| (d) For the purposes of subsection (c) of this section,
the underpaid amount is calculated on the ratio of the balance owed
by the MCC to the total contracted rate, including any patient financial
responsibility, as applied to an amount equal to the billed charges
minus the contracted rate. For example, a claim for a contracted rate
to a noninstitutional preferred provider of $1,000 and billed charges
of $1,500 is initially underpaid at $600, with the insured owing $200
and the MCC owing a balance of $200. The MCC pays the $200 balance
on the 30th day after the end of the applicable statutory claims payment
period. The amount the MCC initially underpaid, $200, is 20 percent
of the contracted rate. To determine the penalty, the MCC must calculate
20 percent of the billed charges minus the contracted rate, which
is $100. This amount represents the underpaid amount for subsection
(c)(1) of this section. The MCC must pay, as a penalty, 50 percent
of $100, or $50.
(e) For purposes of calculating a penalty when an MCC
is a secondary plan MCC for a claim, the contracted rate and billed
charges must be reduced in proportion to the percentage of the entire
claim that is owed by the secondary plan MCC. The following example
illustrates this method: Carrier A pays 80 percent of a claim to a
noninstitutional preferred provider for a contracted rate of $1,000
and billed charges of $1,500, leaving $200 unpaid as the patient's
financial responsibility. The patient has coverage through Carrier
B that is secondary, and Carrier B will owe the $200 balance under
the coordination of benefits provision of Carrier B's policy. If Carrier
B fails to pay the $200 within the applicable statutory claims payment
period, Carrier B will pay a penalty based on the percentage of the
claim that it owed. The contracted rate for Carrier B will be $200
(20 percent of Carrier A's $1,000 contracted rate), and the billed
charges will be $300 (20 percent of $1,500). Although Carrier B may
have a contracted rate with the provider that is different from Carrier
A's contracted rate, it is Carrier A's contracted rate that establishes
the entire claim amount for the purpose of calculating Carrier B's
penalty.
(f) An MCC is not liable for a penalty under this section:
(1) if the failure to pay the claim within the applicable
statutory claims payment period is a result of a catastrophic event
that the MCC certified according to the provisions of §21.2819
of this title (relating to Catastrophic Event); or
(2) if the claim was paid in compliance with §21.2807
of this title, but for less than the contracted rate, and:
(A) the preferred provider notifies the MCC of the
underpayment after the 270th day after the date the underpayment was
received; and
(B) the MCC pays the balance of the claim on or before
the 30th day after the date the insurer receives the notice of underpayment.
(g) Subsection (f) of this section does not relieve
the MCC of the obligation to pay the remaining unpaid contracted rate
owed the preferred provider.
(h) An MCC that pays a penalty under this section must
clearly indicate on the explanation of payment the amount of the contracted
rate paid, the amount of the billed charges as submitted by the physician
or the provider, and the amount paid as a penalty. A nonelectronic
explanation of payment complies with this requirement if it clearly
and prominently identifies the notice of the penalty amount.
|
| Source Note: The provisions of this §21.2815 adopted to be effective May 23, 2000, 25 TexReg 4543; amended to be effective October 2, 2001, 26 TexReg 7542; amended to be effective October 5, 2003, 28 TexReg 8647; amended to be effective January 19, 2006, 31 TexReg 295; amended to be effective February 7, 2008, 33 TexReg 928; amended to be effective February 16, 2014, 39 TexReg 747 |
