Texas Register
TITLE 28 INSURANCE
PART 1TEXAS DEPARTMENT OF INSURANCE
CHAPTER 21TRADE PRACTICES
SUBCHAPTER TSUBMISSION OF CLEAN CLAIMS
RULE §21.2815Failure to Meet the Statutory Claims Payment Period
ISSUE 08/03/2001
ACTION Proposed
Preamble Texas Admin Code Rule
An HMO or preferred provider carrier that fails to comply with the requirements of §21.2807(b) of this title (relating to Effect of Filing a Clean Claim) and §21.2809(a) and (c) of this title (relating to Audit Procedures) shall pay the greater of the full amount of the billed charges submitted on the clean claim or any [pay the] contracted penalty rate for late payment set forth in the contract between the provider or physician and the HMO or preferred provider carrier. Failure to pay a clean claim correctly or denial of a valid clean claim that results in a failure to comply with the requirements of §21.2807(b) and §21.2809(a) and (c) of this title is considered a violation of Article 20A.18B(c) or Article 3.70-3C §3A(c). Any amount previously paid or any charge for a non-covered service shall be deducted from the payment. This section shall not apply when there is failure to comply with a contracted claims payment period of less than 45 calendar days as provided in §21.2802(25)(A) of this title (relating to Definitions), and Article 3.70-3C, §3(m) or Article 20A.09(j) of the Insurance Code.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State, on July 20, 2001

TRD-200104209

Lynda Nesenholtz

General Counsel and Chief Clerk

Texas Department of Insurance

Earliest possible date of adoption: September 2, 2001

For further information, please call: (512) 463-6327

 

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