SUBCHAPTER T. SUBMISSION OF CLEAN CLAIMS

28 TAC §§21.2803, 21.2809, and 21.2810

The Texas Department of Insurance proposes amendments to §§21.2803, 21.2809, and 21.2810 concerning submission of clean claims to health maintenance organizations (HMOs) and insurers who issue preferred provider benefit plans (preferred provider carriers). The sections were adopted earlier this year as part of the "clean claim" rules (28 TAC §§21.2801-21.2816) and apply to claims filed for non-confinement services, treatments, or supplies rendered on or after August 1, 2000, and to claims filed for services, treatments, or supplies for in-patient confinements in a hospital or other institution that began on or after August 1, 2000. Section 21.2803(b)(1) specifies the elements necessary for the submission of a clean claim by physicians and noninstitutional providers. The amendment to §21.2803(b)(1) revises the requirements relating to the element on disclosure of any other health care coverage when the response is "no." The amendment is necessary to facilitate the electronic claims filing process and is proposed in response to petitions from physicians and providers. Section §21.2809(b) addresses procedures for refunds due to the HMO or preferred provider carrier upon completion of the audit. Articles 3.70-3C §3A(e) and 20A.18B(e) of the Insurance Code as enacted by House Bill 610 (Acts 1999, 76 ^th Leg., ch. 1343, p. 4556, eff. Sept. 1, 1999) require notice of the audit results to be provided to the physician or provider and require a refund to be made to the preferred provider carrier or HMO upon completion of the audit in the event of overpayment to the physician or provider. The amendment is necessary to clarify the essential information that is to be included in the notice of audit results and is intended to assist physicians and providers in more efficient and accurate recordkeeping of audited claims. The amendment also clarifies that existing or future contractual arrangements that allow alternative reimbursement methods in the event of overpayment to the physician or provider are not affected by the rule. The amendment is proposed in response to comments received at the January 25, 2000 hearing on the clean claim rules. Section 21.2810 specifies the means for determining when payment is considered to have been made on a clean claim for purposes of determining compliance with the statutory claims payment period. The amendment allows private metered postmarks to be acceptable proof of postmark in those instances when the claim payment is delivered by the U.S. Postal Service. This amendment is in response to information received by the department from the U.S. Postal Service that private metered mail is checked by the post office to verify the correct date and is returned to the customer if incorrectly dated.

Blake O. Brodersen, Deputy Commissioner, HMO Division, has determined that for each year of the first five years the proposed amendments will be in effect, there will be no fiscal impact to state and local governments as a result of the enforcement or administration of the amendments. There will be no measurable effect on local employment or the local economy as a result of the amendments.

Mr. Brodersen has also determined that for each year of the first five years the amendments are in effect the anticipated public benefits resulting from the adoption of the proposal will be the facilitation of electronic claims filing, reduction in claims paperwork, simplification of accounting procedures, and streamlining of the claims payment process. For each year of the first five years the amended sections are in effect, there will be no economic costs to persons required to comply with the amended sections that are in addition to those costs already required as a result of the legislative enactment of Articles 3.70-3C, §3A and 20A.18B of the Insurance Code. The purpose of the proposed amendments is to facilitate electronic claims filing by revising the requirements relating to the element on disclosure of other health coverage, clarify that certain essential information must be included in the statutorily mandated notice of the audit results, and streamline the claims payment process. Therefore, the adoption of the proposed amendments will have no adverse economic impact on regulated entities that are required to comply with the proposed amendments and that qualify as a small or micro-business under the Government Code, §§2006.001-2006.002. It is neither legal nor feasible to waive or modify the requirements of these proposed amendments for small and micro-businesses; to do so would not be consistent with the purpose of Articles 3.70-3C, §3A and 20A.18B and could have an adverse effect on such small and micro-business entities.

To be considered, written comments on the proposal must be submitted no later than 5:00 p.m. on November 20, 2000 to Lynda H. Nesenholtz, General Counsel and Chief Clerk, Mail Code 113-2A, Texas Department of Insurance, P. O. Box 149104, Austin, Texas 78714-9104. An additional copy of the comment must be simultaneously submitted to Pat Brewer, HMO Division, Mail Code 103-6A, Texas Department of Insurance, P.O. Box 149104, Austin, Texas 78714-9104. A request for a public hearing should be submitted separately to the Office of the Chief Clerk.

The amendments are proposed under the Insurance Code Articles 3.70-3C and 20A.18B and §36.001. Articles 3.70-3C, §3A(a) and 20A.18B(a) provide that under these sections, "clean claim" means a completed claim, as determined under department rules, submitted by a physician or provider for medical care or health care services under a health insurance policy or health care plan. Articles 3.70-3C, §3A(e) and 20A.18B(e) provide that following the completion of the audit of a clean claim, any additional payment due a physician or provider or any refund due the preferred provider carrier or HMO shall be made not later than the 30 ^th day after the later of the date that the physician or provider receives notice of the audit results or any appeal rights of the insured are exhausted. Articles 3.70-3C, §3A(c) and 20A.18B(c) specify actions that must be taken by an HMO or preferred provider carrier within 45 days after the date of receipt of a clean claim, including payment of the total amount of the claim in accordance with the contract between the physician or provider and the HMO or preferred provider carrier. Articles 3.70-3C, §3A(n) and 20A.18B(o) authorize the Commissioner to adopt rules as necessary to implement these articles. Section 36.001 provides that the Commissioner of Insurance may adopt rules for the conduct and execution of the powers and duties of the department only as authorized by statute.

The following articles are affected by this proposal:

RuleStatute Insurance Code, Article 3.70-3C, §§3(m) and 3A; Articles 20A.09(j) and 20A.18B

§21.2803. Elements of a Clean Claim.

(a) (No change.)

(b) Required data elements. HCFA has developed claim forms which provide much of the information needed to process claims. Two of these forms, HCFA-1500 and UB-82/HCFA, and their successor forms, have been identified by Insurance Code Article 21.52C as required for the submission of certain claims. The terms used in paragraphs (1), (2) and (3) of this subsection are based upon the terms used by HCFA on successor forms HCFA-1500 (12-90) and UB-92 HCFA-1450 claim forms. The parenthetical information following each term is a reference to the applicable HCFA claim form, and the field number to which that term corresponds on the HCFA claim form.

(1) Essential data elements for physicians or noninstitutional providers. Unless otherwise agreed by contract, the data elements described in this paragraph are necessary for claims filed by physicians and noninstitutional providers.

(A) subscriber´s/patient´s plan ID number (HCFA 1500, field 1a);

(B) patient´s name (HCFA 1500, field 2);

(D) subscriber´s name (HCFA 1500, field 4);

(E) patient´s address (street or P.O. Box, city, zip) (HCFA 1500, field 5);

(F) patient´s relationship to subscriber (HCFA 1500, field 6);

(G) subscriber´s address (street or P.O. Box, city, zip) (HCFA 1500, field 7);

(H) whether patient´s condition is related to employment, auto accident, or other accident (HCFA 1500, field 10);

(I) subscriber´s policy number (HCFA 1500, field 11);

(J) subscriber´s birth date and gender (HCFA 1500, field 11a);

(K) HMO or preferred provider carrier name (HCFA 1500, field 11c);

(L) disclosure of any other health benefit plans (HCFA 1500, field 11d);

(i) if respond "yes", then

(I) data elements specified in paragraph (3)(A)-(E) of this subsection are essential unless the physician or provider submits with the claim documented proof to the HMO or preferred provider carrier that the physician or provider has made a good faith but unsuccessful attempt to obtain from the enrollee or insured any of the information needed to complete the data elements in paragraph (3)(A)-(E) of this subsection;

(II) the data element specified in paragraph (3)(I) of this subsection is essential when submitting claims to secondary payor HMOs or preferred provider carriers;

(ii) if respond "no," the data elements specified in paragraph (3)(A)-(E) of this subsection are not applicable and therefore are not considered essential if the physician or provider has on file a document signed within the past 12 months by the patient or authorized person stating that there is no other health care coverage; although the submission of the signed document is not an essential data element, a copy of the signed document shall be provided to the HMO or preferred provider carrier upon request [ ~~claim is accompanied by a copy of a document signed by the enrollee or insured that there is no other health care coverage~~].

(M) patient´s or authorized person´s signature or notation that the signature is on file with the physician or provider (HCFA 1500, field 12);

(N) subscriber´s or authorized person´s signature or notation that the signature is on file with the physician or provider (HCFA 1500, field 13);

(O) date of current illness, injury, or pregnancy (HCFA 1500, field 14);

(P) first date of previous same or similar illness (HCFA 1500, field 15);

(Q) diagnosis codes or nature of illness or injury (HCFA 1500, field 21);

(R) date(s) of service (HCFA 1500, field 24A);

(S) place of service codes (HCFA 1500, field 24B);

(T) type of service code (HCFA 1500, field 24C);

(U) procedure /modifier code (HCFA 1500, field 24D);

(V) diagnosis code by specific service (HCFA 1500, field 24E);

(W) charge for each listed service (HCFA 1500, field 24F);

(X) number of days or units (HCFA 1500, field 24G);

(Y) physician´s or provider´s federal tax ID number (HCFA 1500, field 25);

(Z) total charge (HCFA 1500, field 28);

(AA) signature of physician or provider or notation that the signature is on file with the HMO or preferred provider carrier (HCFA 1500, field 31);

(BB) name and address of facility where services rendered (if other than home or office) (HCFA 1500, field 32); and

physician´s or provider´s billing name and address (HCFA 1500, field 33).

(2)-(3) (No change.)

(c)-(g) (No change.)

§21.2809. Audit Procedures.

(a) (No change.)

(b) Upon completion of the audit, if the HMO or preferred provider carrier determines that a refund is due from a physician or provider, such refund shall be made within 30 calendar days of the later of notification to the physician or provider of the results of the audit or exhaustion of any subscriber or patient appeal rights if a subscriber or patient appeal is filed before the 30-calendar-day refund period has expired, and may be made by any method, including chargeback against the physician or provider, or agreements by contract. The notification of the results of the audit shall include a listing of the specific claims paid and not paid pursuant to the audit, including specific claims and amounts for which a refund is due. Unless otherwise agreed to by contract, if an HMO or preferred provider carrier intends to make a chargeback, the notification shall also include a statement that the HMO or preferred provider carrier will make a chargeback unless the physician or provider contacts the HMO or preferred provider carrier to arrange for reimbursement through an alternative method. Nothing in this provision shall invalidate or supersede existing or future contractual arrangements that allow alternative reimbursement methods in the event of overpayment to the physician or provider.

§21.2810. Date of Claim Payment. For purposes of determining compliance with the statutory claims payment period, payment is considered to have been paid on the date of:

(1) the [ ~~U.S. Postal Service]~~ postmark, if a claim payment is delivered by the United States Postal Service[ ~~. Private metered postmarks are not acceptable proof of postmark~~];

(2) electronic transmission, if a claim payment is made electronically;

(3) delivery of the claim payment to a commercial carrier, such as UPS or Federal Express; or

(4) receipt by the physician or provider, if a claim payment is made other than as provided in paragraph (1), (2), or (3) of this section.