserve days (UB-92, field 10), is applicable if Medicare is a primary or secondary payor, and the patient was an inpatient;

(O) discharge hour (UB-92, field 21), is applicable if the patient was an inpatient, or was admitted for outpatient observation;

(P) condition codes (UB-92, fields 24-30), are applicable if the HCFA UB-92 manual contains a condition code appropriate to the patient's condition;

(Q) occurrence codes and dates (UB-92, fields 31-36), are applicable if the HCFA UB-92 manual contains an occurrence code appropriate to the patient's condition;

(R) occurrence span code, from and through dates (UB-92, field 36), is applicable if the HCFA UB-92 manual contains an occurrence span code appropriate to the patient's condition;

(S) HCPCS/Rates (UB-92, field 44), is applicable if Medicare is a primary or secondary payor;

(T) prior payments - payor and patient (UB-92, field 54), is applicable if payments have been made to the physician or provider by the patient or another payor or subscriber, on behalf of the patient or subscriber, or by a primary plan as required by subsection (e) of this section;

(U) diagnoses codes other than principle diagnosis code (UB-92, fields 68-75), is applicable if there are diagnoses other than the principle diagnosis;

(V) procedure coding methods used (UB-92, field 79), is applicable if the HCFA UB-92 manual indicates a procedural coding method appropriate to the patient's condition;

(W) principal procedure code (UB-92, field 80), is applicable if the patient has undergone an inpatient or outpatient surgical procedure; and

(X) other procedure codes (UB-92, field 81), is applicable as an extension of subparagraph (W) of this paragraph if additional surgical procedures were performed.

(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 shall 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 shall satisfy the notification procedures set forth in §21.2805 of this title (relating to Disclosure of Additional Clean Claim Elements).

(e) Coordination of benefits or non-duplication of benefits. 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) and §11.511(1) of this title (relating to Optional Provisions) is necessary, the amount paid as a covered claim by the primary plan is considered to be an essential element of a clean claim for purposes of the secondary plan's processing of the claim and HCFA 1500, field 29 or UB-92, field 54 must be completed pursuant to subsection (b)(3)(I) and (T) of this section. If a claim is submitted for covered services or benefits in which non-duplication of benefits pursuant to §3.3053 of this title (relating to Non-duplication of Benefits Provision) is an issue, the amounts paid as a covered claim by all other valid coverage is considered to be an essential element of a clean claim and HCFA 1500, field 29 or UB-92, field 54 must be completed pursuant to subsection (b)(3)(I) and (T) of this section. If a claim is submitted for covered services or benefits and the policy contains a variable deductible provision as set forth in §3.3074(a)(4) of this title (relating to Minimum Standards for Major Medical Expense Coverage) the amount paid as a covered claim by all other health insurance coverages, except for amounts paid by individually underwritten and issued hospital confinement indemnity, specified disease, or limited benefit plans of coverage, is considered to be an essential element of a clean claim and HCFA 1500, field 29 or UB-92, field 54 must be completed pursuant to subsection (b)(3)(I) and (T) of this section.

(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) Additional data elements, attachments, or information. The submission of data elements, attachments, or information by a physician or provider with a claim in addition to those required for a clean claim under this section shall not render such claim deficient.

§21.2809. Audit Procedures.

(a) If an HMO or preferred provider carrier is unable to pay or deny a clean claim, in whole or in part, within the statutory claims payment period specified in §21.2802(25)(B) of this title (relating to Definitions), the unpaid portion of the claim shall be classified as an audit, and the HMO or preferred provider carrier shall pay 85% of the contracted rate on the unpaid portion of the clean claim within the statutory claims payment period. Payment of 85% of the contracted rate on the clean claim is not an admission that the HMO or preferred provider carrier acknowledges liability on that claim.

(b) Upon completion of the audit, if the HMO or preferred provider carrier determines that a refund is due from a physician or provider, such refund shall be made within 30 calendar days of the later of written notification to the physician or provider of the results of the audit or exhaustion of any subscriber or patient appeal rights if a subscriber or patient appeal is filed before the 30-calendar-day refund period has expired, and may be made by any method, including chargeback against the physician or provider, or agreements by contract. The written notification of the results of the audit shall include a listing of the specific claims paid and not paid pursuant to the audit, including specific claims and amounts for which a refund is due. Unless otherwise agreed to by contract, if an HMO or preferred provider carrier intends to make a chargeback, the written notification shall also include a statement that the HMO or preferred provider carrier will make a chargeback unless the physician or provider contacts the HMO or preferred provider carrier to arrange for reimbursement through an alternative method. Nothing in this provision shall invalidate or supersede existing or future contractual arrangements that allow alternative reimbursement methods in the event of overpayment to the physician or provider.

(c) Upon completion of the audit, if the HMO or preferred provider carrier determines that additional payment is due to the physician or provider, such additional payment shall be within 30 calendar days after the completion of the audit.

§21.2810. Date of Claim Payment. For purposes of determining compliance with the statutory claims payment period, payment is considered to have been paid on the date of:

(1) the postmark, if a claim payment is delivered by the United States Postal Service;

(2) electronic transmission, if a claim payment is made electronically;

(3) delivery of the claim payment to a commercial carrier, such as UPS or Federal Express; or

(4) receipt by the physician or provider, if a claim payment is made other than as provided in paragraph (1), (2), or (3) of this section.



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