Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES
Subchapter T - MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES
Section 3.3315 - Standards for Claims Payment
Universal Citation: 28 TX Admin Code § 3.3315
Current through Reg. 50, No. 13; March 28, 2025
(a) Every issuer of Medicare supplement policies, contracts, certificates, or coverage for delivery in this state shall comply with the Social Security Act, §1882(c)(3) (as enacted by the Omnibus Budget Reconciliation Act of 1987 (OBRA) 1987, §4081(b)(2)(C) (Public Law Number 100-203), by:
(1) accepting a notice from a Medicare
carrier on duly assigned claims submitted by participating physicians and
suppliers as a claim for benefits in place of any other claim form otherwise
required and making a payment determination on the basis of the information
contained in that notice;
(2)
notifying the participating physician or supplier and the beneficiary of the
payment determination;
(3) paying
the participating physician or supplier directly;
(4) furnishing, at the time of enrollment,
each enrollee with a card listing the policy name, number, and a central
mailing address to which notices from a Medicare carrier may be sent;
(5) paying user fees for claim notices that
are transmitted electronically or otherwise; and
(6) providing to the secretary of health and
human services, at least annually, a central mailing address to which all
claims may be sent by Medicare carriers.
(b) Compliance with the requirements set forth in subsection (a) of this section shall be certified on the Medicare supplement insurance experience reporting form.
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