Texas Administrative Code

When used in this chapter, the following words or terms have the following meanings unless the context indicates otherwise: (1) Marker. Markers are informational aluminum signs erected by or with the permission of the Texas Historical Commission. (2) Medallion. Medallions are mar…

(a) All policies and procedures relating to museum services shall be determined by the Commission. (b) The Commission may establish a grant program to assist small history museums in the State of Texas. (1) The conditions of eligibility, procedures for consideration, and criteria…

(a) An MCC must submit to the department quarterly claims payment and related penalty and interest payment information, and information regarding complaints, in compliance with the requirements of this section. (b) The MCC must submit the report required by subsection (a) of this…

(a) An MCC, a physician, or a provider must notify the Texas Department of Insurance (TDI) if, due to a catastrophic event, it is unable to meet the deadlines in § 21.2804 of this title (relating to Requests for Additional Information from Treating Preferred Provider), § 21.2806 …

(a) An MCC may recover a refund due to overpayment or completion of an audit if: (1) the MCC notifies the physician or the provider of the overpayment not later than the 180th day after the date of receipt of the overpayment; or (2) the MCC notifies the physician or the provider …

Unless otherwise provided in this subchapter, contracts between MCCs and preferred providers may not include terms that: (1) extend the statutory or regulatory time frames; or (2) waive the preferred provider's right to recover reasonable attorney's fees and court costs under Ins…

(a) Claim submission deadline. A physician or a provider must submit a claim to an MCC not later than the 95th day after the date the physician or the provider delivers the medical care or health care services for which the claim is made. An MCC and a physician or a provider may …

(a) If an MCC requests additional information from a person other than the preferred provider who submitted the claim, the MCC must provide to the preferred provider who submitted the claim a notice containing the name of the physician, the provider, or the other entity from whic…

(a) If necessary to determine whether a claim is payable, an MCC may, within 30 days of receipt of a clean claim, request additional information from the treating preferred provider. The time to request additional information may be extended as allowed by § 21.2819 (c) of this ti…

(a) Filing a clean claim. A physician or a provider submits a clean claim by providing to an MCC or any other entity designated for receipt of claims under § 21.2811 of this title (related to Disclosure of Processing Procedures): (1) for nonelectronic claims other than dental cla…

The following words and terms when used in this subchapter have the following meanings unless the context clearly indicates otherwise: (1) Audit--A procedure authorized by and described in § 21.2809 of this title (relating to Audit Procedures) under which a managed care carrier (…

The purpose of this subchapter is to specify the definitions and procedures necessary to implement Insurance Code Chapters 843 and 1301 relating to clean claims and prompt payment of physician and provider claims. This subchapter applies to all nonelectronic and electronic claims…

(a) A health carrier that issues a health benefit plan to a bona fide association may refuse to provide coverage to all members, and dependents of members if dependent coverage is offered, of a bona fide association in accordance with the health carrier's underwriting standards a…

The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise. (1) Basic benefit--Health care service or coverage, which is included in the evidence of coverage, policy, or certificate, without additional …

Provisions of this subchapter addressing complaint record maintenance and presentation apply to all complaints of an insurer received on or after January 1, 1999. Notes 28 Tex. Admin. Code § 21.2507 The provisions of this §21.2507 adopted to be effective December 7, 1998, 23 TexR…

The complaint record shall be maintained on a calendar-year basis. All information items required to be maintained, including the number of complaints by line of insurance, function, reasons, disposition, complaint origin, and dates received and closed, shall be compiled not less…

(a) Recommended maintenance form. The recommended form for complaint record maintenance is available on TDI's website at www.tdi.texas.gov/forms . (b) Texas Department of Insurance Complaint Record Form. Attached Graphic Notes 28 Tex. Admin. Code § 21.2505 The provisions of this …

(a) Complaint record: general information. The complaint record provided for in this subchapter shall be maintained by all insurers. The complaint record is based on the Model Regulation for Complaint Records to be Maintained adopted by the National Association of Insurance Commi…

An insurer must maintain a complete record of all complaints which it has received during the preceding three years or since the date of its most recent financial examination by the commissioner of insurance, whichever time period is shorter, in substantial compliance with the pr…

The following words or phrases, as used in these sections, shall have the meanings placed opposite them unless the explicit wording of a section or part of a section shall otherwise direct. (1) Complainant--A person making or having made a complaint. (2) Complaint--Any written co…

(a) Template and instructions. Except as provided in § 21.2431 of this title (relating to Required Analyses for Quantitative and Nonquantitative Parity; Alternative Tools), an issuer must use the QTL template and associated technical instructions to: (1) provide the information r…

(a) Deadline for quantitative parity analyses. An issuer must complete the parity analyses of its quantitative treatment limitations (QTLs) required by this division for each existing plan not later than the 180th day after the effective date of this subchapter. (b) Phase-in for …

(a) QTL and NQTL templates. (1) For purposes of this division, "QTL template" is the template titled "Compliance Analysis for Quantitative Parity" and its associated technical instructions, available on TDI's website. (2) For purposes of this division, "NQTL template" is the temp…

(a) Reporting worksheet. An issuer must report the data required by this section within the "MH/SUD Parity Rule Division 2 Data Collection Reporting Form" template in the worksheet titled "Reimbursement Rates." (b) Categories of providers and billing codes. An issuer must report …

Within the "MH/SUD Parity Rule Division 2 Data Collection Reporting Form" template, in the worksheet titled "Claims and Utilization Review," for medical/surgical, MH/SUD, and for each of the classifications listed in § 21.2425 (c) of this title (relating to Claims and Utilization…

(a) Separate reporting. Within the "MH/SUD Parity Rule Division 2 Data Collection Reporting Form" template, in the worksheet titled "Claims and Utilization Review," an issuer must separately report claims and requests for utilization review for medical/surgical and MH/SUD. (b) IC…

(a) Identifying issuer information. For each data collection template an issuer provides to TDI under § 21.2423 of this title (relating to Collecting and Reporting Data), within the "MH/SUD Parity Rule Division 2 Data Collection Reporting Form" template, in the worksheet titled "…

(a) Requirement to collect and report data. An issuer must collect and report the data required by this division for each applicable health benefit plan using the data collection template titled "MH/SUD Parity Rule Division 2 Data Collection Reporting Form," consisting of multipl…

Annual reporting. The information and data an issuer must report as required by Division 2 of this subchapter are due annually. (1) Each reporting period is a calendar year. (2) The first reporting date for this subchapter is December 1, 2021, for data from January 1, 2020, throu…

(a) The annual water quality fee assessment is for the period from September 1 through August 31, and is based on the authorized permit or water right limits as of September 1 each year, as stated in § 21.3 (a) of this title (relating to Fee Assessment). (b) New or amended wastew…

(a) An advertisement in respect of the time within which claims are paid, the dollar amounts of claims paid, the number of claims paid, the number of persons insured under a particular policy or policies, or similar statistical information relating to an insurer or policy may not…

(a) An advertisement may not state or imply anything offering or tending to offer a good, service, or other guarantee or contractual right of pecuniary value outside of the express terms of the policy offered by the advertisement. (1) This subsection does not prohibit, in connect…

(a) An advertisement may not directly or indirectly unfairly disparage competitors, their policies, services, or business methods, and may not unfairly disparage or minimize competing methods of marketing insurance. (b) An advertisement may not contain statements that are untrue …

The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise. (1) Affiliation period--A period of time that under the terms of the coverage offered by an HMO, must expire before the coverage becomes effec…

Each issuer of a health benefit plan shall provide a certification of coverage in accordance with § 21.1103 of this title (relating to Timing of Issuance of Written Certificate of Creditable Coverage to an Individual) through § 21.1108 of this title (relating to Notification of C…

(a) Each issuer of a health benefit plan shall comply with the following: (1) For an individual who is a qualified beneficiary entitled to elect COBRA continuation coverage, a certificate of creditable coverage shall be provided at the time the individual would lose coverage unde…

(a) No advertisement may use the word "dividends" or similar words or illustrations in such a manner as to state or to imply that future dividends are guaranteed or certain to occur. (b) The word "dividends" includes every return of premium and payment to policyholders on a parti…

(a) Advertising file. Each insurer, domestic and foreign, doing an insurance business in Texas shall maintain at its home office or principal (executive) office, a complete file containing a specimen of every institutional advertisement, invitation to inquire advertisement, or in…

This division is not intended to conflict with or supersede and are to be interpreted when possible as not to conflict with any sections except as stated in this section currently in force or subsequently adopted in this state and including without intending any limitation those …

If any provision of this division or the application thereof to any person or circumstance is held invalid for any reason, the invalidity shall not affect the other provisions or any other application of this division which can be given effect without the invalid provisions or ap…

(a) An advertisement shall identify the discount health care program operator offering the discount health care program that is the subject of the advertisement. It is sufficient to state the full registered name of the discount health care program operator or an assumed name fil…

If a court of competent jurisdiction holds that any provision of this division is inconsistent with any statutes of this state, is unconstitutional, or is invalid for any reason, the remaining provisions of this division shall remain in effect. Notes 28 Tex. Admin. Code § 21.154 …

The meanings given to the provisions, terms, and words of this regulation are not to be limited to the common law meaning, which may have been given thereto, but are to be interpreted to accomplish the purpose of these sections in accordance with the provisions of Insurance Code …

The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise. (1) Actuarial assumptions--The value of a parameter, or other choice, having an impact on an estimate of a future cost or other actuarial item…

(a) An insurer shall not deny enrollment of a child who is the subject of a medical support order under the health coverage of the child's parent on the ground that the child: (1) has a preexisting condition; (2) was born out of wedlock; (3) is not claimed as a dependent on the p…

(a) If the insurer offers coverage of dependent children under the policy, enrollment of a child who is the subject of a medical support order in the health coverage shall be automatic for the first 31 days after receipt of a medical support order or notice of a medical support o…

(a) An insurer shall not cancel or refuse to renew coverage of a child entitled to enrollment or enrolled under this subchapter unless satisfactory written evidence is filed with the insurer by the parent or the employer demonstrating that: (1) the court order or administrative o…