The program reimburses providers for covered services for clients. Payment may be made only after the delivery of the service, with the exception of meals, transportation, lodging, and insurance premium payments. Excluding allowable insurance or health maintenance organization co-payments, the client or client's family must not be billed for the service or be required to make a preadmission or pretreatment payment or deposit. Providers may not request or accept payment from the client or the client's family for completing any program forms. Providers must agree to accept established fees as payment in full. The program may negotiate reimbursement alternatives to reduce costs through requests for proposals, contract purchases, or incentive programs.
  (1) Payment or denial of claims. Payments made on behalf of a client will be for claims received by the program or its payment contractor within 95 days of the date of service, within 95 days from the date of discharge from inpatient hospital and inpatient rehabilitation facilities, within 95 days from the date the client's eligibility is added to program automation systems, or within the submission deadlines listed in paragraphs (1)(B)(ii) and (2) of this section, whichever is later. Claims for family support services, drug co-payments, and insurance premium payment assistance must be submitted within 95 days of the last day of the month in which services were provided. If the 95th day for receipt of a claim falls on a weekend or holiday, the deadline shall be extended to the next business day following the weekend or holiday. The program must process the claims of eligible providers within a period not to exceed 30 days of receipt and determination of proper evidence establishing the validity of claims, invoices, and statements. In cases where the program determines that a basis exists for further review, suspension, or other irregularity, extended processing time may be required. The manager of the department unit having responsibility for oversight of the program or his or her designee(s) may waive the filing deadlines according to the conditions and circumstances specified in paragraphs (3) - (5) of this section. A claim must be processed and paid within 24 months of the date of service. Claims received by the program or its payment contractor after this time frame will not be considered for payment by the program.
    (A) Claims will be paid if submitted on claim forms approved by the program (including electronic claims submission systems) and if the required documentation is received with the claim.
    (B) Denied claims are claims which are incomplete, submitted on the wrong form, lack necessary documentation, contain inaccurate information, fail to meet the filing deadline, are for ineligible persons, services, or providers, or are for clients who do not qualify for the health care benefit claimed.
      (i) Corrected claims must be submitted on claim forms approved by the program along with required documentation within the filing deadline established in clause (ii) of this subparagraph.
      (ii) Denied claims may be corrected and resubmitted for reconsideration if received within 120 days of the last denial or adjustment to the original claim. If the results of the reconsideration process are unsatisfactory, denied claims may be appealed according to §38.13 of this title (relating to Right of Appeal).
  (2) Claims involving health insurance coverage, CHIP, or Medicaid. Any health insurance that provides coverage to the client must be utilized before the program can pay for services. Providers must file a claim with health insurance, CHIP, or Medicaid prior to submitting any claim to the program for payment. Claims with health insurance must be received by the program within 95 days of the date of disposition by the other third party resource, and no later than 365 days from the date of service. The program will consider claims received for the first time after the 365-day deadline if a third party resource recoups a payment made in error; however, the claim must be received by the program within 95 days from the third party's disposition. The program may pay for covered health care benefits during CHIP or other health insurance enrollment waiting periods. During these periods, providers may file claims directly with the program without evidence of denial by the other insurer.
    (A) Health insurance denial. If a claim is denied by health insurance, the provider may bill the program if the letter of denial also is submitted with the claim form. If the denial letter is not available, the provider must include on the claim form the date the claim was filed with the insurance company, the reason for the denial, name and telephone number of the insurance company, the policy number, the name of the policy holder and identification numbers for each policy covering the client, the name of the insurance company employee who provided the information on the denial of benefits, and the date of the contact.
    (B) Explanation of benefits (EOB). The health insurance EOB must accompany any claim sent to the program for payment if available. If the EOB is unavailable, the provider must include on the claim form the name and telephone number of the insurance company, the amount paid, the policy number, and name of the insured for each policy covering the client.
    (C) Late filing. Claims denied by health insurance on the basis of late filing will not be considered for payment by the program.
    (D) Deductibles and coinsurance. If the client has other third party coverage, the program may pay a deductible or coinsurance for the client as long as the total amount paid to the provider does not exceed the allowable amount for the covered service and conforms with current program policies regarding third party resources, deductible, and coinsurance.
  (3) Exceptions to the claim receipt or correction and resubmission deadlines. The manager of the department unit having responsibility for oversight of the program or his or her designee(s) will consider a provider's request for an exception to the claim receipt or correction and resubmission deadlines provided in paragraphs (1) and (2) of this section if the delay in claim receipt or correction and resubmission is due to one of the following reasons:
    (A) damage to or destruction of the provider's business office or records by a catastrophic event or natural disaster including, but not limited to fire, flood, hurricane, or earthquake that substantially interferes with normal business operations of the provider;
    (B) damage to or destruction of the provider's business office or records caused by the intentional acts of an employee or agent of the provider only if:
      (i) the employment or agency relationship has been terminated; and
      (ii) the provider has filed criminal charges against the former employee or agent;
    (C) delay, error, or constraint imposed by the program in the eligibility determination of a client or in claims processing, or delay due to erroneous written information from the program or its designee, or another state agency; or
    (D) delay due to problems with the provider's electronic claim system or other documented and verifiable problems with claims submission.
  (4) Exception requests. Providers requesting an exception under paragraph (3)(A) - (D) of this section must submit an affidavit or statement from a person with personal knowledge of the facts detailing the exception being requested, the cause for the delay, verification that the delay was not caused by neglect, indifference, or lack of diligence of the provider or the provider's employee or agent, and any additional information requested by the program. All claims for which the provider requests an exception must accompany the request. The program will consider only the claim(s) attached to the request, and the exception request must be received by the program within 18 months from the date of service.
    (A) For exception requests under paragraph (3)(A) of this section, the provider must submit:
      (i) independent evidence of insurable loss;
      (ii) medical, accident, or death records; or
      (iii) a police or fire department report substantiating the damage or destruction.
    (B) For exception requests under paragraph (3)(B) of this section, the provider must submit a police or fire report substantiating the damage or destruction caused by the former employee or agent's criminal activity.
    (C) For exception requests under paragraph (3)(C) of this section, the provider must submit written documentation from the program, its designee, or another state agency containing the erroneous information or explanation of the delay, error, or constraint.
    (D) For exception requests under paragraph (3)(D) of this section, the provider must submit the following:
      (i) a written repair statement or invoice, a computer or modem generated error report indicating attempts to transmit the data failed for reasons outside the control of the provider, or an explanation for the system implementation or other claim submission problems;
Cont'd...
(ii) a detailed, written statement concerning the relationship of the computer problem to delayed claims submission; and
      (iii) the reason alternative billing procedures were not initiated after the problem(s) became known.
  (5) Other exceptions to claims receipt or correction and resubmission deadlines. The manager of the department unit having responsibility for oversight of the program or his or her designee(s) will consider a provider's request for an exception to claims receipt or correction and resubmission deadlines due to delays caused by entities other than the provider and the program under the following circumstances:
    (A) all claims that are to be considered for the same exception must accompany the request;
    (B) only the claim(s) that are attached to the request will be considered;
    (C) the exception request has been received by the program within 18 months from the date of service; and
    (D) the exception request includes an affidavit or statement from a representative of an original payer, a third party payer, or a person who has personal knowledge of the facts, stating the exception being requested, documenting the cause for the delay, and providing verification that the delay was caused by another entity and not the neglect, indifference, or lack of diligence of the provider or the provider's employee(s) or agent(s).
  (6) Program fees. The program establishes fees and payment methodologies for covered medical, dental, and other services based upon appropriated funds. All fees are subject to reductions or limitations authorized by §38.16(b)(2)(E) of this title (relating to Procedures to Address Program Budget Alignment).
  (7) Required documentation. The program may require documentation of the delivery of goods and services from the provider.
  (8) Overpayments.
    (A) Overpayments are payments made by the program due to the following:
      (i) duplicate billings;
      (ii) services paid by public or private insurance or other resources;
      (iii) payments made for services not delivered;
      (iv) services disallowed by the CSHCN Services Program; and
      (v) subrogation.
    (B) Overpayments made to providers must be reimbursed to the department by lump sum payment or, at the department's discretion, offset against current payments due to the provider for services to other clients. The department also shall require reimbursement of overpayments from any person or persons who have a legal obligation to support the client and have received payments from a payer of other benefits. Providers, clients, and person(s) responsible for clients may appeal proposed recoupment of overpayments by the department according to §38.13 of this title.

Source Note: The provisions of this §351.10 adopted to be effective July 1, 2001, 26 TexReg 2979; amended to be effective October 11, 2001, 26 TexReg 7870; amended to be effective March 27, 2003, 28 TexReg 2523; amended to be effective January 1, 2004, 28 TexReg 11268; amended to be effective August 1, 2004, 29 TexReg 7103; amended to be effective June 1, 2006, 31 TexReg 4200; amended to be effective October 3, 2010, 35 TexReg 8921; amended to be effective April 21, 2013, 38 TexReg 2362; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 982