The Texas Department of Insurance (TDI) has become aware of a practice by some health carriers of providing notice to physicians and providers of "potential" clean claim elements and attachments. The notices purport to list information that a carrier "may" require as an additional clean claim element or attachment. Carriers using these notices are classifying claims as deficient if a "potential" element or attachment is not included.
Under the provisions of TDI´s clean claims rules, a carrier may require additional clean claim elements or attachments only by complying with the notice procedures of 28 Texas Administrative Code (TAC) §§21.2804, 21.2805 and 21.2806. These sections make clear that the notice to physicians and providers must identify with specificity the clean claim elements and attachments required by the carrier. A list of "potential" elements and attachments is not appropriate and fails to satisfy the specificity required by the rules. Furthermore, additional clean claim elements and attachments are limited to information contained in or in the process of being incorporated into a patient´s medical or billing record maintained by the physician or provider. See 28 TAC §21.2803(c) and (d).
TDI directs each carrier to review its practices and procedures to ensure it is complying with Texas law regarding clean claim elements and attachments. TDI will be monitoring compliance and may take enforcement action for non-compliance. We appreciate your cooperation in assuring compliance by your company.
If you have any questions or concerns in assuring compliance on behalf of preferred provider benefit plans, please contact Audrey Selden, Senior Associate Commissioner of Consumer Protection at 512-322-4309 or E-mail at audrey.selden@tdi.state.tx.us. If you have any questions or concerns in assuring compliance on behalf of health maintenance organizations, please contact Pat Brewer, HMO Project Director at 512-305-7277 or E-mail at pat.brewer@tdi.state.tx.us.
Sincerely,
Sara Shiplet Waitt
Senior Associate Commissioner
Legal and Compliance Division