1. (a) The statutory claims payment period begins to run upon receipt of a clean claim from a physician or provider 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 a delegated claims processor. 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 statutory claims payment period specified in §21.2802(25)(B) 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 physician or 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 physician or provider in writing why the clean claim will not be paid;
   3. (3) notify the physician or provider in writing that the entire clean claim will be audited and pay 85% of the contracted rate on the claim to the physician or 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 physician or 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 physician or provider in writing why the remainder of the clean claim will not be paid; or
      2. (B) notify the physician or provider in writing that the remainder of the clean claim will be audited and pay 85% of the contracted rate on the unpaid portion of the clean claim to the physician or provider.

3. (c) With regard to a clean claim for a prescription benefit subject to the statutory claims payment period specified in §21.2802(25)(C) of this title (relating to Definitions), an HMO or preferred provider carrier shall:

   1. (1) after receipt of an electronically submitted clean claim for a prescription benefit that is electronically adjudicated and electronically paid pursuant to Insurance Code Article 3.70-3C, §3A(d) (Preferred Provider Benefit Plans) and Article 20A.18B(d), pay or deny the prescription benefit claim, in whole or in part, within 21 calendar days after the treatment is authorized; or
   2. (2) after receipt of an electronically submitted clean claim for a prescription benefit that is electronically adjudicated and electronically paid pursuant to §21.2814 of this title (relating to Electronic Adjudication of Prescription Benefits) pay or deny the prescription benefit claim, in whole or in part, within 21 calendar days after the clean claim is electronically transmitted.

Source Note:The provisions of this §21.2807 adopted to be effective May 23, 2000, 25 TexReg 4543.