Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 21 - TRADE PRACTICES
Subchapter T - SUBMISSION OF CLEAN CLAIMS
Section 21.2818 - Overpayment of Claims

Universal Citation: 28 TX Admin Code § 21.2818

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

(a) An MCC may recover a refund due to overpayment or completion of an audit if:

(1) the MCC notifies the physician or the provider of the overpayment not later than the 180th day after the date of receipt of the overpayment; or

(2) the MCC notifies the physician or the provider of the completion of an audit under § 21.2809 of this title (relating to Audit Procedures).

(b) Notification under subsection (a) of this section must:

(1) be in written form and include the specific claims and amounts for which a refund is due, and for each claim, the basis and specific reasons for the request for refund;

(2) include notice of the physician's or provider's right to appeal; and

(3) describe the methods by which the MCC intends to recover the refund.

(c) A physician or a provider may appeal a request for refund by providing written notice of disagreement with the refund request not later than 45 days after receipt of notice described in subsection (a) of this section. On receipt of written notice under this subsection, the MCC must begin the appeal process provided for in the MCC's contract with the physician or the provider.

(d) An MCC may not recover a refund under this section until:

(1) for overpayments, the later of the 45th day after notification under subsection (a)(1) of this section or the exhaustion of any physician or provider appeal rights under subsection (c) of this section, where the physician or the provider has not made arrangements for payment with an MCC; or

(2) for audits, the later of the 30th day after notification under subsection (a)(2) of this section or the exhaustion of any physician or provider appeal rights under subsection (c) of this section, where the physician or the provider has not made arrangements for payment with an MCC.

(e) If an MCC is a secondary payor and pays a portion of a claim that should have been paid by the MCC that is the primary payor, the secondary payor may only recover overpayment from the MCC that is primarily responsible for that amount. If the portion of the claim overpaid by the secondary payor was also paid by the primary payor, the secondary payor may recover the amount of overpayment from the physician or the provider that received the payment under the procedures set out in this section.

(f) Subsections (a) - (e) of this section do not affect an MCC's ability to recover an overpayment in the case of fraud or a material misrepresentation by a physician or a provider.

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