Sec. 32.0424. REQUIREMENTS OF THIRD-PARTY HEALTH INSURERS. (a) A third-party health insurer is required to provide to the commission, on the commission's request, information in a form prescribed by the executive commissioner necessary to determine:
(1) the period during which an individual entitled to medical assistance, the individual's spouse, or the individual's dependents may be, or may have been, covered by coverage issued by the health insurer;
(2) the nature of the coverage; and
(3) the name, address, and identifying number of the health plan under which the person may be, or may have been, covered.
(b) A third-party health insurer shall accept the state's right of recovery and the assignment under Section 32.033 to the state of any right of an individual or other entity to payment from the third-party health insurer for an item or service for which payment was made under the medical assistance program.
(c) A third-party health insurer shall respond to any inquiry by the commission regarding a claim for payment for any health care item or service reimbursed by the commission under the medical assistance program not later than the third anniversary of the date the health care item or service was provided.
(d) A third-party health insurer may not deny a claim submitted by the commission or the commission's designee for which payment was made under the medical assistance program solely on the basis of the date of submission of the claim, the type or format of the claim form, or a failure to present proper documentation at the point of service that is the basis of the claim, if:
(1) the claim is submitted by the commission or the commission's designee not later than the third anniversary of the date the item or service was provided; and
(2) any action by the commission or the commission's designee to enforce the state's rights with respect to the claim is commenced not later than the sixth anniversary of the date the commission or the commission's designee submits the claim.
(e) This section does not limit the scope or amount of information required by Section 32.042.
Added by Acts 2009, 81st Leg., R.S., Ch. 745 (S.B. 531), Sec. 3, eff. September 1, 2009.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 4.118, eff. April 2, 2015.
Structure Texas Statutes
Title 2 - Human Services and Protective Services in General
Subtitle C - Assistance Programs
Chapter 32 - Medical Assistance Program
Subchapter B. Administrative Provisions
Section 32.021. Administration of the Program
Section 32.0212. Delivery of Medical Assistance
Section 32.0213. Nursing Facility Bed Certification and Decertification
Section 32.0214. Designations of Primary Care Provider by Certain Recipients
Section 32.0215. Home or Community Care Providers: Civil Monetary Penalties
Section 32.022. Medical and Hospital Care Advisory Committees
Section 32.023. Cooperation With Other State Agencies
Section 32.0231. Announcement of Funding or Program Change
Section 32.024. Authority and Scope of Program; Eligibility
Section 32.0241. Review of Waiver Request
Section 32.0242. Verification of Certain Information
Section 32.0244. Nursing Facility Beds in Certain Counties
Section 32.0245. Nursing Facility Beds for Certain Facilities Treating Alzheimer's Disease
Section 32.0249. Mental Health Screenings in Texas Health Steps Program
Section 32.025. Application for Medical Assistance
Section 32.0251. Eligibility Notification and Review for Certain Children
Section 32.0255. Transitional Medical Assistance
Section 32.0256. Continuation of Medical Assistance for Certain Individuals
Section 32.026. Certification of Eligibility and Need for Medical Assistance
Section 32.0261. Continuous Eligibility
Section 32.026101. Determination of Eligibility by Health Care Exchanges Prohibited
Section 32.02611. Exclusion of Assets in Prepaid Tuition Programs and Higher Education Savings Plans
Section 32.02613. Life Insurance Assets; Life Insurance Policy Conversion
Section 32.0262. Eligibility Transition
Section 32.0263. Health Care Orientation
Section 32.0264. Suspension and Reinstatement of Eligibility for Children in Juvenile Facilities
Section 32.0265. Notice of Certain Placements in Juvenile Facilities
Section 32.027. Selection of Provider of Medical Assistance
Section 32.028. Fees, Charges, and Rates
Section 32.0281. Rules and Notice Relating to Payment Rates
Section 32.0282. Public Hearing on Rates
Section 32.0284. Calculation of Payments Under Certain Supplemental Hospital Payment Programs
Section 32.029. Methods of Payment
Section 32.0291. Prepayment Reviews and Payment Holds
Section 32.031. Receipt and Expenditure of Funds
Section 32.0311. Drug Reimbursement Under Certain Programs
Section 32.0312. Reimbursement for Services Associated With Preventable Adverse Events
Section 32.0313. Induced Deliveries or Cesarean Sections Before 39th Week
Section 32.0314. Reimbursement for Durable Medical Equipment and Supplies
Section 32.0315. Funds for Graduate Medical Education
Section 32.0316. Electronic Transactions; Medicaid
Section 32.032. Prevention and Detection of Fraud and Abuse
Section 32.0322. Criminal History Record Information; Enrollment of Providers
Section 32.034. Contract Cancellation; Notice and Hearing
Section 32.036. Program Payments Nonassignable and Exempt From Legal Process
Section 32.038. Collection of Insurance Payments
Section 32.0381. Icf-Iid Payment Rates
Section 32.039. Damages and Penalties
Section 32.0391. Criminal Offense
Section 32.040. Identification of Husband or Alleged Father
Section 32.042. Information Required From Health Insurers
Section 32.0421. Administrative Penalty for Failure to Provide Information
Section 32.0423. Recovery of Reimbursements From Health Coverage Providers
Section 32.0424. Requirements of Third-Party Health Insurers
Section 32.04242. Payor of Last Resort
Section 32.0425. Reimbursement for Wheeled Mobility Systems
Section 32.043. Procurement Rules for Public Disproportionate Share Hospitals
Section 32.044. Group Purchasing for Disproportionate Share Hospitals
Section 32.045. Enhanced Reimbursement
Section 32.046. Sanctions and Penalties Related to the Provision of Pharmacy Products
Section 32.0461. Vendor Drug Program; Competitive Bidding
Section 32.0462. Vendor Drug Program; Pricing Standard
Section 32.0463. Medications and Medical Supplies
Section 32.047. Prohibition of Certain Health Care Service Providers
Section 32.048. Managed Care Information and Training Plan
Section 32.049. Managed Care Contract Compliance
Section 32.050. Dual Medicaid and Medicare Coverage
Section 32.051. Misdirected Billing
Section 32.052. Waiver Programs for Children With Disabilities or Special Health Care Needs
Section 32.0531. Pace Program Team
Section 32.0532. Pace Program Reimbursement Methodology
Section 32.0533. Data Collection: Pace and Star + Plus Medicaid Managed Care Programs
Section 32.054. Dental Services
Section 32.055. Catastrophic Case Management
Section 32.0551. Optimization of Case Management Systems
Section 32.056. Compliance With Texas Health Steps Comprehensive Care Program
Section 32.0561. Maternal Depression Screening
Section 32.057. Contracts for Disease Management Programs
Section 32.059. Use of Respiratory Therapists for Respiratory Therapy Services
Section 32.061. Community Attendant Services Program
Section 32.062. Admissibility of Certain Evidence Relating to Nursing Institutions
Section 32.063. Third-Party Billing Vendors
Section 32.067. Delivery of Comprehensive Care Services to Certain Recipients of Medical Assistance
Section 32.068. In-Person Evaluation Required for Certain Services
Section 32.069. Chronic Kidney Disease Management Initiative
Section 32.070. Audits of Providers
Section 32.0705. External Audits of Certain Medicaid Contractors Based on Risk
Section 32.071. Recipient and Provider Education
Section 32.072. Direct Access to Eye Health Care Services
Section 32.073. Health Information Technology Standards
Section 32.074. Access to Personal Emergency Response System
Section 32.075. Employment Assistance and Supported Employment