SECTION 354.1137. Review of Questionable Claims

The health insuring agent has physicians, or other professional consultants, or both, as appropriate, review all questionable claims for:

(1) interpretation of benefit coverage with respect to illness or mental disease;

(2) determinations on questions regarding overutilization or other misutilization of services by eligible recipients or eligible providers;

(3) determinations on questions regarding excessive charges by eligible providers;

(4) determination of the reasonable amount to be paid when a claim is made for a procedure or service for which a reasonable charge determination has not been established by the health insuring agent. Such determination is made in comparison with established reasonable charges for other procedures requiring similar degrees of skill, training, or experience, and considering the locale in which the service was provided and the characteristics of the patient;

(5) quality of care provided and unethical practices of eligible providers. Cases where quality of service or ethical practices of the eligible provider are in question are identified and not paid until further review.

Source Note: The provisions of this §354.1137 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