1. (a) A physician or provider and an HMO or preferred provider carrier may agree by contract to establish a procedure to create a rebuttable presumption regarding the date of claim receipt.

2. (b) If a physician or provider and HMO or preferred provider carrier do not by contract agree to a method for the establishment of a rebuttable presumption, then the procedures set forth in paragraphs (1) - (4) of this subsection and subsections (c) - (h) of this section shall be utilized if the physician or provider desires to establish a rebuttable presumption to demonstrate the date of claim receipt. The physician or provider shall, as appropriate:

   1. (1) submit the claim by United States mail, first class, by United States mail return receipt requested or by overnight delivery service, and maintain a log that complies with subsection (f) of this section that identifies each claim included in the submission, include a copy of the log with the relevant submitted claim, fax or electronically submit a copy of the log to the HMO, preferred provider carrier or delegated claims processor on the date of the submission and maintain a copy of the fax transmission acknowledgment or proof of electronic submission;
   2. (2) submit the claim electronically and maintain proof of the electronically submitted claim;
   3. (3) if the HMO or preferred provider carrier accepts claims submission by fax, then fax the claim and maintain proof of facsimile transmission; or
   4. (4) hand deliver the claim, maintain a log that complies with subsection (f) of this section that identifies each claim included in the delivery, include a copy of the log with the relevant hand delivery and maintain a copy of the signed receipt acknowledging the hand delivery.
3. (c) If a claim for medical care or health care services provided to a patient is submitted by United States mail, first class, the claim is presumed to have been received on the third business day after the date the claim is submitted and the faxed or electronically generated log is transmitted, or if the claim is submitted using overnight delivery service or United States mail return receipt requested, on the date the delivery receipt is signed.
4. (d) If the claim is submitted electronically, the claim is presumed received on the date of the electronic verification of receipt by the HMO or preferred provider carrier or the HMO's or preferred provider carrier's clearinghouse. If the HMO's or the preferred provider carrier's clearinghouse does not provide a confirmation of receipt of the claim or a rejection of the claim within 24 hours of submission by the physician or provider or the physician's or provider's clearinghouse, the physician's or provider's clearinghouse shall provide the confirmation. The physician's or provider's clearinghouse must be able to verify that the claim contained the correct payor identification of the entity to receive the claim.
5. (e) If a claim is faxed, the claim is presumed received on the date of the transmission acknowledgment. Claims faxed after the payor's normal business hours are presumed received the following business day.
6. (f) If a claim is hand delivered, the claim is presumed received on the date the delivery receipt is signed.
7. (g) The claims mail log maintained by physicians and providers shall include the following information: name of claimant; address of claimant; telephone number of claimant; claimant's federal tax identification number; name of addressee; name of carrier; designated address, date of mailing or hand delivery; subscriber name; subscriber ID number; patient name; date(s) of service/occurrence, total charge, and delivery method.
8. (h) An example of a claims mail log that may be maintained by physicians and providers is as follows:
   Attached Graphic
   

Source Note:The provisions of this §21.2816 adopted to be effective October 2, 2001, 26 TexReg 7542.