1. (a) An MCC must submit to the department quarterly claims payment information in compliance with the requirements of this section.

2. (b) The MCC must 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 report required by subsection (a) of this section must include, at a minimum, the following information:

   1. (1) number of claims received from noninstitutional preferred providers;
   2. (2) number of claims received from institutional preferred providers;
   3. (3) number of clean claims received from noninstitutional preferred providers;
   4. (4) number of clean claims received from institutional preferred providers;
   5. (5) number of clean claims from noninstitutional preferred providers paid within the applicable statutory claims payment period;
   6. (6) number of clean claims from noninstitutional 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 noninstitutional 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 noninstitutional 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 under the provisions of §21.2809 of this title (relating to Audit Procedures);
   14. (14) number of requests for verification received under §19.1719 of this title (relating to Verification for Health Maintenance Organizations and Preferred Provider Benefit Plans);
   15. (15) number of verifications issued under §19.1719 of this title;
   16. (16) number of declinations of requests for verifications, under §19.1719 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 MCC;
   20. (20) number of electronically submitted, affirmatively adjudicated pharmacy claims paid within the 18-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 18-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 18-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 18-day statutory claims payment period.

4. (d) An MCC must annually submit to the department, on or before August 15th, at a minimum, information related to the number of declinations of requests for verifications from July 1st of the prior year to June 30th of the current year, in the following categories:

   1. (1) policy or contract limitations:

      1. (A) premium payment time frames that prevent verifying eligibility for a 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 for whom membership is canceled;
      5. (E) preexisting condition limitations; and
      6. (F) other;

   2. (2) declinations due to an inability to obtain necessary information 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; amended to be effective January 19, 2006, 31 TexReg 295; amended to be effective February 16, 2014, 39 TexReg 747.