1. (a) The statutory claims payment period begins to run upon receipt of a clean claim, including a corrected claim that is a clean claim, from a preferred provider, pursuant to §21.2816 of this title (relating to Date of Receipt), at the address designated by the HMO or preferred provider carrier, in accordance with §21.2811 of this title (relating to Disclosure of Processing Procedures), whether it be the address of the HMO, preferred provider carrier, or any other entity, including a clearinghouse or a repricing company, designated by the HMO or preferred provider carrier to receive claims. The date of claim payment is as determined in §21.2810 of this title (relating to Date of Claim Payment).

2. (b) After receipt of a clean claim, prior to the expiration of the applicable statutory claims payment period specified in §21.2802(28) of this title (relating to Definitions), an HMO or preferred provider carrier shall:

   1. (1) pay the total amount of the clean claim in accordance with the contract between the preferred provider and the HMO or preferred provider carrier;
   2. (2) deny the clean claim in its entirety after a determination that the HMO or preferred provider carrier is not liable for the clean claim and notify the preferred provider in writing why the clean claim will not be paid;
   3. (3) notify the preferred provider in writing that the entire clean claim will be audited and pay 100% of the contracted rate on the claim to the preferred provider; or

   4. (4) pay the portion of the clean claim for which the HMO or preferred provider carrier acknowledges liability in accordance with the contract between the preferred provider and the HMO or preferred provider carrier, and:

      1. (A) deny the remainder of the clean claim after a determination that the HMO or preferred provider carrier is not liable for the remainder of the clean claim and notify the preferred provider in writing why the remainder of the clean claim will not be paid; or
      2. (B) notify the preferred provider in writing that the remainder of the clean claim will be audited and pay 100% of the contracted rate on the unpaid portion of the clean claim to the preferred provider.
3. (c) With regard to a clean claim for a prescription benefit subject to the statutory claims payment period specified in §21.2802(28)(C) of this title (relating to Definitions), an HMO or preferred provider carrier shall, after receipt of an electronically submitted clean claim for a prescription benefit that is affirmatively adjudicated pursuant to Insurance Code Article 3.70-3C, §3A(f) (Preferred Provider Benefit Plans) and Insurance Code §843.339, pay the prescription benefit claim within 21 calendar days after the clean claim is adjudicated.

Source Note:The provisions of this §21.2807 adopted to be effective May 23, 2000, 25 TexReg 4543; amended to be effective October 2, 2001, 26 TexReg 7542; amended to be effective October 5, 2003, 28 TexReg 8647.