Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 21 - TRADE PRACTICES
Subchapter T - SUBMISSION OF CLEAN CLAIMS
Section 21.2804 - Requests for Additional Information from Treating Preferred Provider

Universal Citation: 28 TX Admin Code § 21.2804

Current through Reg. 50, No. 13; March 28, 2025

(a) If necessary to determine whether a claim is payable, an MCC may, within 30 days of receipt of a clean claim, request additional information from the treating preferred provider. The time to request additional information may be extended as allowed by § 21.2819(c) of this title (relating to Catastrophic Event). An MCC may make only one request to the submitting treating preferred provider for information under this section.

(b) A request for information under this section must:

(1) be in writing;

(2) be specific to the claim or the claim's related episode of care;

(3) describe with specificity the clinical and other information to be included in the response;

(4) be relevant and necessary for the resolution of the claim; and

(5) be for information that is contained in or in the process of being incorporated into the patient's medical or billing record maintained by the preferred provider.

(c) An MCC that requests information under this section must determine whether the claim is payable and pay or deny the claim, or audit the claim in compliance with § 21.2809 of this title (relating to Audit Procedures), on or before the later of:

(1) the 15th day after the date the MCC receives the requested information as required under subsection (e) of this section;

(2) the 15th day after the date the MCC receives a response under subsection (d) of this section; or

(3) the latest date for determining whether the claim is payable under § 21.2807 of this title (relating to Effect of Filing a Clean Claim).

(d) If a preferred provider does not possess the requested information, the preferred provider must submit a written response indicating that the preferred provider does not possess the requested information in order to resume the claims payment period as described in subsection (c) of this section.

(e) An MCC must require the preferred provider responding to a request made under this section to either attach a copy of the request to the response or include with the response the name of the patient, the patient identification number, the claim number as provided by the MCC, the date of service, and the name of the treating preferred provider. If the MCC submitted the request for additional information electronically in compliance with federal requirements concerning electronic transactions, the treating preferred provider must submit the response in compliance with those requirements. To resume the claims payment period as described in subsection (c) of this section, the treating preferred provider must deliver the requested information in compliance with this subsection.

(f) Receipt of a request or a response to a request under this section is subject to the provisions of § 21.2816 of this title (relating to Date of Receipt).

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