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You are here: Home . rules . 2004 . 0426A-059
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Subchapter T. Submission of Clean Claims

28 TAC §21.2821

The Texas Department of Insurance proposes amendments to §21.2821 concerning reporting requirements for pharmacy claims. The proposed amendments are necessary to implement the provisions of Senate Bill (SB) 418, 78th Regular Legislative Session, by ensuring that the department receives complete and accurate information concerning all types of health care claims subject to prompt pay. In addition to all other penalties or remedies authorized by the Insurance Code, SB 418 also allows for administrative penaltites against carriers that are noncompliant in processing more than two percent of clean claims, including electronically submitted, affirmatively adjudicated pharmacy claims. The department originally adopted reporting rules on September 9, 2003, and subsequently informed carriers by bulletin that rules specific to reporting of pharmacy claims would be proposed at a later date. Section 21.2821 generally imposes reporting requirements on carriers subject to prompt pay rules, and the proposed amendments are necessary to address how those reporting rules apply to electronically submitted, affirmatively adjudicated pharmacy claims

Kimberly Stokes, Senior Associate Commissioner of Life, Health, and Licensing, has determined that for each year of the first five years the proposed section will be in effect there will be no fiscal impact to state and local governments as a result of the enforcement or administration of the rule. There will be no measurable effect on local employment or the local economy as a result of the proposal.

Ms. Stokes has determined that for each year of the first five years the section is in effect, the public benefits anticipated as a result of the proposed amendments the department´s receipt of all information required to be evaluated by SB 418 in order to accurately assess carriers compliance with the statute and associated rules. The probable economic cost to persons required to comply with the proposed amendment is the result of SB 418 and not the result of the adoption, administration or enforcement of this section. The reporting requirements that relate to payment of pharmacy claims are required by SB 418, which states that a carrier that violates the claims payment provisions in processing more than two percent of clean claims is subject to an administrative penalty, and requires the department to compute a compliance percentage for clean claims. Because §21.2821 was originally adopted in 2003, the proposed amendments may involve data gathering and reporting practices or procedures that are currently in use and would allow an HMO or preferred provider carrier to make use of existing procedures. The same cost considerations apply regardless the size of the carrier. It is neither legal nor feasible to waive the requirements of the section for small or micro-businesses as the statute requires the department to assess a compliance percentage for each HMO or preferred provider carrier in the state

To be considered, written comments on the proposal must be submitted no later than 5:00 p.m. on June 7, 2004 to Gene C. Jarmon, General Counsel and Chief Clerk, Mail Code 113-2A, Texas Department of Insurance, P. O. Box 149104, Austin, Texas 78714-9104. An additional copy of the comment must be simultaneously submitted to Kimberly Stokes, Senior Associate, Life, Health and Licensing, 107-2A, P.O. Box 149104, Austin, Texas 78714-9104. A request for a public hearing should be submitted separately to the Office of the Chief Clerk.

The amendments are proposed under the Insurance Code Article 3.70-3C §3I(k), and §§843.342(k) and 36.001. Article 3.70-3C §3I(k) and §843.342(k) require the department to assess an insurer´s or health maintenance organization´s prompt pay compliance in processing submitted clean claims and grants the department the authority to subject such entities to an administrative penalty if violations involve the processing of more than two percent of submitted clean claims. Section 36.001 provides that the Commissioner of Insurance may adopt any rules necessary and appropriate to implement the powers and duties of the Texas Department of Insurance under the Insurance Code and other laws of this state.

The following provisions are affected by this proposal:Insurance Code Article 3.70-3C, §3I(k) and §843.342(k)

§21.2821. Reporting Requirements.

(a) - (c) (No change.)

(d) The report required by subsection (a) of this section shall include, at a minimum, the following information:

(1) - (16) (No change.)

(17) number of certifications of catastrophic events sent to the department; [and]

(18) number of calendar days business was interrupted for each corresponding catastrophic event ;[.]

(19) number of electronically submitted, affirmatively adjudicated pharmacy claims received by the HMO or preferred provider carrier from non-institutional providers;

(20) number of electronically submitted, affirmatively adjudicated pharmacy claims received by the HMO or preferred provider carrier from institutional providers;

(21) number of electronically submitted, affirmatively adjudicated pharmacy claims from non-institutional providers paid within the 21-day statutory claims payment period;

(22) number of electronically submitted, affirmatively adjudicated pharmacy claims from institutional providers paid within the 21-day statutory claims payment period;

(23) number of electronically submitted, affirmatively adjudicated pharmacy claims from non-institutional providers paid on or before the 45th day after the end of the 21-day statutory claims payment period;

(24) number of electronically submitted, affirmatively adjudicated pharmacy claims from institutional providers paid on or before the 45th day after the end of the 21-day statutory claims payment period;

(25) number of electronically submitted, affirmatively adjudicated pharmacy claims from non-institutional providers paid on or after the 46th day and before the 91st day after the end of the 21-day statutory claims payment period;

(26) number of electronically submitted, affirmatively adjudicated pharmacy claims from institutional providers paid on or after the 46th day and before the 91st day after the end of the 21-day statutory claims payment period;

(27) number of electronically submitted, affirmatively adjudicated pharmacy claims from non-institutional providers paid on or after the 91st day after the end of the 21-day statutory claims payment period; and

(28) number of electronically submitted, affirmatively adjudicated pharmacy claims from institutional providers paid on or after the 91st day after the end of the 21-day statutory claims payment period.

(e)(No change.)



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