| (a) Notice and payment required. If an MCC is unable
to pay or deny a clean claim, in whole or in part, within the applicable
statutory claims payment period specified in §21.2802 of this
title (relating to Definitions) and intends to audit the claim to
determine whether the claim is payable, the MCC must notify the preferred
provider that the claim is being audited and pay 100 percent of the
contracted rate within the applicable statutory claims payment period.
(b) Failure to provide notice and payment. An MCC that
fails to provide notice of the decision to audit the claim and pay
100 percent of the applicable contracted rate subject to copayments
and deductibles within the applicable statutory claims payment period,
or, if applicable, the extended periods allowed for by §21.2804(c)
of this title (relating to Requests for Additional Information from
Treating Preferred Provider) or §21.2819(c) of this title (relating
to Catastrophic Event), may not make use of the audit procedures set
out in this section. A preferred provider that receives less than
100 percent of the contracted rate with a notice of intent to audit
has received an underpayment and must notify the MCC within 270 days
in compliance with the provisions of §21.2815(f)(2) of this title
(relating to Failure to Meet the Statutory Claims Payment Period)
to qualify to receive a penalty for the underpaid amount.
(c) Explanation of payment. The MCC must clearly indicate
on the explanation of payment that the claim is being audited and
that the preferred provider is being paid 100 percent of the contracted
rate, subject to completion of the audit. A nonelectronic explanation
of payment complies with this requirement if the notice of the audit
is clearly and prominently identified.
(d) Audit deadline and requirements. The MCC must complete
the audit within 180 calendar days from receipt of the clean claim.
The HMO or preferred provider carrier must provide written notice
of the results of the audit. The MCC must include in the notice a
listing of the specific claims paid and not paid under the audit,
as well as a listing of specific claims and amounts for which a refund
is due and, for each claim, the basis and specific reasons for requesting
a refund. An MCC seeking recovery of any refund under this section
must comply with the procedures set out in §21.2818 of this title
(relating to Overpayment of Claims).
(e) Requests for information. An MCC may recover the
total amount paid on the claim under subsection (a) of this section
if a physician or a provider fails to timely provide additional information
requested under the requirements of Insurance Code §1301.105
or §843.340(c). Section 21.2816 of this title (relating to Date
of Receipt) applies to the submission and receipt of a request for
information under this subsection.
(f) Opportunity for appeal. Before seeking a refund
for a payment made under this section, an MCC must provide a preferred
provider with the opportunity to appeal the request for a refund in
compliance with §21.2818 of this title. An MCC may not seek to
recover the refund until all of the preferred provider's internal
appeal rights under §21.2818 of this title have been exhausted.
(g) No admission of liability. Payments made under
this section on a clean claim are not an admission that the MCC acknowledges
liability on that claim.
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| Source Note: The provisions of this §21.2809 adopted to be effective May 23, 2000, 25 TexReg 4543; amended to be effective February 14, 2001, 26 TexReg 1341; amended to be effective October 2, 2001, 26 TexReg 7542; amended to be effective October 5, 2003, 28 TexReg 8647; amended to be effective February 16, 2014, 39 TexReg 747 |
