28 Tex. Admin. Code § 21.2809 - Audit Procedures
(a) Notice and
payment required. If an MCC is unable to pay or deny a clean claim, in whole or
in part, within the applicable statutory claims payment period specified in §
21.2802 of this title (relating to
Definitions) and intends to audit the claim to determine whether the claim is
payable, the MCC must notify the preferred provider that the claim is being
audited and pay 100 percent of the contracted rate within the applicable
statutory claims payment period.
(b) Failure to provide notice and payment. An
MCC that fails to provide notice of the decision to audit the claim and pay 100
percent of the applicable contracted rate subject to copayments and deductibles
within the applicable statutory claims payment period, or, if applicable, the
extended periods allowed for by §
21.2804(c) of
this title (relating to Requests for Additional Information from Treating
Preferred Provider) or §
21.2819(c) of
this title (relating to Catastrophic Event), may not make use of the audit
procedures set out in this section. A preferred provider that receives less
than 100 percent of the contracted rate with a notice of intent to audit has
received an underpayment and must notify the MCC within 270 days in compliance
with the provisions of §
21.2815(f)(2) of
this title (relating to Failure to Meet the Statutory Claims Payment Period) to
qualify to receive a penalty for the underpaid amount.
(c) Explanation of payment. The MCC must
clearly indicate on the explanation of payment that the claim is being audited
and that the preferred provider is being paid 100 percent of the contracted
rate, subject to completion of the audit. A nonelectronic explanation of
payment complies with this requirement if the notice of the audit is clearly
and prominently identified.
(d)
Audit deadline and requirements. The MCC must complete the audit within 180
calendar days from receipt of the clean claim. The HMO or preferred provider
carrier must provide written notice of the results of the audit. The MCC must
include in the notice a listing of the specific claims paid and not paid under
the audit, as well as a listing of specific claims and amounts for which a
refund is due and, for each claim, the basis and specific reasons for
requesting a refund. An MCC seeking recovery of any refund under this section
must comply with the procedures set out in §
21.2818 of this title (relating to
Overpayment of Claims).
(e)
Requests for information. An MCC may recover the total amount paid on the claim
under subsection (a) of this section if a physician or a provider fails to
timely provide additional information requested under the requirements of
Insurance Code §
1301.105 or §
843.340(c).
Section 21.2816 of this title (relating to
Date of Receipt) applies to the submission and receipt of a request for
information under this subsection.
(f) Opportunity for appeal. Before seeking a
refund for a payment made under this section, an MCC must provide a preferred
provider with the opportunity to appeal the request for a refund in compliance
with §
21.2818 of this title. An MCC may
not seek to recover the refund until all of the preferred provider's internal
appeal rights under §
21.2818 of this title have been
exhausted.
(g) No admission of
liability. Payments made under this section on a clean claim are not an
admission that the MCC acknowledges liability on that claim.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.