28 Tex. Admin. Code § 133.200 - Insurance Carrier Receipt of Medical Bills from Health Care Providers
(a) On receipt of
medical bills submitted in accordance with §
133.10 of this chapter (relating
to Required Billing Forms/Formats), an insurance carrier must evaluate each
medical bill for completeness as defined in §
133.2 of this chapter (relating to
Definitions).
(1) Insurance carriers must not
return medical bills that are complete, unless the bill is a duplicate
bill.
(2) Within 30 days after the
day it receives a medical bill that is not complete as defined in §
133.2 of this chapter, an
insurance carrier must:
(A) complete the bill
by adding missing information already known to the insurance carrier, except
for the following:
(i) dates of
service;
(ii) procedure or modifier
codes;
(iii) number of units;
and
(iv) charges; or
(B) return the bill to the sender,
in accordance with subsection (c) of this section.
(3) The insurance carrier may contact the
sender to get the information necessary to make the bill complete, including
the information specified in paragraph (2)(A)(i) - (iv) of this subsection. If
the insurance carrier gets the missing information and completes the bill, the
insurance carrier must document the name and telephone number of the person who
supplied the information.
(b) An insurance carrier must not return a
medical bill except as provided in subsection (a) of this section. When
returning a medical bill, the insurance carrier must include a document
identifying the reasons for returning the bill. The reasons related to the
procedure or modifier codes must identify the reasons by line item.
(c) The proper return of an incomplete
medical bill in accordance with this section fulfills the insurance carrier's
obligations with regard to the incomplete bill.
(d) An insurance carrier must not combine
bills submitted in separate envelopes as a single bill or separate single bills
spanning several pages submitted in a single envelope.
Notes
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