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TITLE 28INSURANCE
PART 1TEXAS DEPARTMENT OF INSURANCE
CHAPTER 21TRADE PRACTICES
SUBCHAPTER CCELECTRONIC HEALTH CARE TRANSACTIONS
RULE §21.3701Electronic Claims Filing Requirements

(a) The purpose of this section is to implement Article 21.52Z of the Insurance Code. This section applies to a contract between an issuer of a health benefit plan and a health care professional or health care facility (hereinafter referred to as "physicians or providers").

(b) Consistent with Insurance Code Article 21.52Z and this section, the issuer of a health benefit plan may, by contract, require physicians and providers to electronically submit the following:

  (1) health care claims or equivalent encounter information;

  (2) referral certifications; and/or

  (3) any authorization or eligibility transactions.

(c) An issuer of a health benefit plan must give 90 calendar days written notice prior to requiring electronic filing of any information described in subsection (b) of this section.

(d) A contract between the issuer of a health benefit plan and a physician or provider that requires electronic submission of any information described in subsection (b) of this section shall include a provision stating that in the event of a systems failure, or a catastrophic event as defined in §21.2803 of this title (relating to Definitions), that substantially interferes with the business operations of the physician or provider, the physician or provider may submit non-electronic claims in accordance with the requirements in this subchapter and for the number of calendar days during which substantial interference with business operations occurs as of the date of the catastrophic event or systems failure. A physician or provider shall provide written notice of the physician's or provider's intent to submit non-electronic claims to the issuer of the health benefit plan within five calendar days of the catastrophic event or systems failure.

(e) A contract between the issuer of a health benefit plan and a physician or provider that requires electronic submission of the information described in subsection (b) of this section shall include a provision allowing for a waiver of the electronic submission requirements in any of the following circumstances:

  (1) No method available for the submission of claims in electronic form. This exception applies to situations in which the federal standards for electronic submissions (45 C.F.R., Parts 160 and 162) do not support all of the information necessary to process the claim.

  (2) The operation of small physician and provider practices. This exception applies to those physicians and providers with fewer than ten full-time-equivalent employees, consistent with 42 C .F.R. §424.32(d)(1)(viii).

  (3) Demonstrable undue hardship, including fiscal or operational hardship.

  (4) Any other special circumstances that would justify a waiver.

(f) The physician's or provider's request for a waiver must be in writing and must include documentation supporting the issuance of a waiver.

(g) Upon receipt of a request for a waiver from a physician or provider, the issuer of a health benefit plan shall, within 14 calendar days, issue or deny a waiver.

(h) A waiver or denial of a waiver must be issued in writing to the requesting physician or provider. A written waiver shall contain any restrictions, conditions or limitations related to the waiver. A written denial of a request for a waiver or the issuance of a qualified or conditional waiver shall include the reason for the denial or any restrictions, conditions or limitations, and notice of the physician's or provider's right to appeal the determination to the Texas Department of Insurance.

(i) A physician or provider that is denied a waiver of the electronic submission requirements, or granted a waiver with restrictions, conditions or limitations, may, within 14 calendar days of receipt, appeal the waiver determination. The request for appeal and accompanying documentation shall be sent to the Deputy Commissioner, HMO Division, P.O. Box 149104, Austin, Texas 78714-9104 and to the issuer of the health benefit plan. The information shall include:

  (1) the physician's or provider's initial request for a waiver sent to the issuer of the health benefit plan, including the documentation required by subsection (f) of this section;

  (2) the waiver determination received from the issuer of the health benefit plan;

  (3) any additional documentation supporting issuance of a waiver or removal of restrictions, conditions or limitations of a granted waiver; and

  (4) any additional information necessary for the determination of the appeal.

(j) Upon receipt of notice of a request for appeal under this section, an issuer of a health benefit plan shall, within 14 calendar days, submit to the Deputy Commissioner of the HMO Division and to the physician or provider:

  (1) documentation supporting the waiver determination issued to the physician or provider; and

  (2) any additional information necessary for the determination of the appeal.

(k) The Deputy Commissioner of the HMO Division may request additional information from either party and may request the parties to appear at a hearing. Either party may choose to attend a hearing conducted at the department or participate in a hearing via telephone.

(l) Upon receipt of all information required by subsections (i) and (j) of this section, the Deputy Commissioner of the HMO Division shall issue a determination within 14 calendar days of the later of the receipt of all necessary information or the conclusion of the hearing.

(m) Either party may request a hearing before the Senior Associate Commissioner of the Life, Health and Licensing Program for reconsideration of the Deputy Commissioner of the HMO Division's determination. Either party may choose to attend a hearing conducted at the department or participate in a hearing via telephone. A request for reconsideration must be received by the Senior Associate Commissioner at P.O. Box 149104, Austin, Texas 78714-9104 within 14 calendar days of receiving notice of the appeal determination.

(n) The physician or provider requesting or receiving a waiver, appealing a waiver determination, or requesting reconsideration of an appeal determination under this section may elect to file the required electronic transactions in a non-electronic format until a final determination on the request is made.

(o) The issuer of a health benefit plan may not refuse to contract or to renew a contract with a physician or provider based in whole or in part on the physician or provider requesting or receiving a waiver, appealing a waiver determination, or requesting reconsideration of an appeal determination under this section.

(p) This section applies to:

  (1) a contract between a physician or provider and an issuer of a health benefit plan that requires electronic submission of the information described in subsection (b) of this section and entered into or renewed on or after September 1, 2004; and

  (2) existing contracts to the extent that any contract provisions related to electronic submission of the information described in subsection (b) of this section are made applicable to a physician or provider on or after September 1, 2004.


Source Note: The provisions of this §21.3701 adopted to be effective August 29, 2004, 29 TexReg 8357

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