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Commissioner’s Bulletin # B-0031-07

July 17, 2007

TO: ALL INSURERS WRITING PREFERRED PROVIDER HEALTH BENEFIT PLANS (PPBPS) AND ALL HEALTH MAINTENANCE ORGANIZATIONS (HMOS)

RE: CALL FOR REPORTS REGARDING PROVIDER CLAIMS PROCESSING AND RELATED FUNCTIONS

DUE: August 15, 2007 - Second Quarter 2007 (April - June) Provider Claims Data and Annual Report of Reasons for Declinations

Pursuant to §38.001 of the Texas Insurance Code (TIC), the Texas Department of Insurance (TDI) issues the attached mandatory data call for insurers writing preferred provider health benefit plans in Texas, and for health maintenance organizations doing business in Texas (collectively, hereafter, "carriers"). This data call is necessary for TDI to determine carriers' compliance with various "prompt pay" requirements relating to claims submitted by providers, as addressed under TIC Ch. 1301 and Ch. 843, Subchapter J and rules adopted to implement those statutes. Carriers' complete responses to this data call are also necessary for compliance with 28 Texas Administrative Code (TAC) §21.2821.

Second Quarter 2007 Provider Claims Data: The provider claims data for the reporting period April through June, 2007 and annual report of reasons for declinations are due no later than August 15, 2007. Please use the tips listed on page three to review the data before you submit it.

In certain circumstances, claims will be reported in more than one quarter. Specifically, if an initial underpayment is made (and reported) and a subsequent additional payment is made in a different quarter, then the subsequent payment must be reported as a late payment, as appropriate. If the subsequent payment is made outside the applicable statutory claims payment period, the carrier must reflect this in the report.

SB 418 Annual Report of Declination Data: Carriers are required to report annually the reasons for declining to verify a claim, referred to as declinations. Carriers should report declination data from July 1, 2006, through June 30, 2007. Also, carriers must submit reports about declinations issued by each delegated entity that processes that carrier's insured and/or enrollees' claims. Carriers and their delegated entities, if applicable, must retain the data used to calculate the totals reported to TDI for a minimum of three years, and the data must be available for review by TDI. The annual report of declination data is due no later than August 15, 2007.

As a reminder about this data call, TDI staff will e-mail the link to the data collection application to your data contact. If you have questions about the data call or how to access the data collection application, please contact Katrina Daniel via e-mail at katrina.daniel@tdi.state.tx.us or call her at 512-322-4315.

Sincerely,

Mike Geeslin

Commissioner of Insurance

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