SECTION 21.2807. Effect of Filing a Clean Claim

(a) The statutory claims payment period begins to run on receipt of a clean claim, including a corrected claim that is a clean claim, from a preferred provider, under §21.2816 of this title (relating to Date of Receipt), at the address designated by the MCC, in compliance with §21.2811 of this title (relating to Disclosure of Processing Procedures), whether it be the address of the MCC or any other entity, including a clearinghouse or a repricing company, designated by the MCC to receive claims. The date of claim payment is determined in §21.2810 of this title (relating to Date of Claim Payment).

(b) After receipt of a clean claim and before the expiration of the applicable statutory claims payment period specified in §21.2802 of this title (relating to Definitions), an MCC must:

(1) pay the total amount of the clean claim as specified in the contract between the preferred provider and the MCC;

(2) deny the clean claim in its entirety after a determination that the MCC is not liable for the clean claim and notify the preferred provider in writing why the clean claim will not be paid;

(3) notify the preferred provider in writing that the entire clean claim will be audited and pay 100 percent of the contracted rate on the claim to the preferred provider; or

(4) pay the portion of the clean claim for which the MCC acknowledges liability as specified in the contract between the preferred provider and the MCC, and:

(A) deny the remainder of the clean claim after a determination that the MCC is not liable for the remainder of the clean claim and notify the preferred provider in writing why the remainder of the clean claim will not be paid; or

(B) notify the preferred provider in writing that the remainder of the clean claim will be audited and pay 100 percent of the contracted rate on the unpaid portion of the clean claim to the preferred provider.

(c) An MCC or an MCC's clearinghouse that receives an electronic clean claim is subject to the requirements of this subchapter regardless of whether the claim is submitted together with, or in a batch submission with, a claim that is deficient.

Source Note: The provisions of this §21.2807 adopted to be effective May 23, 2000, 25 TexReg 4543; amended to be effective October 2, 2001, 26 TexReg 7542; amended to be effective October 5, 2003, 28 TexReg 8647; amended to be effective January 19, 2006, 31 TexReg 295; amended to be effective February 16, 2014, 39 TexReg 747