DUE: May 15, 2012 - First Quarter 2012 (January - March) Provider Claims Data Report
Pursuant to 28 Texas Administrative Code (TAC) §21.2821, TDI issues this mandatory data call for insurers with PPBPs filed in Texas and for health maintenance organizations HMOs doing business in Texas (collectively "carriers").
This data call is necessary for TDI to determine carriers' compliance with "prompt pay" requirements relating to claims submitted by providers, under Texas Insurance Code Chapter 1301, Subchapters C and C-1; Texas Insurance Code Chapter 843, Subchapter J; and 28 TAC Chapter 21, Subchapter T.
Both the HB 610, 76th Legislature, Regular Session, quarterly report and the Senate Bill (SB) 418, 78th Legislature, Regular Session, quarterly report are due with this data call. These reports are due on May 15, 2012, as required by 28 TAC §21.2821. The reporting database will lock down at 11:59 p.m. CST on the date the report is due.
The HB 610 report applies to provider claims paid under provider contracts issued or renewed before August 16, 2003. The SB 418 report applies to provider claims paid under provider contracts issued or renewed on or after August 16, 2003.
The payment deadline for pharmacy claims submitted electronically has changed. HB 2292 reduced the claims payment deadline for a carrier to pay an electronically submitted pharmacy claim from the 21st to the 18th day after the date on which the claim is affirmatively adjudicated. The 21-day claims payment deadline still applies to pharmacy claims that are not submitted electronically. Carriers should be aware of this change in payment deadlines when reporting claims data in the pharmacy field.
Exemptions: TDI understands that some carriers may no longer have claims subject to these reporting requirements. Carriers should submit exemption requests when applicable.
A carrier must enter an exemption request for the HB 610 report if it no longer has provider contracts last issued or renewed before August 16, 2003. A carrier may submit all zeros only if it has provider contracts within the HB 610 criteria, but paid no claims in the quarter. Entering a one-time exemption request for the HB 610 report does not affect the ability to enter data for the SB 418 report.
A carrier must enter an exemption request for the SB 418 report if it no longer has provider contracts last issued or renewed on or after August 16, 2003. A one-time exemption request submitted for the SB 418 quarterly report will automatically extend to the SB 418 annual report of reasons for declinations of verifications.
Once a carrier submits an exemption form for a report, it no longer needs to respond to the data call for that particular report. However, if a carrier only submits one exemption form, the carrier is still required to respond to the other applicable report on a quarterly or annual basis, as applicable.
Delegated Entity Data: TDI is aware that some carriers use delegated entities to pay claims, but do not report the delegated entity claims data separately. Carriers must submit data for each delegated entity on a separate reporting form under the carrier's TDI number. A carrier may submit multiple reporting forms to accommodate data for all delegated entities in addition to data for claims the carrier processes. Both the carrier and its delegated entity are required to meet the statutory claims payment deadlines and compliance with the 98 percent timely claims payment requirement.
Reporting: The online claims data reporting application and forms are available on the TDI website at https://apps.tdi.state.tx.us/SB418company/Login.do.
To provide additional information on reporting, a tips guide with detailed additional information is available at http://www.tdi.texas.gov/health/documents/provclaimstips.pdf.
If you have questions concerning this bulletin, please contact TDI via email at promptpay@tdi.state.tx.us.
Eleanor Kitzman
Commissioner of Insurance