1 Life, Health & Licensing Program Jennifer Ahrens Senior Associate Commissioner Provider Ombudsman

2 TDI Jurisdiction Pursuant to Tex. Ins. Code § , TDI must: Regulate the business of insurance in Texas Ensure the Insurance Code and other laws regarding insurance and insurance companies are executed Texas Prompt Pay Statutes Apply to: HMOs Insured PPO Plans Texas Prompt Pay Statutes Do Not Apply to: Self-funded ERISA plans Indemnity plans (even if insured) Medicaid, Medicare, Med Supp Government and school plans (except HMO or fully insured PPO plans) Childrens Health Insurance Program (CHIP)

3 Prompt Pay Statutes HMO prompt payment provisions Tex. Ins. Code §§ – PPO prompt payment provisions Tex. Ins. Code §§ –

4 New Underpayment Calculation SB 1884 – Effective September 1, 2007 Paid on or before the 45th day after the end of the applicable statutory claim period: Billed charges = $1,500 Amount of contracted rate = $1,000 Patients cost share = 0 Amount paid timely = $800 Amount underpaid on contracted rate = $200 $200 / $1,000 (= 20%) X $1,500 = $300 (the underpaid amount) Multiply by 50% $150 = penalty payment

5 Recent Rule Activity 28 TAC § and § CMS-1500 (08/05) and UB-04 CMS-1450 NPI (Contingency Plans) pdf Underpayment Calculation rule to be published for comment soon

6 Technical Advisory Committee on Claims Processing 2005 & 2006 meetings Rules to implement new legislation Prompt pay data summary Coding and bundling standards National provider identifiers CMS claim form revisions Silent/rental PPOs Standard contract language

7 Reference Materials TDI Web site Physician/Provider Resource page Rules page FAQs page Physician/Provider Complaint form

8 TDI Web Site:

9 Physician/Provider Resource Page

10 Physician/Provider Complaint Form On-line ( Phone ( )/Fax ( )/

11 Workers Compensation HB UR Licensing HB Specialization

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13 SB 1731 Consumer Guide to Health Care Written disclosures from providers and carriers Data collection: Reimbursement Rates Annual Reports

14 HB 522 Health Care ID Card Pilot Program ID cards containing standardized electronic data health benefit plan coverage plan limits deductibles covered services payor and enrollee contact information.

15 Helpful Resources TDI Website: Life, Health, and Licensing Main Line: Life/Health Division: Health & Workers Compensation Network Certification and Quality Assurance Division The Texas Health Options Website: TDI Proposed/Adopted Rules: Texas Legislature Website: