The program reimburses providers for covered services for clients.
Payment may be made only after the delivery of the service, with the
exception of meals, transportation, lodging, and insurance premium
payments. Excluding allowable insurance or health maintenance organization
co-payments, the client or client's family must not be billed for
the service or be required to make a preadmission or pretreatment
payment or deposit. Providers may not request or accept payment from
the client or the client's family for completing any program forms.
Providers must agree to accept established fees as payment in full.
The program may negotiate reimbursement alternatives to reduce costs
through requests for proposals, contract purchases, or incentive programs.
(1) Payment or denial of claims. Payments made on behalf
of a client will be for claims received by the program or its payment
contractor within 95 days of the date of service, within 95 days from
the date of discharge from inpatient hospital and inpatient rehabilitation
facilities, within 95 days from the date the client's eligibility
is added to program automation systems, or within the submission deadlines
listed in paragraphs (1)(B)(ii) and (2) of this section, whichever
is later. Claims for family support services, drug co-payments, and
insurance premium payment assistance must be submitted within 95 days
of the last day of the month in which services were provided. If the
95th day for receipt of a claim falls on a weekend or holiday, the
deadline shall be extended to the next business day following the
weekend or holiday. The program must process the claims of eligible
providers within a period not to exceed 30 days of receipt and determination
of proper evidence establishing the validity of claims, invoices,
and statements. In cases where the program determines that a basis
exists for further review, suspension, or other irregularity, extended
processing time may be required. The manager of the department unit
having responsibility for oversight of the program or his or her designee(s)
may waive the filing deadlines according to the conditions and circumstances
specified in paragraphs (3) - (5) of this section. A claim must be
processed and paid within 24 months of the date of service. Claims
received by the program or its payment contractor after this time
frame will not be considered for payment by the program.
(A) Claims will be paid if submitted on claim forms
approved by the program (including electronic claims submission systems)
and if the required documentation is received with the claim.
(B) Denied claims are claims which are incomplete,
submitted on the wrong form, lack necessary documentation, contain
inaccurate information, fail to meet the filing deadline, are for
ineligible persons, services, or providers, or are for clients who
do not qualify for the health care benefit claimed.
(i) Corrected claims must be submitted on claim forms
approved by the program along with required documentation within the
filing deadline established in clause (ii) of this subparagraph.
(ii) Denied claims may be corrected and resubmitted
for reconsideration if received within 120 days of the last denial
or adjustment to the original claim. If the results of the reconsideration
process are unsatisfactory, denied claims may be appealed according
to §38.13 of this title (relating to Right of Appeal).
(2) Claims involving health insurance coverage, CHIP,
or Medicaid. Any health insurance that provides coverage to the client
must be utilized before the program can pay for services. Providers
must file a claim with health insurance, CHIP, or Medicaid prior to
submitting any claim to the program for payment. Claims with health
insurance must be received by the program within 95 days of the date
of disposition by the other third party resource, and no later than
365 days from the date of service. The program will consider claims
received for the first time after the 365-day deadline if a third
party resource recoups a payment made in error; however, the claim
must be received by the program within 95 days from the third party's
disposition. The program may pay for covered health care benefits
during CHIP or other health insurance enrollment waiting periods.
During these periods, providers may file claims directly with the
program without evidence of denial by the other insurer.
(A) Health insurance denial. If a claim is denied by
health insurance, the provider may bill the program if the letter
of denial also is submitted with the claim form. If the denial letter
is not available, the provider must include on the claim form the
date the claim was filed with the insurance company, the reason for
the denial, name and telephone number of the insurance company, the
policy number, the name of the policy holder and identification numbers
for each policy covering the client, the name of the insurance company
employee who provided the information on the denial of benefits, and
the date of the contact.
(B) Explanation of benefits (EOB). The health insurance
EOB must accompany any claim sent to the program for payment if available.
If the EOB is unavailable, the provider must include on the claim
form the name and telephone number of the insurance company, the amount
paid, the policy number, and name of the insured for each policy covering
the client.
(C) Late filing. Claims denied by health insurance
on the basis of late filing will not be considered for payment by
the program.
(D) Deductibles and coinsurance. If the client has
other third party coverage, the program may pay a deductible or coinsurance
for the client as long as the total amount paid to the provider does
not exceed the allowable amount for the covered service and conforms
with current program policies regarding third party resources, deductible,
and coinsurance.
(3) Exceptions to the claim receipt or correction and
resubmission deadlines. The manager of the department unit having
responsibility for oversight of the program or his or her designee(s)
will consider a provider's request for an exception to the claim receipt
or correction and resubmission deadlines provided in paragraphs (1)
and (2) of this section if the delay in claim receipt or correction
and resubmission is due to one of the following reasons:
(A) damage to or destruction of the provider's business
office or records by a catastrophic event or natural disaster including,
but not limited to fire, flood, hurricane, or earthquake that substantially
interferes with normal business operations of the provider;
(B) damage to or destruction of the provider's business
office or records caused by the intentional acts of an employee or
agent of the provider only if:
(i) the employment or agency relationship has been
terminated; and
(ii) the provider has filed criminal charges against
the former employee or agent;
(C) delay, error, or constraint imposed by the program
in the eligibility determination of a client or in claims processing,
or delay due to erroneous written information from the program or
its designee, or another state agency; or
(D) delay due to problems with the provider's electronic
claim system or other documented and verifiable problems with claims
submission.
(4) Exception requests. Providers requesting an exception
under paragraph (3)(A) - (D) of this section must submit an affidavit
or statement from a person with personal knowledge of the facts detailing
the exception being requested, the cause for the delay, verification
that the delay was not caused by neglect, indifference, or lack of
diligence of the provider or the provider's employee or agent, and
any additional information requested by the program. All claims for
which the provider requests an exception must accompany the request.
The program will consider only the claim(s) attached to the request,
and the exception request must be received by the program within 18
months from the date of service.
(A) For exception requests under paragraph (3)(A) of
this section, the provider must submit:
(i) independent evidence of insurable loss;
(ii) medical, accident, or death records; or
(iii) a police or fire department report substantiating
the damage or destruction.
(B) For exception requests under paragraph (3)(B) of
this section, the provider must submit a police or fire report substantiating
the damage or destruction caused by the former employee or agent's
criminal activity.
(C) For exception requests under paragraph (3)(C) of
this section, the provider must submit written documentation from
the program, its designee, or another state agency containing the
erroneous information or explanation of the delay, error, or constraint.
(D) For exception requests under paragraph (3)(D) of
this section, the provider must submit the following:
(i) a written repair statement or invoice, a computer
or modem generated error report indicating attempts to transmit the
data failed for reasons outside the control of the provider, or an
explanation for the system implementation or other claim submission
problems;
(ii) a detailed, written statement concerning the relationship
of the computer problem to delayed claims submission; and
(iii) the reason alternative billing procedures were
not initiated after the problem(s) became known.
(5) Other exceptions to claims receipt or correction
and resubmission deadlines. The manager of the department unit having
responsibility for oversight of the program or his or her designee(s)
will consider a provider's request for an exception to claims receipt
or correction and resubmission deadlines due to delays caused by entities
other than the provider and the program under the following circumstances:
(A) all claims that are to be considered for the same
exception must accompany the request;
(B) only the claim(s) that are attached to the request
will be considered;
(C) the exception request has been received by the
program within 18 months from the date of service; and
(D) the exception request includes an affidavit or
statement from a representative of an original payer, a third party
payer, or a person who has personal knowledge of the facts, stating
the exception being requested, documenting the cause for the delay,
and providing verification that the delay was caused by another entity
and not the neglect, indifference, or lack of diligence of the provider
or the provider's employee(s) or agent(s).
(6) Program fees. The program establishes fees and
payment methodologies for covered medical, dental, and other services
based upon appropriated funds. All fees are subject to reductions
or limitations authorized by §38.16(b)(2)(E) of this title (relating
to Procedures to Address Program Budget Alignment).
(7) Required documentation. The program may require
documentation of the delivery of goods and services from the provider.
(8) Overpayments.
(A) Overpayments are payments made by the program due
to the following:
(i) duplicate billings;
(ii) services paid by public or private insurance or
other resources;
(iii) payments made for services not delivered;
(iv) services disallowed by the CSHCN Services Program;
and
(v) subrogation.
(B) Overpayments made to providers must be reimbursed
to the department by lump sum payment or, at the department's discretion,
offset against current payments due to the provider for services to
other clients. The department also shall require reimbursement of
overpayments from any person or persons who have a legal obligation
to support the client and have received payments from a payer of other
benefits. Providers, clients, and person(s) responsible for clients
may appeal proposed recoupment of overpayments by the department according
to §38.13 of this title.
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| Source Note: The provisions of this §38.10 adopted to be effective July 1, 2001, 26 TexReg 2979; amended to be effective October 11, 2001, 26 TexReg 7870; amended to be effective March 27, 2003, 28 TexReg 2523; amended to be effective January 1, 2004, 28 TexReg 11268; amended to be effective August 1, 2004, 29 TexReg 7103; amended to be effective June 1, 2006, 31 TexReg 4200; amended to be effective October 3, 2010, 35 TexReg 8921; amended to be effective April 21, 2013, 38 TexReg 2362 |
