DUE: August 15, 2008 - Second Quarter 2008 (April - June) Provider Claims Data and Annual Report of Reasons for Declinations
Pursuant to §38.001 of the Texas Insurance Code (TIC), the Texas Department of Insurance (TDI) issues the attached mandatory data call for insurers writing preferred provider health benefit plans in Texas, and for health maintenance organizations doing business in Texas (collectively, hereafter, "carriers"). This data call is necessary for TDI to determine carriers' compliance with various "prompt pay" requirements relating to claims submitted by providers, as addressed under TIC Ch. 1301 and Ch. 843, Subchapter J and rules adopted to implement those statutes. Carriers' complete responses to this data call are also necessary for compliance with 28 Texas Administrative Code (TAC) §21.2821.
Second Quarter 2008 Provider Claims Data: The provider claims data for the reporting period April through June, 2008 and annual report of reasons for declinations are due no later than August 15, 2008 . Please be advised that failure to report by the deadline may result in regulatory action, including enforcement. Please use the tips listed on page three to review the data before you submit it.
In certain circumstances, claims will be reported in more than one quarter. Specifically, if an initial underpayment is made (and reported) and a subsequent additional payment is made in a different quarter, then the subsequent payment must be reported as a late payment, as appropriate. If the subsequent payment is made outside the applicable statutory claims payment period, the carrier must reflect this in the report.
SB 418 Annual Report of Declination Data: Carriers are required to report annually the reasons for declining to verify a claim, referred to as declinations. Carriers should report declination data from July 1, 2007, through June 30, 2008. Also, carriers must submit reports about declinations issued by each delegated entity that processes that carrier's insured and/or enrollees' claims. Carriers and their delegated entities, if applicable, must retain the data used to calculate the totals reported to TDI for a minimum of three years, and the data must be available for review by TDI. The annual report of declination data is due no later than August 15, 2008.
The online data reporting forms may be accessed on the TDI website at: https://wwwapps.tdi.state.tx.us/scpsb418/login.jsp. You can still access the data reporting forms from the TDI website: www.tdi.state.tx.us. From the TDI home page, click on "more links" under the quick start links on the left side of the page. When the new page opens, click on "Surveys" under the quick start links on the left side of the page. Then scroll down to Life Health Data Calls and select Senate Bill 418. Your data collection contact will receive a reminder of this data call by email as well. If you have questions about the data call or how to access the data collection application, please contact Judy Wooten via email at: promptpay@tdi.state.tx.us or call her at 512-305-7319.
Sincerely,
Mike Geeslin
Commissioner of Insurance