Texas Register, Volume 38, Number 46, Pages 8023-8312, November 15, 2013 Page: 8,124

                                
(d) An MCC or an MCC's [HM    or preferred  v dercarrier
er an HMOs er preferred provider carrier's] clearinghouse that receives
an electronic clean claim is subject to the requirements of this subchap-
ter regardless of whether the claim is submitted together with, or in a
batch submission with, a claim that is deficient.
21.2808. Effect of Filing a Deficient Claim.
If an MCC [14M     r preferred prvider arier] determines that a
submitted claim is [to be] deficient, the MCC must [HMO or preferred
provider easier shall] notify the preferred provider submitting the
claim that the claim is deficient within 45 calendar days of the MCC's
[HMOs or preferred provider barriers] receipt of the nonelectronic
claim, or within 30 days of receipt of an electronic claim. If an
MCC [MO       r preferred provider carter] determines that a [an
electronically submitted] claim for a prescription benefit is [to be]
deficient, the MCC must [HMO or preferred provider earlier shall]
notify the provider that the claim is deficient within 21 calendar days
of the MCC's [HMO's or preferred provider career's] receipt of the
nonelectronic claim, or within 18 days of receipt of an electronic
claim.
21.2809. Audit Procedures.
(a) Notice and payment required. If an MCC [HMO er pre-
ferred pr-vider earier] is unable to pay or deny a clean claim, in whole
or in part, within the applicable statutory claims payment period speci-
fied in 21.2802 [21.280t2(28)] of this title (relating to Definitions) and
intends to audit the claim to determine whether the claim is payable,
the MCC must [4MO or preferred provider carrier shal] notify the
preferred provider that the claim is being audited and pay 100 percent
[100%] of the contracted rate within the applicable statutory claims
payment period.
(b) Failure to provide notice and payment. An MCC [HMO or
referred provider carrier] that fails to provide notice [notification] of
the decision to audit the claim and pay 100 percent [400%] of the ap-
plicable contracted rate subject to copayments and deductibles within
the applicable statutory claims payment period, or, if applicable, the
extended periods allowed for by 21.2804(c) of this title (relating to
Requests for Additional Information from Treating Preferred Provider)
or 21.2819(c) of this title (relating to Catastrophic Event), may not
make use of the audit procedures set forth in this section. A preferred
provider that receives less than 100 percent [t400%] of the contracted
rate [in conjunction] with a notice of intent to audit has received an
underpayment and must notify the MCC [HMO or prefeed prvider
carrier] within 270 [80] days in compliance [aeeordanee] with the pro-
visions of 21.2815(f)(2) [[21.2815(e ]2)]t of this title (relating to Fail-
ure to Meet the Statutory Claims Payment Period) to qualify to receive
a penalty for the underpaid amount.
(c) [(b)] Explanation of payment. The MCC must [HIMO or
preferred provider carrier shall] clearly indicate on the explanation of
payment that the claim is being audited and that the preferred provider
is being paid 100 percent [t400%] of the contracted rate, subject to com-
pletion of the audit. A nonelectronic [paper] explanation of payment
complies with this requirement if the notice of the audit is clearly and
prominently identified.
(d) [(c-)] Audit deadline and requirements. The MCC must
[HMO or preferred provider carrier shall] complete the audit within
180 calendar days from receipt of the clean claim. The HMO or pre-
ferred provider carrier must [shall] provide written notice [notification]
of the results of the audit. The MCC must include in the notice [shall ki-
chude] a listing of the specific claims paid and not paid under [pursuant
to] the audit, as well as a listing of specific claims and amounts for
which a refund is due and, for each claim, the basis and specific rea-
sons for requesting a refund. An MCC [HMO er preferred provider
carrier] seeking recovery of any refund under this section must [shall]

comply with the procedures set forth in 21.2818 of this title (relating
to Overpayment of Claims).
(e) [(d)] Requests for information. An MCC [14MO or pre-
ferred provider earlier] may recover the total amount paid on the claim
under subsection (a) of this section if a physician or a provider fails to
timely provide additional information requested under [pursuant to] the
requirements of Insurance Code 1301.105 [Article 3 70-3C 3A(g)]
or 843.340(c). Section 21.2816 of this title (relating to Date of Re-
ceipt) applies to the submission and receipt of a request for information
under this subsection.
(f) [(e)] Opportunity for appeal. Prior to seeking a refund for a
payment made under this section, an MCC [HMO r preferred provider
carrier] must provide a preferred provider with the opportunity to ap-
peal the request for a refund in compliance [accordance] with 21.2818
of this title. An MCC [H4MOr preferred provider arrier] may not seek
to recover the refund until all of the preferred provider's internal appeal
rights under 21.2818 of this title have been exhausted.
(g)  [(f)] No admission of liability. Payments made under
[pursuant to] this section on a clean claim are not an admission that
the MCC [4      r pre erred provider carrier] acknowledges liability
on that claim.
21.2811. Disclosure of Processing Procedures.
(a) In contracts with preferred providers, or in the physician
or the provider manual or other document that sets forth the procedure
for filing claims, or by any other method mutually agreed upon by the
contracting parties, an MCC [HMO r preferred provider carier] must
disclose to its preferred providers:
(1) (No change.)
(2) the telephone number to [at] which preferred providers'
questions and concerns regarding claims may be directed;
(3) any entity, along with its address, including physical
address and telephone number, to which the MCC [HMO or preferred
vproAider carrier] has delegated claim payment functions[, if applica-
ble]; and
(4) the mailing address, [and] physical address, and tele-
phone number of any separate claims processing centers for specific
types of services[, if applicable].
(b) An MCC must [HMO r preferred rider carrier shall]
provide no less than 60 calendar days prior written notice of any
changes of address for submission of claims, and of any changes
of delegation of claims payment functions, to all affected preferred
providers [with whom the 44M  or prefered poder carrier has
contracts].
21.2812. Denial of Clean Claim Prohibited for Change of Address.
After a change of claims payment address or a change in delegation
of claims payment functions, an MCC [HMO or pref-erred pider
carrier] may not premise the denial of a clean claim upon a preferred
provider's failure to file a [clean] claim within the claim [claims] filing
deadline set forth in 21.2806 of this title (relating to Claim [Glaims]
Filing Deadline), unless the MCC has given timely written notice as
required by 21.281 1(b) of this title (relating to Disclosure of Process-
ing Procedures) [has been given].
21.2813. Requirements Applicable to Other Contracting Entities.
Any contract or delegation agreement between an MCC [HMO r pre-
ferred pro-ider carrier] and an entity that processes or pays claims, ob-
tains the services of physicians and providers to provide health care ser-
vices, or issues verifications or preauthorizations may not [e construed
to] limit the MCC's [HMO'0 s or preferred provider carrier's] authority

38 TexReg 8124  November 15, 2013  Texas Register