| Proposed §3.3703(a)(20) & §11.901(10) |
Proposed §3.3703(a)(21) & §11.901(11) |
| A contract between a carrier and a physician or provider must contain physician-specific or provider-specific information in a sufficient level of detail that a reasonable person with sufficient training, experience and competence in claims processing can determine the payment to be made according to the terms of the contract. §3.3703(a)(20) and §11.901(10). |
A contract between a carrier and a physician or provider must provide that the physician or provider may request a description of any coding guidelines and fee schedules, §3.3703(a)(21) and §11.901(11), and the carrier will provide them not later than the 30th day after the request. §3.3703(a)(21)(a) and §11.901(11)(a). |
| A contract can refer to information not actually included in the contract only if the source of the information is clearly identified and incorporated by reference into the contract. If it is information within the control of the carrier, the carrier must provide it to the contracting physician or provider no later than the time of execution of the contract. If it is not, such as a state Medicaid fee schedule, the contract must describe the source of the information and provide a means by which it can be readily accessed by the contracting physician or provider. §3.3703(a)(20)(B) and §11.901(10)(B). |
Not specified. However, nothing would preclude the inclusion of this specific language in the contract. |
| The information must explain all methodologies that will be used to process and pay claims submitted in accordance with the contract, including a fee schedule, any non-standard coding methodologies, bundling processes, downcoding policies, and any other applicable policy or procedure used by the carrier in processing or paying claims under the contract. §3.3703(a)(20) and §11.901(10). |
The information must include any underlying bundling, recoding, or other payment process and fee schedules applicable to specific procedures that the physician or provider will receive under the contract. §3.3703(a)(21) and §11.901(11) |
| The fee schedule must include, if applicable, CPT, HCPCS, ICD-9-CM codes and modifiers. The fee schedule can cover all types of claims or only those that pertain to the range of health care services reasonably expected to be delivered by that type of contracting physician or provider on a routine basis. §3.3703(a)(20)(A)(i) and §11.901(10)(A)(i). In the latter case, the carrier must arrange for access to this information for any covered services that the physician or health care provider intends to provide to an insured and any other information required by this paragraph, including non-standard coding methodologies, bundling processes, and downcoding policies, that pertain to the service for which the fee schedule is being requested if that information has not previously been provided. §3.3703(a)(20)(A)(i)(II) and §11.901(10)(A)(i)(II). |
Not specified. However, nothing would preclude the inclusion of this specific language in the contract. |
| Bundling processes must include, if applicable, global service periods, comprehensive codes, component codes and mutually exclusive procedures. §3.3703(a)(20)(A)(iii) and §11.901(10)(A)(iii). |
Not specified. However, nothing would preclude the inclusion of this specific language in the contract. |
| Downcoding policies must include, if applicable, evaluation and management criteria. §3.3703(a)(20)(A)(iv) and §11.901(10)(A)(iv). |
Not specified. However, nothing would preclude the inclusion of this specific language in the contract. |
| Information provided must include any addenda, schedules, exhibits or policies used by the carrier in processing or payment of claims submitted by or on behalf of the preferred provider that are necessary to provide a reasonable understanding of the information. §3.3703(a)(20)(A)(vi) and §11.901(10)(A)(vi). |
Not specified. However, nothing would preclude the inclusion of this specific language in the contract. |
| Information provided must include, if applicable, non-standard coding methodologies, §3.3703(a)(20)(A)(ii) and §11.901(10)(A)(ii), as well as a description of any other applicable policy or procedure the carrier may use that affects the processing or payment of specific claims submitted by or on behalf of the preferred provider, including recoupment. §3.3703(a)(20)(A)(v) and §11.901(10)(A)(v). |
Not specified. However, nothing would preclude the inclusion of this specific language in the contract. |
| Information must include any information required to be provided by the carrier to the preferred provider through the contract under any applicable statutes and rules pertaining to prompt payment of clean claims. §3.3703(a)(20)(A)(vii) and §11.901(10)(A)(vii). |
Not specified. However, proposed §3.3703(a)(10) & §11.901(7) as well as the existing prompt pay rules already clarify that all HMO physician and provider contracts and all preferred provider contracts must comply with these provisions. |
| The proposed paragraph applies to contracts entered into or renewed on or after the effective date of the rule. In cases of contracts that have not been amended or renewed prior to the effective date of the rule, and if the requirements are not contained in the contract, the carrier must make the information available to any contracting provider within 90 days of the paragraph's effective date . §3.3703(a)(20)(F) and §11.901(10)(F). |
The proposed paragraph applies only to contracts entered into or renewed on or after the effective date of the paragraph. §3.3703(a)(21)(E) and §11.901(11)(E). |
| The carrier must also provide all other information affecting claim payment processing such as recoupment practices and any materials necessary to understand the information provided pursuant to the rule, such as exhibits or carrier internal policies or procedures. §3.3703(a)(20)(A)(vi) and §11.901(10)(A)(vi). |
Not specified but the preamble states that a carrier must disclose information "concerning fees and coding that relates to or affects the claim payment process and the payment to be made to a [preferred provider or contracting physician or provider] for services that [the preferred provider or contracting physician or provider] has contracted to provide on behalf of an [insurer or HMO]." |
| The carrier must provide notice of material changes to the information including required coding guidelines and fee schedule not later than the 60th day before the effective date of the change. §3.3703(a)(20)(A) and §11.901(10)(A). As noted above, §3.3703(a)(20)(F) and §11.901(10)(F) extend the right to obtain information affecting the payment of claims to any provider once the rules are in effect. The required notice of any material changes within 60 days in the proposed rules is also extended to these providers. |
The carrier will provide notice of material changes to the coding guidelines and fee schedule not later than the 60th day before the effective date and will not make retroactive revisions to the coding guidelines and fee schedule. §3.3703(a)(21)(B) and §11.901(11)(B). |
| A carrier is not required to violate copyright or licensing agreements. The carrier may supply a summary of the information instead of the protected information but it must meet the same requirements, including the "reasonable person" standard. §3.3703(a)(20)(C) & §11.901(10)(C). |
A carrier is not required to violate copyright or other law. The carrier shall, on request of a physician or provider, provide the name, edition, and model version of the software that the insurer uses to determine bundling and unbundling of claims. §3.3703(a)(21)(D) & §11.901(11)(D). |
| A physician or provider can only use or disclose the information for the purpose of practice management, billing activities and business operations. §3.3703(a)(20)(G)(i) & §11.901(10)(G)(i). |
A physician or provider can only use or disclose the information for the purpose of practice management, billing activities and business operations. §3.3703(a)(21)(C) & §11.901(11)(C). |
| A physician or provider cannot knowingly submit a claim with coding that does not represent the level of service actually provided. §3.3703(a)(20)(G)(ii) & §11.901(10)(G)(ii). |
Not in paragraph, but this type of activity would be precluded by statutes and regulations relating to fraudulent billing practices. |
| A physician or provider may not rely upon information provided about a service as a verification that an insured is covered for that service under the terms of the insured's policy or certificate. §3.3703(a)(20)(G)(iii) & §11.901(10)(G)(iii). |
Not specified but the preamble states that "Information provided pursuant to these amendments about a particular service does not constitute a verification that the service that [the preferred provider or contracting physician or provider] has provided or proposes to provide is a covered benefit for a particular insured." |
| The requirements may not be amended or waived by contract. §3.3703(a) & §11.901. |
The requirements may not be waived or altered by contract. §3.3703(a) & §11.901. |
Texas Department of Insurance
