| (a) An MCC must submit to the department quarterly
claims payment and related penalty and interest payment information,
and information regarding complaints, in compliance with the requirements
of this section.
(b) The MCC must submit the report required by subsection
(a) of this section to the department on or before:
(1) May 15th for the months of January, February, and
March of each year;
(2) August 15th for the months of April, May, and June
of each year;
(3) November 15th for the months of July, August, and
September of each year; and
(4) February 15th for the months of October, November,
and December of each preceding calendar year.
(c) The report required by subsection (a) of this section
must include, at a minimum, the following information:
(1) number of claims received from noninstitutional
preferred providers;
(2) number of claims received from institutional preferred
providers;
(3) number of clean claims received from noninstitutional
preferred providers;
(4) number of clean claims received from institutional
preferred providers;
(5) number of clean claims from noninstitutional preferred
providers paid within the applicable statutory claims payment period;
(6) number of clean claims from noninstitutional preferred
providers paid on or before the 45th day after the end of the applicable
statutory claims payment period;
(7) number of clean claims from institutional preferred
providers paid on or before the 45th day after the end of the applicable
statutory claims payment period;
(8) number of clean claims from noninstitutional preferred
providers paid on or after the 46th day and before the 91st day after
the end of the applicable statutory claims payment period;
(9) number of clean claims from institutional preferred
providers paid on or after the 46th day and before the 91st day after
the end of the applicable statutory claims payment period;
(10) number of clean claims from noninstitutional preferred
providers paid on or after the 91st day after the end of the applicable
statutory claims payment period;
(11) number of clean claims from institutional preferred
providers paid on or after the 91st day after the end of the applicable
statutory claims payment period;
(12) number of clean claims from institutional preferred
providers paid within the applicable statutory claims payment period;
(13) number of claims paid under the provisions of §21.2809
of this title (relating to Audit Procedures);
(14) number of requests for verification received under §19.1719
of this title (relating to Verification for Health Maintenance Organizations
and Preferred Provider Benefit Plans);
(15) number of verifications issued under §19.1719
of this title;
(16) number of declinations of requests for verifications
under §19.1719 of this title;
(17) number of certifications of catastrophic events
sent to the department;
(18) number of calendar days business was interrupted
for each corresponding catastrophic event;
(19) number of electronically submitted, affirmatively
adjudicated pharmacy claims received by the MCC;
(20) number of electronically submitted, affirmatively
adjudicated pharmacy claims paid within the 18-day statutory claims
payment period;
(21) number of electronically submitted, affirmatively
adjudicated pharmacy claims paid on or before the 45th day after the
end of the 18-day statutory claims payment period;
(22) number of electronically submitted, affirmatively
adjudicated pharmacy claims paid on or after the 46th day and before
the 91st day after the end of the 18-day statutory claims payment
period; and
(23) number of electronically submitted, affirmatively
adjudicated pharmacy claims paid on or after the 91st day after the
end of the 18-day statutory claims payment period.
(d) An MCC must annually submit to the department,
on or before August 15th, at a minimum, information related to the
number of declinations of requests for verifications from July 1st
of the prior year to June 30th of the current year, in the following
categories:
(1) policy or contract limitations:
(A) premium payment time frames that prevent verifying
eligibility for a 30-day period;
(B) policy deductible, specific benefit limitations,
or annual benefit maximum;
(C) benefit exclusions;
(D) no coverage or change in membership eligibility,
including individuals not eligible, not yet effective, or for whom
membership is canceled;
(E) preexisting condition limitations; and
(F) other;
(2) declinations due to an inability to obtain necessary
information to verify requested services from the following persons:
(A) the requesting physician or provider;
(B) any other physician or provider; and
(C) any other person.
(e) In addition to the information reported under subsection
(c) of this section, the report required by subsection (a) of this
section must also include, at a minimum, the following information:
(1) the total dollar amount of the claims described
in each of the following subparagraphs:
(A) clean claims from noninstitutional preferred providers
paid on or before the 45th day after the end of the applicable statutory
claims payment period;
(B) clean claims from institutional preferred providers
paid on or before the 45th day after the end of the applicable statutory
claims payment period;
(C) clean claims from noninstitutional preferred providers
paid on or after the 46th day and before the 91st day after the end
of the applicable statutory claims payment period;
(D) clean claims from institutional preferred providers
paid on or after the 46th day and before the 91st day after the end
of the applicable statutory claims payment period;
(E) clean claims from noninstitutional preferred providers
paid on or after the 91st day after the end of the applicable statutory
claims payment period; and
(F) clean claims from institutional preferred providers
paid on or after the 91st day after the end of the applicable statutory
claims payment period;
(2) the dollar amount that the MCC paid late to an
institutional preferred provider for each clean claim that the MCC
paid to the institutional preferred provider:
(A) on or before the 45th day after the end of the
applicable statutory claims payment period;
(B) on or after the 46th day and before the 91st day
after the end of the applicable statutory claims payment period; and
(C) on or after the 91st day after the end of the applicable
statutory claims payment period;
(3) the dollar amount that the MCC paid late to a noninstitutional
preferred provider for each clean claim that the MCC paid to the noninstitutional
preferred provider:
(A) on or before the 45th day after the end of the
applicable statutory claims payment period;
(B) on or after the 46th day and before the 91st day
after the end of the applicable statutory claims payment period; and
(C) on or after the 91st day after the end of the applicable
statutory claims payment period:
(4) the amount of interest, based on the penalty dollar
amount, that the MCC paid to the department for each clean claim that
the MCC paid to a noninstitutional preferred provider on or after
the 91st day after the end of the applicable statutory claims payment
period;
(5) for each clean claim, the associated penalty dollar
amount as reported under subsection (e), paragraphs (2) and (3) of
this section; and
(6) the total number of written complaints received
by the MCC for failure to pay a clean claim on time.
(f) The claim-level data required by subsections (e)(2)
- (e)(5) must be reported using a unique identifier for each claim,
created and maintained solely by the MCC, that is not the claim number.
The unique identifier must consist of no more than 15 characters and
may not contain any of the identifiers listed in 45 C.F.R. §164.514(b).
The MCC must relate the unique identifier back to the claim on request
by the department during an examination.
(g) The quarterly report required in subsection (a)
of this section must be submitted electronically as specified on the
department's website.
(h) Subsections (e), (f), and (g) of this section apply
to reports submitted under subsection (a) of this section beginning
with the report required to be submitted by May 15, 2022, for the
months of January, February, and March of that year.
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| Source Note: The provisions of this §21.2821 adopted to be effective October 5, 2003, 28 TexReg 8647; amended to be effective July 11, 2004, 29 TexReg 6301; amended to be effective January 19, 2006, 31 TexReg 295; amended to be effective February 16, 2014, 39 TexReg 747; amended to be effective June 7, 2021, 46 TexReg 3531 |
