28 Tex. Admin. Code § 21.3701 - Electronic Claims Filing Requirements
(a) The purpose of this section is to
implement Insurance Code Chapter 1213. This section applies to a contract
between an issuer of a health benefit plan and a health care professional or
health care facility (hereinafter referred to as "physicians or
providers").
(b) Consistent with
Insurance Code Chapter 1213 and this section, the issuer of a health benefit
plan may, by contract, require physicians and providers to electronically
submit the following:
(1) health care claims
or equivalent encounter information;
(2) referral certifications; and/or
(3) any authorization or eligibility
transactions.
(c) An
issuer of a health benefit plan must give 90 calendar days written notice prior
to requiring electronic filing of any information described in subsection (b)
of this section.
(d) A contract
between the issuer of a health benefit plan and a physician or provider that
requires electronic submission of any information described in subsection (b)
of this section must include a provision stating that in the event of a systems
failure or a catastrophic event as defined in §
21.2802 of this title (relating to
Definitions) that substantially interferes with the business operations of the
physician or provider, the physician or provider may submit non-electronic
claims in accordance with the requirements in this subchapter and for the
number of calendar days during which substantial interference with business
operations occurs as of the date of the catastrophic event or systems failure.
A physician or provider must provide written notice of the physician's or
provider's intent to submit non-electronic claims to the issuer of the health
benefit plan within five calendar days of the catastrophic event or systems
failure.
(e) A contract between the
issuer of a health benefit plan and a physician or provider that requires
electronic submission of the information described in subsection (b) of this
section must include a provision allowing for a waiver of the electronic
submission requirements in any of the following circumstances:
(1) No method available for the submission of
claims in electronic form. This exception applies to situations in which the
federal standards for electronic submissions (45 C.F.R., Parts 160 and 162) do
not support all of the information necessary to process the claim.
(2) The operation of small physician and
provider practices. This exception applies to those physicians and providers
with fewer than 10 full-time-equivalent employees, consistent with
42 C.F.R. §
424.32(d)(1)
(viii).
(3) Demonstrable undue
hardship, including fiscal or operational hardship.
(4) Any other special circumstances that
would justify a waiver.
(f) The physician's or provider's request for
a waiver must be in writing and must include documentation supporting the
issuance of a waiver.
(g) Upon
receipt of a request for a waiver from a physician or provider, the issuer of a
health benefit plan must, within 14 calendar days, issue or deny a
waiver.
(h) A waiver or denial of a
waiver must be issued in writing to the requesting physician or provider. A
written waiver must contain any restrictions, conditions, or limitations
related to the waiver. A written denial of a request for a waiver or the
issuance of a qualified or conditional waiver must include the reason for the
denial or any restrictions, conditions, or limitations, and notice of the
physician's or provider's right to appeal the determination to the
department.
(i) A physician or
provider that is denied a waiver of the electronic submission requirements or
granted a waiver with restrictions, conditions, or limitations, may, within 14
calendar days of receipt, appeal the waiver determination. The request for
appeal and accompanying documentation must be sent to the Director of MCQA,
MC-LH-MCQA, P.O. Box 12030, Austin, Texas 78711-2030 and to the issuer of the
health benefit plan. The information must include:
(1) the physician's or provider's initial
request for a waiver sent to the issuer of the health benefit plan, including
the documentation required by subsection (f) of this section;
(2) the waiver determination received from
the issuer of the health benefit plan;
(3) any additional documentation supporting
issuance of a waiver or removal of restrictions, conditions or limitations of a
granted waiver; and
(4) any
additional information necessary for the determination of the appeal.
(j) Upon receipt of notice of a
request for appeal under this section, an issuer of a health benefit plan must,
within 14 calendar days, submit to the department and to the physician or
provider:
(1) documentation supporting the
waiver determination issued to the physician or provider; and
(2) any additional information necessary for
the determination of the appeal.
(k) The department may request additional
information from either party and may request the parties to appear at a
hearing. Either party may choose to attend a hearing conducted at the
department or participate in a hearing via telephone.
(l) Upon receipt of all information required
by subsections (i) and (j) of this section, the Director of Managed Care
Quality Assurance will issue a determination within 14 calendar days of the
later of the receipt of all necessary information or the conclusion of the
hearing.
(m) Either party may
request a hearing before the Deputy Commissioner of Life and Health for
reconsideration of the Director of the Managed Care Quality Assurance Office's
determination. Either party may choose to attend a hearing conducted at the
department or participate in a hearing via telephone. A request for
reconsideration must be received by the Chief Clerk at MC-GC-CCO, P.O. Box
12030, Austin, Texas 78711-2030 within 14 calendar days of receiving notice of
the appeal determination.
(n) The
physician or provider requesting or receiving a waiver, appealing a waiver
determination, or requesting reconsideration of an appeal determination under
this section may elect to file the required electronic transactions in a
non-electronic format until a final determination on the request is
made.
(o) The issuer of a health
benefit plan may not refuse to contract or to renew a contract with a physician
or provider based in whole or in part on the physician or provider requesting
or receiving a waiver, appealing a waiver determination, or requesting
reconsideration of an appeal determination under this section.
(p) This section applies to:
(1) a contract between a physician or
provider and an issuer of a health benefit plan that requires electronic
submission of the information described in subsection (b) of this section and
entered into or renewed on or after September 1, 2004; and
(2) existing contracts to the extent that any
contract provisions related to electronic submission of the information
described in subsection (b) of this section are made applicable to a physician
or provider on or after September 1, 2004.
Notes
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