1. (a) If necessary to determine whether a claim is payable, an HMO or preferred provider carrier may, within 30 days of receipt of a clean claim, request additional information from the treating preferred provider. The time period to request additional information may be extended as allowed by §21.2819(c) of this title (relating to Catastrophic Event). An HMO or preferred provider carrier may make only one request to the submitting preferred provider for information under this section.

2. (b) A request for information under this section must:

   1. (1) be in writing;
   2. (2) be specific to the claim or the claim's related episode of care;
   3. (3) describe with specificity the clinical and other information to be included in the response;
   4. (4) be relevant and necessary for the resolution of the claim; and
   5. (5) be for information that is contained in or in the process of being incorporated into the patient's medical or billing record maintained by the preferred provider.

3. (c) An HMO or preferred provider carrier that requests information under this section shall determine whether the claim is payable and pay or deny the claim, or audit the claim in accordance with §21.2809 of this title (relating to Audit Procedures), on or before the later of:

   1. (1) the 15th day after the date the HMO or preferred provider carrier receives the requested information as required under subsection (e) of this section;
   2. (2) the 15th day after the date the HMO or preferred provider carrier receives a response under subsection (d) of this section; or
   3. (3) the latest date for determining whether the claim is payable under §21.2807 of this title (relating to Effect of Filing a Clean Claim).
4. (d) If a preferred provider does not possess the requested information, the preferred provider must submit a written response indicating that the preferred provider does not possess the requested information in order to resume the claims payment period as described in subsection (c) of this section.
5. (e) An HMO or preferred provider carrier shall require the preferred provider responding to a request made under this section to either attach a copy of the request to the response or include with the response, the name of the patient, the patient identification number, the claim number as provided by the HMO or preferred provider carrier, the date of service, and the name of the treating preferred provider. If the HMO or preferred provider carrier submitted the request for additional information electronically in accordance with federal requirements concerning electronic transactions, the preferred provider must submit the response in accordance with those requirements. To resume the claims payment period as described in subsection (c) of this section, the preferred provider must deliver the requested information in compliance with this subsection.
6. (f) Receipt of a request or a response to a request under this section is subject to the provisions of §21.2816 of this title (relating to Date of Receipt).

Source Note:The provisions of this §21.2804 adopted to be effective October 5, 2003, 28 TexReg 8647.