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You are here: Home . rules . 2004 . 0621a-059
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SUBCHAPTER T. Submission of Clean Claims

28 TAC §21.2821

The Commissioner of Insurance adopts amendments to §21.2821 concerning reporting requirements for pharmacy claims. The amendments are adopted with changes to the proposed text as published in the May 7, 2004 issue of the Texas Register (29 TexReg 4410).

The amendments are necessary to implement the provisions of Senate Bill (SB) 418, 78 th Regular Legislative Session, by ensuring that the department receives complete and accurate information concerning all types of health care claims subject to prompt pay requirements. In addition to all other penalties or remedies authorized by the Insurance Code, SB 418 also allows for administrative penalties 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 15, 2003 , and subsequently informed carriers by bulletin that staff would propose rules specific to reporting of pharmacy claims at a later date.

The department has made a change that affects several of the proposed subsection paragraphs as published; however, that change does not introduce new subject matter or impact persons other than those subject to the proposal as originally published. In response to a comment, the department has categorized all pharmacy claims that are subject to the 21-day statutory claims payment period in one group, without distinguishing between claims from non-institutional and institutional providers. The department has deleted references to non-institutional and institutional providers from §21.2821(d)(19)-(28). Also, clarification language has been added and grammatical corrections have been made to subsection (e) of the section.

Adopted §21.2821 generally imposes reporting requirements on carriers subject to prompt pay rules and addresses how those reporting rules apply to electronically submitted, affirmatively adjudicated pharmacy claims.

SUMMARY OF COMMENTS AND AGENCY´S RESPONSE TO COMMENTS.

Comment: A commenter supports the proposed rule, but suggests that the department not distinguish between non-institutional and institutional providers with regard to pharmacy claims. The commenter explains that pursuant to the definition of institutional provider, pharmacy claims would always be considered to be received from non-institutional providers because contracted pharmacies would always be considered to be non-institutional providers. Prescription drugs may be a covered service when provided by an institutional provider, but such service would be considered to be covered as a medical or health care service rather than as a pharmacy claim. The commenter states that separating pharmacy claims into non-institutional and institutional provider categories may inject an unintended administrative complication into institutional claims processing, and accordingly suggests that the pharmacy reporting requirements for claims be referenced simply as pharmacy claims rather than identifying them as derived from either non-institutional or institutional providers.

Agency Response: After further consideration of the definition of institutional provider in the context of pharmacy claims, the department agrees that pharmacy claims should not be separated into non-institutional and institutional provider claims categories because such a distinction is not applicable. Accordingly, the department has removed the distinction from the adopted rule.

NAMES OF THOSE COMMENTING FOR AND AGAINST THE SECTION.

For, with changes: Scott & White Health Plan.

The amendments are adopted 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.

§21.2821. Reporting Requirements.

(a) An HMO or preferred provider carrier shall submit to the department quarterly claims payment information in accordance with the requirements of this section.

(b) The HMO or preferred provider carrier shall submit the report required by subsection (a) of this section to the department on or before:

(1) May 15th for the months of January, February and March of each year;

(2) August 15th for the months of April, May and June of each year;

(3) November 15th for the months of July, August and September of each year; and

(4) February 15th for the months of October, November and December of each preceding calendar year.

(c) The HMO or preferred provider carrier shall submit the first report required by this section to the department on or before February 15, 2004 and shall include information for the months of September, October, November and December of the prior calendar year.

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

(1) number of claims received from non-institutional preferred providers;

(2) number of claims received from institutional preferred providers;

(3) number of clean claims received from non-institutional preferred providers;

(4) number of clean claims received from institutional preferred providers;

(5) number of clean claims from non-institutional preferred providers paid within the applicable statutory claims payment period;

(6) number of clean claims from non-institutional preferred providers paid on or before the 45th day after the end of the applicable statutory claims payment period;

(7) number of clean claims from institutional preferred providers paid on or before the 45th day after the end of the applicable statutory claims payment period;

(8) number of clean claims from non-institutional preferred providers paid on or after the 46th day and before the 91st day after the end of the applicable statutory claims payment period;

(9) number of clean claims from institutional preferred providers paid on or after the 46th day and before the 91st day after the end of the applicable statutory claims payment period;

(10) number of clean claims from non-institutional preferred providers paid on or after the 91st day after the end of the applicable statutory claims payment period;

(11) number of clean claims from institutional preferred providers paid on or after the 91st day after the end of the applicable statutory claims payment period;

(12) number of clean claims from institutional preferred providers paid within the applicable statutory claims payment period;

(13) number of claims paid pursuant to the provisions of §21.2809 of this title (relating to Audit Procedures);

(14) number of requests for verification received pursuant to §19.1724 of this title (relating to Verification);

(15) number of verifications issued pursuant to §19.1724 of this title;

(16) number of declinations, pursuant to §19.1724 of this title;

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

(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;

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

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

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

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

(e) An HMO or preferred provider carrier shall annually submit to the department, on or before July 31, at a minimum, information related to the number of declinations of requests for verifications in the following categories:

(1) policy or contract limitations:

(A) premium payment timeframes that prevent verifying eligibility for 30-day period;

(B) policy deductible, specific benefit limitations or annual benefit maximum;

(C) benefit exclusions;

(D) no coverage or change in membership eligibility, including individuals not eligible, not yet effective or membership cancelled;

(E) pre-existing condition limitations; and

(F) other.

(2) declinations due to inability to obtain necessary information in order to verify requested services from the following persons:

(A) the requesting physician or provider;

(B) any other physician or provider; and

(C) any other person.



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