Presentation on theme: "Texas Department of Insurance Jose Montemayor, Commissioner."— Presentation transcript:
1 TexasDepartment of InsuranceJose Montemayor, Commissioner
2 Prompt Payment to Providers 28 TAC §§21.2801-21.2816 Patricia Brewer, HMO Projects DirectorCady Crismon, MSN, RN, Director, HMO Quality AssuranceTexas Department of Insurance
3 Who Does Not Have to Comply? Self-funded ERISA plansWorkers’ compensation coverageGovernment, school, and church health plansOut-of-state insuredsMedicaid/MedicareState employee plans (except those involving HMO complaints)Federal employee plansTeacher Retirement System-CareUniversity of Texas employeesTRICARE Standard (CHAMPUS)Texas Association of School Boards coverage
4 When Does a Company Have to Pay a Claim for a Health Service? Texas law provides different requirements depending upon:Type of coverage - HMO vs. PPO vs. Non-network IndemnityWho filed the claim - Insured, Enrollee, Physician, or ProviderStatus of physician or provider - Contracted vs. Non-contracted
5 Clean Claim RulesMeant to implement and clarify HB 610 passed during 1999 legislative sessionApply to:HMOsPPOsContracted Physicians and ProvidersEffective for:Claims filed for outpatient care received on or after 8/1/00Claims filed for inpatient stays that began on or after 8/1/00
6 Clean Claim Rules Perform three main functions: Define elements of a clean claimClarify when the prompt payment period clock starts runningClarify the required actions of a carrier upon receipt of a clean claim
7 What is a Clean Claim? Data elements - see handouts HCFA 1500 UB-92 AttachmentsAdditional clean claim elementsFormatLegible, accurate, completeToo much information does not render an otherwise clean claim deficient!
8 Coordination of Benefits The amount(s) paid by primary carrier(s) is a clean claim element for secondary carriersThe statutory claim processing period for secondary carriers does not begin until primary payor information is provided
9 Proof of Claims Submission Return receiptElectronic confirmationFax confirmation*The 45-day time period to pay a claim begins on the date the claim is received by the carrier
10 What are the Carrier’s Responsibilities? Notice of revised or additional data elements and/or attachments. Disclosure may be made by:Written notice at least 60 days prior to requiring additional or revised informationRevision of physician or provider manual at least 60 days prior to requiring additional or revised informationContract provisions
11 Act on clean claims within 45-day statutory claims processing period Pay the claim, in total, in accordance with the contractDeny the claim in total and notify the physician or provider in writing of the reason for denialPay portion and deny portion, and notify physician or provider in writing of reason for denialPay portion and audit portion, notify physician or provider in writing that claim is being audited, and pay 85% of the contracted rate on the audited portionAudit entire claim, notify physician or provider in writing that claim is being audited, and pay 85% of the contracted rate
12 Notice of deficient claims within 45 days Notice of changes in claims addresses, processors, etc.
13 AuditsCarrier acknowledges coverage of an enrollee, but claim processing takes longer than the 45-day statutory claim processing periodThe rule does not specify a time limit for audit completion
14 A physician or provider must refund the 85% audit payment: After the audit is completed, the carrier must give written notice of the results and pay the additional 15% balance of contracted rate 30 days after the audit is completedA physician or provider must refund the 85% audit payment:30 days after the later of (a) receiving notice of audit results, or (b) exhaustion of enrollee’s appeal rights, if appealed within 30-day refund periodChargebacks are allowed with written notice and opportunity to arrange an alternative reimbursement method
15 Penalties if Carriers Fail to Comply with the Clean Claim Rules Full amount of billed charges up to U&C charges, orContracted penalty rate provided in the physician or provider’s contractAdministrative penalties, up to $1,000/day per claim, may be assessed and collected by the State of Texas
16 Date of Claim PaymentClaim is considered to have been paid on the date of:U.S. Postal Service postmarkElectronic transmissionDelivery of the claim payment to a commercial carrier, such as UPS or Federal Express, orReceipt by the physician or provider, if a claim payment is made other than provided above
17 Filing a Clean Claim File the claim within the contractual timeframes Send claims to the correct billing addressInclude all required data elements and attachmentsMaintain proof of timely filing
19 TDI Complaint Process Consumer Protection - PPO/Indemnity HMO Quality Assurance Section - HMOComplaints are reviewed and assignedCarriers have 10 days to respond to TDI inquiries, per Texas Insurance Code Article
22 TDI’s Authority Some issues fall under other agencies’ jurisdiction Self-funded ERISA plansWorkers’ compensation coverageGovernment, school, and church health plansOut-of-state insuredsMedicaid/MedicareState employee plans (except those involving HMO complaints)Federal employee plansTeacher Retirement System-CareUniversity of Texas employeesTRICARE Standard (CHAMPUS)Texas Association of School Boards coverage
23 Physician and Provider Responsibilities Read and understand your contractKnow contractual provisions for attachmentsAssure front office/billing service is aware of correct billing location for each carrierSubmit clean claimsRefund audit payments if claim is denied after auditUpdate accounts receivable regularlyAllow 45 days for processing and payment of claim before resubmitting
24 What TDI Needs to “Work” a Claims Complaint Written complaintCopy of patient’s health insurance ID cardHCFA 1500 or UB-92 claim form submitted to the company for each patient and date of serviceClaims separated by the HMO or insurance carrier name
25 Valid evidence of claim submission for each claim Electronic transmission confirmationCertified mail return receiptFax confirmationCourier delivery confirmation, orClaims mail log evidenced by faxed confirmation of date submitted via US first-class mail (proposed)Claim is presumed received on the third day after the date the claim is submittedEvidence of the collection activities undertaken for each claimDocumentation of phone conversations made to the health carrier and/orCopies of correspondence mailed to the health carrierThe replies received from the health carrier
26 Scenario #1 DOS 5/29/01 with contracted provider Claim submitted to carrier via certified mail on 6/20/01 with return receipt dated 6/26/01HCFA 1500 missing elements 14 & 15Provider filed complaint with Department on 7/12/01Clean claim violation?
27 Scenario #2 DOS 11/21/00 with contracted provider Submitted HCFA 1500 within contractual timeframesProvider resubmitted HCFA 1500 every 15 days after original submission until paidClaim paid at contracted rate 45 days after original submission receiptClean claim violation?
28 Scenario #3 ER DOS 10/4/00 Facility is a contracted provider Billed carrier at end of month, submitted claim via certified mail, received by carrier on 11/20/00All required elements on HCFA 1500 and all attachments providedER followed up on unpaid claim on 2/1/01Clean claim violation?
29 Scenario #4Contracted provider filed clean claim with multiple CPT codes for DOS 5/1/01Carrier notified provider of audit, in writing, within 45 days, paying 85% of contracted rate for each CPT codeCompleted audit within 60 days and paid provider remaining 15% of contracted rateClean claim violation?
30 Scenario #5 Office visit with contracted physician, DOS 5/5/01 Physician billed for multiple CPT codes for this office visitCarrier deducted copay on each CPT code, but paid within 45 daysClean claim violation?
31 Scenario #6 DOS 1/15/01 with contracted provider Provider submitted clean claim via electronic submissionCarrier processed and paid claims within 30 days, but paid at incorrect contract rateProvider appealed payment twice, then filed complaint with TDICarrier responded that they had incorrectly paid claim and then paid the difference between the incorrect rate and the contracted rateCarrier refused to pay billed chargesClean claim violation?
32 Scenario #7Provider filed complaint with TDI requesting assistance in collecting full-billed chargesInformation provided included:Contracted provider submitted claim to carrier via electronic submission for DOS 8/30/00Carrier states they did not receive claimClaim resubmitted on paper, then denied for timely filingProof of the electronic filing was submitted to carrier and claim paid at contracted rateClean claim violation?
33 Resources Website: Provider Ombudsman Toll Free Information Provider OmbudsmanAudrey Selden, Senior Associate Commissioner(512)Toll Free Information
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