CHAPTER 1215. REPORTING OF CLAIMS INFORMATION

State Codes and Statutes

Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1215-reporting-of-claims-information

INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE A. HEALTH COVERAGE IN GENERAL

CHAPTER 1215. REPORTING OF CLAIMS INFORMATION

Sec. 1215.001. DEFINITIONS. (a) Except as provided by

Subsection (b), in this chapter:

(1) "Employer" has the meaning assigned by 29 U.S.C. Section

1002(5).

(2) "Governmental entity" means a state agency or political

subdivision of this state.

(3) "Group health plan" has the meaning assigned by 45 C.F.R.

Section 160.103, except that the term does not include disability

income or long-term care insurance.

(4) "Health insurance issuer" has the meaning assigned by 45

C.F.R. Section 160.103.

(5) "Plan" means an employee welfare benefit plan as defined by

29 U.S.C. Section 1002(1).

(6) "Plan administrator" means an administrator as defined by 29

U.S.C. Section 1002(16)(A).

(7) "Plan sponsor" has the meaning assigned by 29 U.S.C. Section

1002(16)(B).

(8) "Political subdivision" means a county, municipality, school

district, special-purpose district, or other subdivision of state

government that has jurisdiction limited to a geographic portion

of the state.

(9) "Protected health information" has the meaning assigned by

45 C.F.R. Section 160.103.

(b) A reference to a federal statute or regulation under

Subsection (a) means that statute or regulation as it existed on

September 1, 2007, except that the commissioner, by rule, may

adopt a definition based on a later amended, enacted, or adopted

federal statute or regulation if the commissioner determines that

use of the later amended, enacted, or adopted statute or

regulation is consistent with the purposes of this chapter and

promotes regulatory consistency.

Added by Acts 2007, 80th Leg., R.S., Ch.

700, Sec. 1, eff. September 1, 2007.

Sec. 1215.002. APPLICABILITY OF CHAPTER TO GOVERNMENTAL ENTITY;

APPLICABILITY OF OTHER LAW WITH REFERENCE TO GOVERNMENTAL ENTITY.

(a) This chapter applies to a governmental entity that enters

into a contract with a health insurance issuer that results in

the health insurance issuer delivering, issuing for delivery, or

renewing a group health plan.

(b) For purposes of this chapter, a health insurance issuer

shall treat a governmental entity described by Subsection (a) as

a plan sponsor or plan administrator.

a governmental entity is confidential and exempt from public

disclosure under Chapter 552, Government Code.

Added by Acts 2007, 80th Leg., R.S., Ch.

700, Sec. 1, eff. September 1, 2007.

Sec. 1215.003. RECEIPT OF AND RESPONSE TO REQUEST FOR CLAIM

INFORMATION. (a) Not later than the 30th day after the date a

health insurance issuer receives a written request for a written

report of claim information from a plan, plan sponsor, or plan

administrator, the health insurance issuer shall provide the

requesting party the report, subject to Subsections (d), (e), and

(f). The health insurance issuer is not obligated to provide a

report under this subsection regarding a particular employer or

group health plan more than twice in any 12-month period.

(b) A health insurance issuer shall provide the report of claim

information under Subsection (a):

(1) in a written report;

(2) through an electronic file transmitted by secure electronic

mail or a file transfer protocol site; or

(3) by making the required information available through a

secure website or web portal accessible by the requesting plan,

plan sponsor, or plan administrator.

must contain all information available to the health insurance

issuer that is responsive to the request made under Subsection

(a), including, subject to Subsections (d), (e), and (f),

protected health information, for the 36-month period preceding

the date of the report or the period specified by Subdivisions

(4), (5), and (6), if applicable, or for the entire period of

coverage, whichever period is shorter. Subject to Subsections

(d), (e), and (f), a report provided under Subsection (a) must

include:

(1) aggregate paid claims experience by month, including claims

experience for medical, dental, and pharmacy benefits, as

applicable;

(2) total premium paid by month;

(3) total number of covered employees on a monthly basis by

coverage tier, including whether coverage was for:

(A) an employee only;

(B) an employee with dependents only;

(D) an employee with a spouse and dependents;

(4) the total dollar amount of claims pending as of the date of

the report;

(5) a separate description and individual claims report for any

individual whose total paid claims exceed $15,000 during the

12-month period preceding the date of the report, including the

following information related to the claims for that individual:

(A) a unique identifying number, characteristic, or code for the

individual;

(B) the amounts paid;

(D) applicable procedure codes and diagnosis codes; and

(6) for claims that are not part of the report described by

Subdivisions (1)-(5), a statement describing precertification

requests for hospital stays of five days or longer that were made

during the 30-day period preceding the date of the report.

(d) A health insurance issuer may not disclose protected health

information in a report of claim information provided under this

section if the health insurance issuer is prohibited from

disclosing that information under another state or federal law

that imposes more stringent privacy restrictions than those

imposed under federal law under the Health Insurance Portability

and Accountability Act of 1996 (Pub. L. No. 104-191). To

withhold information in accordance with this subsection, the

health insurance issuer must:

(1) notify the plan, plan sponsor, or plan administrator

requesting the report that information is being withheld; and

(2) provide to the plan, plan sponsor, or plan administrator a

list of categories of claim information that the health insurance

issuer has determined are subject to the more stringent privacy

restrictions under another state or federal law.

(e) A plan sponsor is entitled to receive protected health

information under Subsections (c)(5) and (6) and Section 1215.004

only after an appropriately authorized representative of the plan

sponsor makes to the health insurance issuer a certification

substantially similar to the following certification:

"I hereby certify that the plan documents comply with the

requirements of 45 C.F.R. Section 164.504(f)(2) and that the plan

sponsor will safeguard and limit the use and disclosure of

protected health information that the plan sponsor may receive

from the group health plan to perform the plan administration

functions."

(f) A plan sponsor that does not provide the certification

required by Subsection (e) is not entitled to receive the

protected health information described by Subsections (c)(5) and

(6) and Section 1215.004, but is entitled to receive a report of

claim information that includes the information described by

Subsections (c)(1)-(4).

(g) In the case of a request made under Subsection (a) after the

date of termination of coverage, the report must contain all

information available to the health insurance issuer as of the

date of the report that is responsive to the request, including

protected health information, and including the information

described by Subsections (c)(1)-(6), for the period described by

Subsection (c) preceding the date of termination of coverage or

for the entire policy period, whichever period is shorter.

Notwithstanding this subsection, the report may not include the

protected health information described by Subsections (c)(5) and

(6) unless a certification has been provided in accordance with

Subsection (e).

(h) A plan, plan sponsor, or plan administrator must request a

report under Subsection (a) before or on the second anniversary

of the date of termination of coverage under a group health plan

issued by the health benefit plan issuer.

Added by Acts 2007, 80th Leg., R.S., Ch.

700, Sec. 1, eff. September 1, 2007.

Sec. 1215.004. REQUEST FOR ADDITIONAL INFORMATION. (a) On

receipt of the report required by Section 1215.003(a), the plan,

plan sponsor, or plan administrator may review the report and,

not later than the 10th day after the date the report is

received, may make a written request to the health insurance

issuer for additional information in accordance with this section

for specified individuals.

(b) With respect to a request for additional information

concerning specified individuals for whom claims information has

been provided under Section 1215.003(c)(5), the health insurance

issuer shall provide additional information on the prognosis or

recovery if available and, for individuals in active case

management, the most recent case management information,

including any future expected costs and treatment plan, that

relate to the claims for that individual.

additional information under this section not later than the 15th

day after the date of the request under this section unless the

requesting plan, plan sponsor, or plan administrator agrees to a

request for additional time.

(d) The health insurance issuer is not required to produce the

report described by this section unless a certification has been

provided in accordance with Section 1215.003(e).

Added by Acts 2007, 80th Leg., R.S., Ch.

700, Sec. 1, eff. September 1, 2007.

Sec. 1215.005. COMPLIANCE WITH CHAPTER DOES NOT CREATE

LIABILITY. A health insurance issuer that releases information,

including protected health information, in accordance with this

chapter has not violated a standard of care and is not liable for

civil damages resulting from, and is not subject to criminal

prosecution for, releasing that information.

Added by Acts 2007, 80th Leg., R.S., Ch.

700, Sec. 1, eff. September 1, 2007.

Sec. 1215.006. ADMINISTRATIVE PENALTIES. A health insurance

issuer that does not comply with this chapter is subject to

administrative penalties under Chapter 84.

Added by Acts 2007, 80th Leg., R.S., Ch.

700, Sec. 1, eff. September 1, 2007.

State Codes and Statutes

State Codes and Statutes

State Codes and Statutes

State Codes and Statutes

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