SECTION 354.1135. Claims Procedures

The health insuring agent:

(1) rejects all claims not payable under this chapter;

(2) suspends payments to any eligible provider in accordance with procedures approved by the department or after notification from the department to suspend such payments and promptly provides the department appropriate information pertaining to any such suspension;

(3) notifies any provider submitting the claims of their reduction or rejection and the reason therefor;

(4) collects any payments made in error, as set forth in this chapter, effects a current record credit to the department, and provides the department with required data relating to such error corrections;

(5) within a period not to exceed 30 days of receipt and determination of proper evidence establishing the validity of claims, invoices, and statements, prepares checks or drafts to providers, except for cases in which the department agrees that a basis exists for further review, suspension, or other irregularity;

(6) with respect to eligible providers who have furnished eligible recipient's benefits, payment for which is to be made on a reasonable cost basis, the health insuring agent makes provisions for payments:

(A) on an interim basis, not less often than once each calendar month, in amount which will approximate the reasonable cost of such services; and

(B) on a final audited annual basis for the reasonable cost of such services;

(7) when the eligible recipient has such another source of payment, the health insuring agent withholds payment of claim for a reasonable time to enable the amount of such other benefits to be determined and reported to the health insuring agent by the eligible provider;

(8) employs and assigns a physician, or physicians, and other professionals as necessary, to establish suitable standards for the audit of claims for services delivered and payment to eligible providers, to develop and maintain necessary safeguards to ensure the quality of care, and to provide appropriate prior authorizations as required;

(9) requires eligible providers to submit information on claims on forms designated by the health insuring agent and approved by the department.

Source Note: The provisions of this §354.1135 adopted to be effective May 30, 1977, 2 TexReg 1929; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561