(a) A third party resource must accept HHSC's right
of recovery and the assignment to the State of any right of an individual
or other entity to payment from the third party resource for a health
care item or service provided by the Medicaid program.
(b) A payment made by a third party resource to HHSC
or a provider on a claim for payment of a health care item or service
provided to a Medicaid recipient is final on the date that is two
years after the third party payment was made. After a claim is final,
the claim is subject to adjustment only if an action for recovery
of an overpayment was commenced under §354.2321(b) of this subchapter
(relating to Provider Billing and Recovery From Third Party Resources)
before the date the claim became final and the recovery is agreed
to by HHSC under §354.2321(c) of this subchapter.
(c) Third party health insurers must maintain and provide
to HHSC, on request, information HHSC deems necessary to determine:
(1) the period during which an individual entitled
to medical assistance, the individual's spouse, or the individual's
dependents may be, or may have been, covered by coverage issued by
the health insurer;
(2) the nature of the coverage; and
(3) the name, address, and identifying number of the
health plan under which the individual may be, or may have been, covered.
(d) Not later than the 60th day after the date a third
party resource receives an inquiry from HHSC regarding a claim for
payment for any health care item or service submitted to the third
party resource within three years of the date the health care item
or service was provided, the third party resource must respond to
the inquiry.
(e) A third party health insurer must accept authorization
provided by HHSC that a health care item or service is covered by
Medicaid as if that authorization is a prior authorization made by
the third party health insurer for a health care item or service provided
to an individual entitled to Medicaid that was previously paid for
by HHSC and or which the third party health insurer is responsible
for payment.
(f) Subsection (e) of this section does not apply to:
(1) hospital insurance benefits or supplementary insurance
benefits under Part A or B of Title XVIII of the Social Security Act
(codified at 42 U.S.C. §1395c et seq. or 1395j et seq.);
(2) a health care prepayment plan under Section 1833(a)(1)(A),
Social Security Act (codified at 42 U.S.C. §1395l(a)(1)(A));
(3) a Medicare Advantage plan under Part C of Title
XVIII of the Social Security Act (codified at 42 U.S.C. §1395w-21
et seq.);
(4) a prescription drug plan as a prescription drug
plan sponsor under Part D of Title XVIII of the Social Security Act
(codified at 42 U.S.C. §1395w-101 et seq.); or
(5) a reasonable cost reimbursement plan under Section
1876, Social Security Act (codified at 42 U.S.C. §1395mm).
(g) A third party resource may not deny a claim submitted
by HHSC for which payment was made under the Medicaid program solely
on the basis of the date of submission of the claim, the type or format
of the claim form, or for a responsible third party resource, other
than a third party resource described in subsection (f)(1)-(5) of
this section, a failure to obtain prior authorization for the health
care item or service for which the claim is being submitted, if:
(1) the claim is submitted by HHSC not later than the
third anniversary of the date the health care item or service was
provided; and
(2) any action by HHSC to enforce the State's rights
with respect to the claim is commenced not later than the sixth anniversary
of the date HHSC submits the claim.
(h) If a third party resource denies a claim for payment
submitted by HHSC for reasons outlined in subsection (g) of this section,
HHSC may appeal the claim without any limitation on the number of
appeals.
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Source Note: The provisions of this §354.2341 adopted to be effective June 28, 2000, 25 TexReg 6137; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4562; amended to be effective March 28, 2004, 29 TexReg 2867; amended to be effective February 22, 2024, 49 TexReg 855 |