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Life, Health & Licensing Program

Life, Health & Licensing Program. Jennifer Ahrens Senior Associate Commissioner Provider Ombudsman jennifer.ahrens@tdi.state.tx.us 512-305-7342. TDI Jurisdiction. Pursuant to Tex. Ins. Code § 31.002, TDI must: Regulate the business of insurance in Texas

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Life, Health & Licensing Program

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  1. Life, Health & Licensing Program Jennifer Ahrens Senior Associate Commissioner Provider Ombudsman jennifer.ahrens@tdi.state.tx.us 512-305-7342

  2. TDI Jurisdiction • Pursuant to Tex. Ins. Code § 31.002, TDI must: • Regulate the business of insurance in Texas • Ensure the Insurance Code and other laws regarding insurance and insurance companies are executed • Texas Prompt Pay Statutes Apply to: • HMOs • Insured PPO Plans • Texas Prompt Pay Statutes Do Not Apply to: • Self-funded ERISA plans • Indemnity plans (even if insured) • Medicaid, Medicare, Med Supp • Government and school plans (except HMO or fully insured PPO plans) • Children’s Health Insurance Program (CHIP)

  3. Prompt Pay Statutes • HMO prompt payment provisions • Tex. Ins. Code §§ 843.336 – 843.353 • PPO prompt payment provisions • Tex. Ins. Code §§ 1301.101 – 1301.138

  4. New Underpayment Calculation • SB 1884 – Effective September 1, 2007 • Paid on or before the 45th day after the end of the applicable statutory claim period: • Billed charges = $1,500 • Amount of contracted rate = $1,000 • Patient’s cost share = 0 • Amount paid timely = $800 • Amount underpaid on contracted rate = $200 • $200 / $1,000 (= 20%) X $1,500 = • $300 (the “underpaid amount”) • Multiply by 50% • $150 = penalty payment

  5. Recent Rule Activity • 28 TAC §21.2802 and §21.2803 • CMS-1500 (08/05) and UB-04 CMS-1450 • NPI (Contingency Plans) http://www.tdi.state.tx.us/rules/documents/212802-212803.pdf • Underpayment Calculation rule to be published for comment soon

  6. Technical Advisory Committee on Claims Processing • 2005 & 2006 meetings • Rules to implement new legislation • Prompt pay data summary • Coding and bundling standards • National provider identifiers • CMS claim form revisions • Silent/rental PPOs • Standard contract language • http://www.tdi.state.tx.us/consumer/ccwg.html

  7. Reference Materials • TDI Web site • Physician/Provider Resource page • Rules page • FAQs page • Physician/Provider Complaint form

  8. TDI Web Site:www.tdi.state.tx.us

  9. Physician/Provider Resource Pagewww.tdi.state.tx.us/consumer/doctors.html

  10. Physician/Provider Complaint Form On-line (https://wwwapps.tdi.state.tx.us/inter/perlroot/consumer/prcompform/prcompform.html) Phone (1-800-252-3439)/Fax (512-475-1771)/Email (ConsumerProtection@tdi.state.tx.us)

  11. Workers’ Compensation • HB 1006 - UR Licensing • HB 2004 - Specialization

  12. SB 1731 • Consumer Guide to Health Care • Written disclosures from providers and carriers • Data collection: • Reimbursement Rates • Annual Reports

  13. HB 522 • Health Care ID Card Pilot Program • ID cards containing standardized electronic data • health benefit plan coverage • plan limits • deductibles • covered services • payor and enrollee contact information.

  14. Helpful Resources • TDI Website: www.tdi.state.tx.us • Life, Health, and Licensing Main Line: 512-305-7342 • Life/Health Division: LifeHealth@tdi.state.tx.us • Health & Workers’ Compensation Network Certification and Quality Assurance Division HWCN@tdi.state.tx.us • The Texas Health Options Website: www.TexasHealthOptions.com • TDI Proposed/Adopted Rules: www.tdi.state.tx.us/commish/parules.html • Texas Legislature Website: www.capitol.state.tx.us

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