SECTION 3.3315. Standards for Claims Payment

(a) Every issuer of Medicare supplement policies, contracts, certificates, or coverage for delivery in this state shall comply with the Social Security Act, §1882(c)(3) (as enacted by the Omnibus Budget Reconciliation Act of 1987 (OBRA) 1987, §4081(b)(2)(C) (Public Law Number 100-203), by:

(1) accepting a notice from a Medicare carrier on duly assigned claims submitted by participating physicians and suppliers as a claim for benefits in place of any other claim form otherwise required and making a payment determination on the basis of the information contained in that notice;

(2) notifying the participating physician or supplier and the beneficiary of the payment determination;

(3) paying the participating physician or supplier directly;

(4) furnishing, at the time of enrollment, each enrollee with a card listing the policy name, number, and a central mailing address to which notices from a Medicare carrier may be sent;

(5) paying user fees for claim notices that are transmitted electronically or otherwise; and

(6) providing to the secretary of health and human services, at least annually, a central mailing address to which all claims may be sent by Medicare carriers.

(b) Compliance with the requirements set forth in subsection (a) of this section shall be certified on the Medicare supplement insurance experience reporting form.

Source Note: The provisions of this §3.3315 adopted to be effective February 14, 1990, 15 TexReg 540; amended to be effective April 15, 1992, 17 TexReg 2238.