Current through Reg. 50, No. 13; March 28, 2025
(a) Payors must
submit monthly data files according to the following schedule:
(1) January data must be submitted no later
than March 7 of that year;
(2)
February data must be submitted no later than April 7 of that year;
(3) March data must be submitted no later
than May 7 of that year;
(4) April
data must be submitted no later than June 7 of that year;
(5) May data must be submitted no later than
July 7 of that year;
(6) June data
must be submitted no later than August 7 of that year;
(7) July data must be submitted no later than
September 7 of that year;
(8)
August data must be submitted no later than October 7 of that year;
(9) September data must be submitted no later
than November 7 of that year;
(10)
October data must be submitted no later than December 7 of that year;
(11) November data must be submitted no later
than January 7 of the following year; and
(12) December data must be submitted no later
than February 7 of the following year.
(b) Payors must submit test data files as
provided in the submission guide:
(1) after
registering for the first time with the Center as a payor that is subject to
reporting under this subchapter;
(2) after a merger, acquisition, divestiture,
or other change of ownership that requires an update to a payor's registration;
and
(3) before the effective date
of a new version of the Texas APCD CDL, consistent with §
21.5403 of this title (relating to
Texas APCD Common Data Layout and Submission Guide) that contains additional
data elements.
(c) A
payor may request a temporary exception or extension of time from complying
with one or more requirements of this subchapter or the Texas APCD CDL by
submitting a request to the Center, as provided in the submission guide posted
on https://go.uth.edu/DSG, no less than 15 calendar days before the date the
payor is otherwise required to comply with the requirement.
(1) The Center may grant an exception or
extension for good cause for not more than 12 consecutive months, if the payor
demonstrates that compliance would impose an unreasonable cost or burden
relative to the public value that would be gained from full compliance. An
exception may not be granted from any requirement contained in Insurance Code
Chapter 38, Subchapter I, concerning Texas All Payor Claims Database.
(2) A payor that registers with the Center
and demonstrates that it has fewer than 10,000 covered lives in plans subject
to this subchapter qualifies for an extension under this subsection for the
payor's first required reporting. The Center may grant an extension for new
payors for not more than 12 consecutive months.
(3) The Center may request additional
information from a payor in order to make a determination on an exception or
extension request. A request for additional information must be in writing and
must be submitted to the payor within 14 calendar days from the date the
payor's request is received. The deadline for data submission is tolled while
the Center makes a determination on an exception or extension
request.
(4) A request for an
exception or extension that is neither accepted nor rejected by the Center
within 14 calendar days from the date the payor's request is received will be
deemed accepted. If the Center has requested additional information from a
payor under paragraph (3) of this subsection, the 14-day timeline begins the
day after the payor submits the information. If a payor does not respond to or
fails to provide the Center with additional information as requested, the
payor's request for an exception or extension may be deemed withdrawn by the
Center at the end of the 14-day period.
(5) In order to assist TDI's oversight and
enforcement required by Insurance Code §
38.409, the Center
will provide TDI on or before July 1st of each year for the prior year:
(A) the names of payors that timely reported
data;
(B) information about payors
that did not report data and either requested an exception or extension that
the Center did not grant or otherwise failed to demonstrate an exemption from
reporting under this subchapter;
(C) information about payors that obtained
exceptions and extensions, including the nature of the exceptions and amount of
extensions granted;
(D) information
about payors that failed to report timely without obtaining an exception or
extension, including the filing due dates and the dates of actual filing;
and
(E) information about payors
that otherwise failed to materially comply with the requirements of Insurance
Code Chapter 38, Subchapter I, or this subchapter.
(d) The Center will assess each
data submission to ensure the data files are complete, accurate, and correctly
formatted.
(e) The Center will
communicate receipt of data within 14 calendar days, inform the payor of the
data quality assessments, and specify any required data corrections and
resubmissions.
(f) Payors must
provide reasonable follow-up information requested by the Center, limited to
ensuring that the payor submitted complete and correct information.
(g) Upon receipt of a resubmission request,
the payor must respond within 14 calendar days with either a revised and
corrected data file or an extension request.
(h) If a payor fails to submit required data
or fails to correct submissions rejected due to errors or omissions, the Center
will provide written notice to the payor. If the payor fails to provide the
required information within 30 calendar days following receipt of the written
notice, the Center will notify the department of the failure to report. The
department may pursue compliance with this subchapter via any appropriate
corrective action, sanction, or penalty that is within the authority of the
department.
(i) The reporting
schedule under subsection (a) of this section applies to monthly data
submissions due on or after March 7, 2025, containing data for months beginning
January 1, 2025. Payors must submit data for November and December 2024 at the
same time as January 2025 data.
