DUE: August 15, 2009 - Second Quarter 2009 (April - June) Provider Claims Data and the 2008 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 2009 Provider Claims Data: The provider claims data for the reporting period April through June, 2009 and annual report of reasons for declinations are due no later than August 15, 2009. Please be advised that failure to report by the deadline may result in regulatory action, including enforcement. Please use the tips beginning on page 3 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, 2008, through June 30, 2009. 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, 2009.
The online data reporting forms may be accessed on the TDI website at: https://wwwapps.tdi.state.tx.us/scpsb418/login.jsp. You can also access the data reporting forms from the TDI website: www.tdi.state.tx.us. From the TDI home page, click on Popular Links under the Quick Start links on the left side of the page. When the new page opens, click on Data Calls under the Quick Start links on the left side of the page. Scroll down to Life, Health & Licensing Data Calls and select Senate Bill 418.
Your data collection contact will receive a reminder of this data call by email as well.
In addition to these quarterly and annual data calls, TDI would also like to remind all carriers that the providers' claims reporting forms will be migrating to a new server in time for the third quarter data call. The reports you are submitting in response to this bulletin will be in the current database and will be accessed as you normally do through the links and passwords that you have used in the past. Upon migration to the new server, access to the new database will require new user names and login passwords. This migration process will occur in several steps. We recently faxed letters to your companies/HMOs providing instructions on the first step of the migration process. It is very important that you send your email to the DATAACCESS mailbox providing us with the email addresses of your authorized reporters. Please note that the email must be in the exact format as specified in the letter. Instructions on how to set up your user account and password will be emailed to your authorized reporters after July 22.
Please note that even if you were previously exempted from reporting this data, you will need to log into the new database to enter a one-time exemption for both the HB610 and SB418 quarterly reports.
If you have questions about the data calls, how to access the data collection application, or the migration process, please contact Judy Wooten via email at: promptpay@tdi.state.tx.us or call her at 512-305-7319.
Mike Geeslin
Commissioner of Insurance