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Life, Health & Licensing Program. Jennifer Ahrens Senior Associate Commissioner Provider Ombudsman [email protected] 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

Life, Health & Licensing Program

Jennifer Ahrens

Senior Associate Commissioner

Provider Ombudsman

[email protected]

512-305-7342

tdi jurisdiction
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)
prompt pay statutes
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
new underpayment calculation
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
recent rule activity
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
technical advisory committee on claims processing
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
reference materials
Reference Materials
  • TDI Web site
    • Physician/Provider Resource page
    • Rules page
    • FAQs page
    • Physician/Provider Complaint form
physician provider resource page www tdi state tx us consumer doctors html
Physician/Provider Resource Pagewww.tdi.state.tx.us/consumer/doctors.html
physician provider complaint form
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 ([email protected])

workers compensation
Workers’ Compensation
  • HB 1006 - UR Licensing
  • HB 2004 - Specialization
sb 1731
SB 1731
  • Consumer Guide to Health Care
  • Written disclosures from providers and carriers
  • Data collection:
    • Reimbursement Rates
    • Annual Reports
hb 522
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.
slide15
Helpful Resources
  • TDI Website:

www.tdi.state.tx.us

  • Life, Health, and Licensing Main Line:

512-305-7342

  • Life/Health Division:

[email protected]

  • Health & Workers’ Compensation Network Certification and Quality Assurance Division

[email protected]

  • 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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