1 TDI Claims Payment Rules Lynda Nesenholtz, Special Advisor, Life, Health & Licensing Ryan Tredway, Staff Attorney, Legal & Compliance

2 What and when? Referred to as the bundling or disclosure rules Adopted September 18, 2002 Effective October 8, 2002 Apply to contracted physicians and providers Rule for HMOs: 28 TAC § Rule for PPOs: 28TAC §

3 Purpose To assure that physicians and providers who have a contract with an HMO or insurer have access to all information necessary to determine that they are being compensated in accordance with the contract.

4 Request Physician or provider makes request Request can be made by any reasonable and verifiable means including and fax

5 Carriers Response Include a provider-specific summary Explain methodologies used to pay claims Include a fee schedule, applicable coding methodologies, bundling processes, and downcoding policies

6 Response is in sufficient detail that a skilled, reasonable person can determine the payment to be made under the contract Provide 60 days written notice of changes Provide the information using any reasonable method: , disk, paper, or access to a website

7 If the information is held by an outside source, such as Medicare or Medicaid fee schedules, then the carrier must explain the procedure for obtaining the information If the information is subject to copyright or licensing agreements, then the carrier must provide a summary in adequate detail

8 Important to Note Requesters may not use or disclose the information received for any purpose other than practice management or billing Requesters may not use the information to misrepresent the level of services performed Receipt of the information does not verify the service provided is a covered benefit

9 Carriers Response Provide the information under both existing and new contracts Provide within 30 days of the date of the request If a new contract: upon request, provide it contemporaneously with other contractual materials

10 What are the timeframes? Check the date of the contract to determine whether the information should be provided with other contractual materials or upon request Note: Carriers had a 90-day grace period from the effective date of the rule to provide the information If the providers contract will expire during the 30-day response period, then the carrier must still respond to the request if it was received during the effective dates of the contract

11 What methods may be used? Any reasonable method If less than the full fee schedule information is provided, then the carrier must make additional information available by toll free telephone number or an electronic address

12 What information is included? The rules list general categories, not specifics, due to the variety of claim processing methods that carriers may use Standard: The information must include a level of detail sufficient to enable a reasonable person with sufficient training, experience, and competence in claims processing to determine the payment to be made according to the terms of the contract for covered services that are rendered to enrollees.

13 What about changes? Same standard applies: …a level of detail sufficient to enable a reasonable person with sufficient raining, experience and competence in claims processing to determine the payment to be made according to the terms of the contract for covered services that are rendered to enrollees.

14 What about the summaries? Same standard: The information must include a level of detail sufficient to enable a reasonable person with sufficient training, experience, and competence in claims processing to determine the payment to be made according to the terms of the contract for covered services that are rendered to enrollees.

15 What about changes in information from outside sources? The carriers control over the outside source will determine whether a change requires notification

16 What about Delegated Entities and Preferred Provider Networks? Carriers are always responsible for complying with the rule Carriers may direct requesters to send their requests to another party