Tex.
Ins. Code Section 843.349
Coordination of Payment
(a)
A health maintenance organization may require a physician or provider to retain in the physician’s or provider’s records updated information concerning other health benefit plan coverage and to provide the information to the health maintenance organization on the applicable form described by Section 843.336 (Definition). Except as provided by this section, a health maintenance organization may not require a physician or provider to investigate coordination of other health benefit plan coverage.(b)
Coordination of other payment under this section does not extend the period for determining whether a service is eligible for payment under Section 843.338 (Deadline for Action on Clean Claims) or 843.339 (Deadline for Action on Prescription Claims; Payment) or for auditing a claim under Section 843.340 (Audited Claims).(c)
A participating physician or provider who submits a claim for particular health care services to more than one health maintenance organization or insurer shall provide written notice on the claim submitted to each health maintenance organization or insurer of the identity of each other health maintenance organization or insurer with which the same claim is being filed.(d)
On receipt of notice under Subsection (c), a health maintenance organization shall coordinate and determine the appropriate payment for each health maintenance organization or insurer to make to the physician or provider.(e)
Except as provided by Subsection (f), if a health maintenance organization is a secondary payor and pays a portion of a claim that should have been paid by the health maintenance organization or insurer that is the primary payor, the overpayment may only be recovered from the health maintenance organization or insurer that is primarily responsible for that amount.(f)
If the portion of the claim overpaid by the secondary health maintenance organization was also paid by the primary health maintenance organization or insurer, the secondary health maintenance organization may recover the amount of the overpayment under Section 843.350 (Overpayment) from the physician or provider who received the payment. A health maintenance organization processing an electronic claim as a secondary payor shall rely on the primary payor information submitted on the claim by the physician or provider. Primary payor information may be submitted electronically by the primary payor to the secondary payor.(g)
A health maintenance organization may share information with another health maintenance organization or an insurer to the extent necessary to coordinate appropriate payment obligations on a specific claim.
Source:
Section 843.349 — Coordination of Payment, https://statutes.capitol.texas.gov/Docs/IN/htm/IN.843.htm#843.349 (accessed Jun. 5, 2024).
