1 life, health & licensing program jennifer ahrens senior associate commissioner provider...

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Life, Health & Licensing Program

Jennifer AhrensSenior Associate Commissioner

Provider Ombudsman

jennifer.ahrens@tdi.state.tx.us512-305-7342

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TDI Jurisdiction Pursuant to Tex. Ins. Code § 31.002, 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) Children’s Health Insurance Program (CHIP)

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Prompt Pay Statutes

HMO prompt payment provisions Tex. Ins. Code §§ 843.336 – 843.353

PPO prompt payment provisions Tex. Ins. Code §§ 1301.101 –

1301.138

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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 Patient’s 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

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Recent Rule Activity 28 TAC §21.2802 and §21.2803

CMS-1500 (08/05) and UB-04 CMS-1450 NPI (Contingency Plans)

http://www.tdi.state.tx.us/rules/documents/212802-212803.pdf

Underpayment Calculation rule to be published for comment soon

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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

http://www.tdi.state.tx.us/consumer/ccwg.html

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Reference Materials

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

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TDI Web Site:www.tdi.state.tx.us

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Physician/Provider Resource Pagewww.tdi.state.tx.us/consumer/doctors.html

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Physician/Provider Complaint Form

On-line (https://wwwapps.tdi.state.tx.us/inter/perlroot/consumer/prcompform/prcompform.html)

Phone (1-800-252-3439)/Fax (512-475-1771)/Email (ConsumerProtection@tdi.state.tx.us)

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Workers’ Compensation

HB 1006 - UR Licensing HB 2004 - Specialization

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SB 1731

Consumer Guide to Health Care Written disclosures from providers

and carriers Data collection:

Reimbursement Rates Annual Reports

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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.

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Helpful Helpful ResourcesResources

TDI Website: www.tdi.state.tx.us

Life, Health, and Licensing Main Line:512-305-7342

Life/Health Division: LifeHealth@tdi.state.tx.us

Health & Workers’ Compensation Network Certification and Quality Assurance Division HWCN@tdi.state.tx.us

The Texas Health Options Website: www.TexasHealthOptions.com

TDI Proposed/Adopted Rules: www.tdi.state.tx.us/commish/parules.html

Texas Legislature Website: www.capitol.state.tx.us