SECTION 354.2341. Third Party Health Insurer Payment and Information Requirements

(a) A third party resource must accept HHSC's right of recovery and the assignment to the State of any right of an individual or other entity to payment from the third party resource for a health care item or service provided by the Medicaid program.

(b) A payment made by a third party resource to HHSC or a provider on a claim for payment of a health care item or service provided to a Medicaid recipient is final on the date that is two years after the third party payment was made. After a claim is final, the claim is subject to adjustment only if an action for recovery of an overpayment was commenced under §354.2321(b) of this subchapter (relating to Provider Billing and Recovery From Third Party Resources) before the date the claim became final and the recovery is agreed to by HHSC under §354.2321(c) of this subchapter.

(c) Third party health insurers must maintain and provide to HHSC, on request, information HHSC deems necessary to determine:

(1) the period during which an individual entitled to medical assistance, the individual's spouse, or the individual's dependents may be, or may have been, covered by coverage issued by the health insurer;

(2) the nature of the coverage; and

(3) the name, address, and identifying number of the health plan under which the individual may be, or may have been, covered.

(d) Not later than the 60th day after the date a third party resource receives an inquiry from HHSC regarding a claim for payment for any health care item or service submitted to the third party resource within three years of the date the health care item or service was provided, the third party resource must respond to the inquiry.

(e) A third party health insurer must accept authorization provided by HHSC that a health care item or service is covered by Medicaid as if that authorization is a prior authorization made by the third party health insurer for a health care item or service provided to an individual entitled to Medicaid that was previously paid for by HHSC and or which the third party health insurer is responsible for payment.

(f) Subsection (e) of this section does not apply to:

(1) hospital insurance benefits or supplementary insurance benefits under Part A or B of Title XVIII of the Social Security Act (codified at 42 U.S.C. §1395c et seq. or 1395j et seq.);

(2) a health care prepayment plan under Section 1833(a)(1)(A), Social Security Act (codified at 42 U.S.C. §1395l(a)(1)(A));

(3) a Medicare Advantage plan under Part C of Title XVIII of the Social Security Act (codified at 42 U.S.C. §1395w-21 et seq.);

(4) a prescription drug plan as a prescription drug plan sponsor under Part D of Title XVIII of the Social Security Act (codified at 42 U.S.C. §1395w-101 et seq.); or

(5) a reasonable cost reimbursement plan under Section 1876, Social Security Act (codified at 42 U.S.C. §1395mm).

(g) A third party resource may not deny a claim submitted by HHSC for which payment was made under the Medicaid program solely on the basis of the date of submission of the claim, the type or format of the claim form, or for a responsible third party resource, other than a third party resource described in subsection (f)(1)-(5) of this section, a failure to obtain prior authorization for the health care item or service for which the claim is being submitted, if:

(1) the claim is submitted by HHSC not later than the third anniversary of the date the health care item or service was provided; and

(2) any action by HHSC to enforce the State's rights with respect to the claim is commenced not later than the sixth anniversary of the date HHSC submits the claim.

(h) If a third party resource denies a claim for payment submitted by HHSC for reasons outlined in subsection (g) of this section, HHSC may appeal the claim without any limitation on the number of appeals.

Source Note: The provisions of this §354.2341 adopted to be effective June 28, 2000, 25 TexReg 6137; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4562; amended to be effective March 28, 2004, 29 TexReg 2867; amended to be effective February 22, 2024, 49 TexReg 855