1. (a) If an HMO or preferred provider carrier is unable to pay or deny a clean claim, in whole or in part, within the statutory claims payment period specified in §21.2802(25)(B) of this title (relating to Definitions), the unpaid portion of the claim shall be classified as an audit, and the HMO or preferred provider carrier shall pay 85% of the contracted rate on the unpaid portion of the clean claim within the statutory claims payment period. Payment of 85% of the contracted rate on the clean claim is not an admission that the HMO or preferred provider carrier acknowledges liability on that claim.
2. (b) Upon completion of the audit, if the HMO or preferred provider carrier determines that a refund is due from a physician or provider, such refund shall be made within 30 calendar days of the later of notification to the physician or provider of the results of the audit or exhaustion of any subscriber or patient appeal rights if a subscriber or patient appeal is filed before the 30-calendar-day refund period has expired, and may be made by any method, including chargeback against the physician or provider, or agreements by contract.
3. (c) Upon completion of the audit, if the HMO or preferred provider carrier determines that additional payment is due to the physician or provider, such additional payment shall be within 30 calendar days after the completion of the audit.

Source Note:The provisions of this §21.2809 adopted to be effective May 23, 2000, 25 TexReg 4543.