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TITLE 25HEALTH SERVICES
PART 1DEPARTMENT OF STATE HEALTH SERVICES
CHAPTER 37MATERNAL AND INFANT HEALTH SERVICES
SUBCHAPTER FHEMOPHILIA ASSISTANCE PROGRAM
RULE §37.116Claims Payment

(a) Prior authorization is required for all allowable products.

(b) The program reimburses program providers for allowable product(s) for eligible clients. Payment may be made only after the allowable product(s) has been dispensed and submission of a valid claim. Claims must be:

  (1) submitted on the claim form accepted by the program;

  (2) submitted by a program provider; and

  (3) filed directly with the program.

(c) The program reimburses eligible clients for insurance premium payments made to program approved health plans. Reimbursements may be made after the program's receipt of a valid proof of insurance premium payment.

(d) Filing Deadlines.

  (1) Complete claims must be received by the program within 95 calendar days from the end of the month of the date of service or 95 calendar days from the end of the month for which the premium was paid.

  (2) Incomplete and ineligible claims will be denied.

  (3) Denied claims may be considered for payment if the claim is corrected and resubmitted within 30 days following the date of the program notice of denial or within the initial 95 day filing deadline, whichever is later.


Source Note: The provisions of this §37.116 adopted to be effective April 16, 2015, 40 TexReg 2090; amended to be effective March 1, 2017, 42 TexReg 764

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