SECTION 61.24. Payment for Services

(a) Payee identification number. Payment for services is made to providers who have a State of Texas payee identification number. To obtain a payee identification number, providers must complete the information requested on the department's fee-for-service contract and return the completed contract to the Texas Diabetes Program, 1100 West 49th Street, Austin, Texas 78756.

(b) Conditions for payment. The DEDP will pay providers only for approved services that have been authorized by the nominator prior to the performance of such services. Payment for any service will be made only after the delivery of the service. Providers must agree to accept program fees as payment in full for service rendered, although such fee may be less than usual and customary charges.

(c) Time limit. The eye examination must be completed within 60 days of the service approval date and the signed tracking forms described in §61.21(d) of this title (relating to General Information) must be received by the DEDP within 75 days of the date service was authorized.

(d) Procedures for claims payment. The procedures for claims payment shall be in accordance with the DEDP-developed publication titled Manual for Providers of Services.

(e) Claim denials. Payment for eye examinations will not be made if:

(1) the patient is ineligible;

(2) the services provided were not specifically covered by the DEDP;

(3) the patient failed to appear for treatment and no service was rendered (no-shows); or

(4) claims for the same eye examination were previously paid for by the DEDP (duplicate claims).

(f) Reconsideration of denied claims. A claim that has been denied in error by the DEDP will be reconsidered for payment if:

(1) the original claim with the error identified and corrected is returned to the DEDP within 30 days from receipt of the notice of denial; and

(2) the claim is accompanied by a copy of the DEDP notice of denial.

(g) Payment of claims that exceed time limit. Eye examinations must be completed within 60 days from the date services were approved and the tracking form must be forwarded to the Texas Diabetes Program within 75 days of the date that service was authorized. If special or extenuating circumstances exist that make it impossible or impractical for the provider to complete services within that time period, such claims will be evaluated by the department's Bureau of Chronic Disease and Tobacco Prevention, on an individual basis, with due consideration given to the circumstances.

Source Note: The provisions of this §61.24 adopted to be effective July 23, 1990, 15 TexReg 3853; amended to be effective July 25, 2004, 29 TexReg 6905