1. (a) An HMO or preferred provider carrier shall submit to the department quarterly claims payment information in accordance with the requirements of this section.

2. (b) The HMO or preferred provider carrier shall submit the report required by subsection (a) of this section to the department on or before:

   1. (1) May 15th for the months of January, February and March of each year;
   2. (2) August 15th for the months of April, May and June of each year;
   3. (3) November 15th for the months of July, August and September of each year; and
   4. (4) February 15th for the months of October, November and December of each preceding calendar year.
3. (c) The HMO or preferred provider carrier shall submit the first report required by this section to the department on or before February 15, 2004 and shall include information for the months of September, October, November and December of the prior calendar year.

4. (d) The report required by subsection (a) of this section shall include, at a minimum, the following information:

   1. (1) number of claims received from non-institutional preferred providers;
   2. (2) number of claims received from institutional preferred providers;
   3. (3) number of clean claims received from non-institutional preferred providers;
   4. (4) number of clean claims received from institutional preferred providers;
   5. (5) number of clean claims from non-institutional preferred providers paid within the applicable statutory claims payment period;
   6. (6) number of clean claims from non-institutional preferred providers paid on or before the 45th day after the end of the applicable statutory claims payment period;
   7. (7) number of clean claims from institutional preferred providers paid on or before the 45th day after the end of the applicable statutory claims payment period;
   8. (8) number of clean claims from non-institutional preferred providers paid on or after the 46th day and before the 91st day after the end of the applicable statutory claims payment period;
   9. (9) number of clean claims from institutional preferred providers paid on or after the 46th day and before the 91st day after the end of the applicable statutory claims payment period;
   10. (10) number of clean claims from non-institutional preferred providers paid on or after the 91st day after the end of the applicable statutory claims payment period;
   11. (11) number of clean claims from institutional preferred providers paid on or after the 91st day after the end of the applicable statutory claims payment period;
   12. (12) number of clean claims from institutional preferred providers paid within the applicable statutory claims payment period;
   13. (13) number of claims paid pursuant to the provisions of §21.2809 of this title (relating to Audit Procedures);
   14. (14) number of requests for verification received pursuant to §19.1724 of this title (relating to Verification);
   15. (15) number of verifications issued pursuant to §19.1724 of this title;
   16. (16) number of declinations, pursuant to §19.1724 of this title;
   17. (17) number of certifications of catastrophic events sent to the department;
   18. (18) number of calendar days business was interrupted for each corresponding catastrophic event;
   19. (19) number of electronically submitted, affirmatively adjudicated pharmacy claims received by the HMO or preferred provider carrier;
   20. (20) number of electronically submitted, affirmatively adjudicated pharmacy claims paid within the 21-day statutory claims payment period;
   21. (21) number of electronically submitted, affirmatively adjudicated pharmacy claims paid on or before the 45th day after the end of the 21-day statutory claims payment period;
   22. (22) number of electronically submitted, affirmatively adjudicated pharmacy claims paid on or after the 46th day and before the 91st day after the end of the 21-day statutory claims payment period; and
   23. (23) number of electronically submitted, affirmatively adjudicated pharmacy claims paid on or after the 91st day after the end of the 21-day statutory claims payment period.

5. (e) An HMO or preferred provider carrier shall annually submit to the department, on or before July 31, at a minimum, information related to the number of declinations of requests for verifications in the following categories:

   1. (1) policy or contract limitations:

      1. (A) premium payment timeframes that prevent verifying eligibility for 30-day period;
      2. (B) policy deductible, specific benefit limitations or annual benefit maximum;
      3. (C) benefit exclusions;
      4. (D) no coverage or change in membership eligibility, including individuals not eligible, not yet effective or membership cancelled;
      5. (E) pre-existing condition limitations; and
      6. (F) other.

   2. (2) declinations due to inability to obtain necessary information in order to verify requested services from the following persons:

      1. (A) the requesting physician or provider;
      2. (B) any other physician or provider; and
      3. (C) any other person.

Source Note:The provisions of this §21.2821 adopted to be effective October 5, 2003, 28 TexReg 8647; amended to be effective July 11, 2004, 29 TexReg 6301.