DUE: November 15, 2010 - Third Quarter 2010 (July - September) Provider Claims Data Report
Pursuant to 28 Texas Administrative Code §21.2821, the Texas Department of Insurance (Department) issues this mandatory data call for insurers with preferred provider health benefit plans (PPOs) filed in Texas, and for health maintenance organizations (HMOs) doing business in Texas (collectively, hereafter, "carriers").
This data call is necessary for the Department to determine carriers' compliance with various "prompt pay" requirements relating to claims submitted by providers, as addressed under Texas Insurance Code (TIC) Ch. 1301 and Ch. 843, Subchapter J and rules adopted to implement those statutes.
The Department would like to remind carriers that two reports are due with this data call, the HB610 quarterly report and the SB418 quarterly report. These reports are due on November 15, 2010. These deadlines are set in 28 TAC 21.2821 and the database will lock down at 11:59 pm on the date the report is due.
The HB610 report is to be used to report provider claims paid under contracts that were last issued or renewed before August 16, 2003.
The SB418 report is to be used to report provider claims paid under contracts that were last issued or renewed on or after August 16, 2003.
Exemptions: The Department understands that some carriers may no longer have claims subject to prompt pay reporting requirements. As such, carriers should submit exemption requests when applicable.
An exemption request for the HB610 report should be entered if a carrier no longer has provider claims paid under contracts that were last issued or renewed before August 16, 2003. A carrier may submit all zeros only if the carrier has provider contracts within the HB610 criteria, but paid no claims in the quarter. Entering a one-time exemption request for the HB610 report does not affect the ability to enter data for the SB418 report.
An exemption request for the SB418 reports should be entered if a carrier has no provider claims paid under contracts that were last issued or renewed on or after August 16, 2003. A one-time exemption request submitted for the SB418 quarterly report will automatically extend to the SB418 annual report of reasons for declinations.
Once a carrier has submitted an exemption form for a report, the carrier no longer needs to respond to the data call for that particular report. If only one exemption form has been submitted, the carrier is still required to respond to the other applicable report on a quarterly or annual basis.
Delegated Entity Data: The Department is aware that a number of carriers use delegated entities to pay claims, but do not report the delegated entity's claims data separately. Data for each delegated entity must be submitted on a separate reporting form under the carrier's TDI number with the delegated entity's legal name included. A carrier may submit multiple reporting forms each quarter to accommodate all delegated entities, as well as, any claims the carrier processes. The Department looks to both the carrier and its delegated entity 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 may be accessed on the Department's website at: https://apps.tdi.state.tx.us/SB418company/Login.do. In the event the link fails to work, you may also access the data reporting application and forms from the Department's home page at: www.tdi.state.tx.us. From there, 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, then scroll down to Life, Health & Licensing Data Calls and select Claims Data Reporting (HB610/SB418).
In order to provide additional information on reporting, the Department has created a webpage with detailed additional information here:
www.tdi.state.tx.us/health/documents/provclaimstips.doc.
If you have questions about the data calls 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.
Mike Geeslin
Commissioner of Insurance