| (a) An MCC that determines under §21.2807 of this
title (relating to Effect of Filing a Clean Claim) that a claim is
payable must pay the contracted rate owed on the claim; and:
(1) if the claim is paid on or before the 45th day
after the end of the applicable statutory claims payment period, pay
to a noninstitutional preferred provider a penalty in the amount of
the lesser of:
(A) 50 percent of the difference between the billed
charges and the contracted rate; or
(B) $100,000;
(2) if the claim is paid on or after the 46th day and
before the 91st day after the end of the applicable statutory claims
payment period, pay to a noninstitutional preferred provider, a penalty
in the amount of the lesser of:
(A) 100 percent of the difference between the billed
charges and the contracted rate; or
(B) $200,000;
(3) if the claim is paid on or after the 91st day after
the end of the applicable statutory claims payment period:
(A) pay to the noninstitutional preferred provider
a penalty computed under paragraph (2) of this subsection; and
(B) pay to the Texas Health Insurance Pool until its
dissolution, and after its dissolution to Texas Department of Insurance
(department) 18 percent annual interest on the penalty amount paid
to a noninstitutional preferred provider under paragraph (2) of this
subsection. Interest under this paragraph accrues beginning on the
date the MCC was required to pay the claim and ending on the date
the claim and the penalty are paid in full to the noninstitutional
provider;
(4) if the claim is paid to an institutional preferred
provider on or before the 45th day after the end of the applicable
statutory claims payment period, pay a penalty in the amount specified
in subparagraph (A) or (B) of this paragraph. The MCC must pay 50
percent of the penalty to the institutional preferred provider and
50 percent of the penalty to the Texas Health Insurance Pool until
its dissolution, and after its dissolution to the department. The
penalty under this paragraph is in the amount of the lesser of:
(A) 50 percent of the difference between the billed
charges and the contracted rate; or
(B) $100,000;
(5) if the claim is paid to an institutional preferred
provider on or after the 46th day and before the 91st day after the
end of the applicable statutory claims payment period, pay a penalty
in the amount specified in subparagraph (A) or (B) of this paragraph.
The MCC must pay 50 percent of the penalty to the institutional preferred
provider and 50 percent of the penalty to the Texas Health Insurance
Pool until its dissolution, and after its dissolution to the department.
The penalty under this paragraph is in the amount of the lesser of:
(A) 100 percent of the difference between the billed
charges and the contracted rate; or
(B) $200,000; and
(6) if the claim is paid to an institutional preferred
provider on or after the 91st day after the end of the applicable
statutory claims payment period:
(A) pay the penalty amount to the institutional provider
and the Texas Health Insurance Pool until its dissolution, and after
its dissolution to the department as specified in paragraph (5) of
this subsection; and
(B) pay 18 percent annual interest on the penalty amount
computed under paragraph (5) of this subsection. Interest under this
paragraph accrues beginning on the date the MCC was required to pay
the claim and ending on the date the claim and the institutional provider's
portion of the penalty are paid in full. The MCC must pay 50 percent
of the interest to the institutional preferred provider and 50 percent
of the interest to the Texas Health Insurance Pool until its dissolution,
and after its dissolution to the department.
(b) The following examples demonstrate how to calculate
penalty amounts under subsection (a)(1) - (3) of this section:
(1) if the contracted rate, including any patient financial
responsibility, is $10,000 and the billed charges are $15,000, and
the MCC pays the claim on or before the 45th day after the end of
the applicable statutory claims payment period, the MCC must pay,
in addition to the amount owed on the claim, 50 percent of the difference
between the billed charges ($15,000) and the contracted rate ($10,000)
or $2,500. The basis for the penalty is the difference between the
total contracted amount, including any patient financial responsibility,
and the noninstitutional provider's billed charges;
(2) if the claim is paid on or after the 46th day and
before the 91st day after the end of the applicable statutory claims
payment period, the MCC must pay, in addition to the contracted rate
owed on the claim, 100 percent of the difference between the billed
charges and the contracted rate or $5,000; and
(3) if the claim is paid on or after the 91st day after
the end of the applicable statutory claims payment period, the MCC
must pay to the noninstitutional provider, in addition to the contracted
rate owed on the claim, the $5,000 penalty. The MCC must also pay
to the Texas Health Insurance Pool until its dissolution, and after
its dissolution to the department 18 percent annual interest on the
$5,000 penalty amount accruing from the statutory claim payment deadline
until the date the claim and penalty are paid in full to the noninstitutional
provider.
(c) Except as provided by this section, an MCC that
determines under §21.2807 of this title that a claim is payable,
pays only a portion of the amount of the claim on or before the end
of the applicable statutory claims payment period, and pays the balance
of the contracted rate owed for the claim after that date must, in
addition to paying the contracted amount owed:
(1) if the balance of the claim is paid to a noninstitutional
preferred provider on or before the 45th day after the applicable
statutory claims payment period, pay to the preferred provider a penalty
on the amount not timely paid in the amount of the lesser of:
(A) 50 percent of the underpaid amount; or
(B) $100,000;
(2) if the balance of the claim is paid to a noninstitutional
preferred provider on or after the 46th day and before the 91st day
after the end of the applicable statutory claims payment period, pay
to the preferred provider a penalty in the amount of the lesser of:
(A) 100 percent of the underpaid amount; or
(B) $200,000;
(3) if the balance of the claim is paid to a noninstitutional
preferred provider on or after the 91st day after the end of the applicable
statutory claims payment period, pay to the preferred provider a penalty
computed under paragraph (2) of this subsection plus 18 percent annual
interest on the penalty amount. Interest under this subsection accrues
beginning on the date the MCC was required to pay the claim and ending
on the date the claim and the penalty are paid in full;
(4) if the balance of the claim is paid to an institutional
preferred provider on or before the 45th day after the applicable
statutory claims payment period, pay a penalty in the amount specified
in subparagraphs (A) and (B) of this paragraph. The MCC must pay 50
percent of the penalty to the institutional preferred provider and
50 percent of the penalty to the Texas Health Insurance Pool until
its dissolution, and after its dissolution to the department. The
penalty under this paragraph on the amount not timely paid is in the
amount of the lesser of:
(A) 50 percent of the underpaid amount; or
(B) $100,000;
(5) if the balance of the claim is paid to an institutional
preferred provider on or after the 46th day and before the 91st day
after the end of the applicable statutory claims payment period, pay
a penalty in the amount specified in subparagraphs (A) and (B) of
this paragraph. The MCC must pay 50 percent of the penalty to the
institutional preferred provider and 50 percent of the penalty to
the Texas Health Insurance Pool until its dissolution, and after its
dissolution to the department. The penalty under this paragraph is
in the amount of the lesser of:
(A) 100 percent of the underpaid amount; or
(B) $200,000; and
(6) if the balance of the claim is paid to an institutional
preferred provider on or after the 91st day after the end of the applicable
statutory claims payment period, pay a penalty computed under paragraph
(5) of this subsection plus 18 percent annual interest on the penalty
amount. Interest under this subsection accrues beginning on the date
the MCC was required to pay the claim and ending on the date the claim
and the institutional provider's portion of the penalty are paid in
full. The MCC must pay 50 percent of the interest to the institutional
preferred provider and 50 percent of the interest to the Texas Health
Insurance Pool until its dissolution, and after its dissolution to
the department.
Cont'd... |
