Claim Procedures

For claims involving participants who are Texas HMO participants and to the extent required by applicable Texas statutes and rules pertaining to the prompt payment of Clean Claims, the following provisions shall apply:

  1. Effect of Filing a Clean Claim
    1. The Statutory Claims Payment Period begins to run upon receipt by Cigna B Behavioral of Texas of a Clean Claim from PROVIDER as determined under Texas law. The date of claim payment is as determined under Texas law.
    2. After the receipt of a Clean Claim from PROVIDER at the address designated by Cigna Behavioral of Texas and prior to the expiration of the applicable Statutory Claims Payment Period (subject to any extensions of time permitted under Texas law):
      1. Payor shall pay the total amount of the Clean Claim in accordance with the terms of the Agreement;
      2. The Clean Claim shall be denied in its entirety after a determination that Payor is not liable for the Clean Claim and PROVIDER shall be notified in writing why the Clean Claim will not be paid;
      3. PROVIDER shall be notified in writing that the entire Clean Claim will be audited and Payor shall pay 100% of the Contracted Rate on the claim to PROVIDER; or
      4. Payor shall pay the portion of the Clean Claim for which liability is acknowledged in accordance with the terms of this Agreement, and;
        1. The remainder of the Clean Claim shall be denied after a determination that Payor is not liable for the remainder of the Clean Claim and PROVIDER shall be notified in writing why the remainder of the Clean Claim will not be paid; or
        2. PROVIDER shall be notified in writing that the remainder of the Clean Claim will be audited and Payor shall pay 100% of the Contracted Rate on the unpaid portion of the Clean Claim to PROVIDER.
    3. Requests for Additional Information From Treating Provider. If necessary to determine whether a claim is payable, Cigna Behavioral of Texas may, within 30 days of receipt of a Clean Claim, request additional information from the treating provider. The time period to request additional information may be extended as allowed under Texas law. In the event that Cigna Behavioral of Texas requests information under this section, Cigna Behavioral of Texas shall determine whether the Clean Claim is payable and Payor shall pay or Cigna Behavioral of Texas will deny the Clean Claim or audit the Clean Claim on or before the later of:
      1. The 15th day after the date Cigna Behavioral of Texas receives the requested information from the treating provider along with a copy of Cigna Behavioral of Texas's written request for information or with the name of the patient, patient identification number, the claim number as provided by Cigna Behavioral of Texas, the date of service and the name of the treating provider (If Cigna Behavioral of Texas submitted the request for additional information electronically in accordance with federal requirements concerning electronic transactions, the treating provider must submit the response in accordance with those requirements);
      2. The 15th day after the date Cigna Behavioral of Texas receives a written response from the treating provider that the treating provider does not possess the requested information; or
      3. The latest date for determining whether the claim is payable under Sections 2.A.1. and 2 above.
    4. Requests for Additional Information From Other Sources. If Cigna Behavioral of Texas requests additional information from a person other than PROVIDER, Cigna Behavioral of Texas will provide PROVIDER with a notice containing the name of the PROVIDER, provider or other entity from whom Cigna Behavioral of Texas is requesting information. Payor may not withhold payment beyond the applicable Statutory Claims Payment Period pending receipt of information under this section. If on receiving information requested under this section Cigna Behavioral of Texas determines that there was an error in payment of the claim, the overpayment may be recovered pursuant to Section F below.
    5. To the extent applicable, Cigna Behavioral of Texas will not refuse to process or pay an electronically submitted Clean Claim because the claim is submitted with or in a batch submission with a Clean Claim that is deficient. A "batch submission" is a group of electronic claims submitted for processing at the same time within HIPAA standard ASC X12N 837 Transaction Set and identified by a batch control number.
  2. Effect of Filing a Deficient Claim. If a submitted claim is determined by Cigna Behavioral of Texas to be deficient, PROVIDER shall be notified that the claim is deficient within 45 calendar days of Cigna Behavioral of Texas's receipt of the claim at the address designated by Cigna Behavioral of Texas or within 30 days of receipt by Cigna Behavioral of Texas of an electronic claim. If the deficient claim is a claim for a prescription, Cigna Behavioral of Texas will notify PROVIDER that the claim is deficient within 21 calendar days of receipt of the nonelectronic claim by Cigna Behavioral of Texas, or wihtin 18 days of receipt of an electronic claim. The failure to notify PROVIDER that a claim is deficient within the timelines specified in this section shall not render a deficient claim a Clean Claim.
  3. Audit Procedures. If Payor is unable to pay or deny a Clean Claim, in whole or in part, within the applicable Statutory Claims Payment period and intends to audit the Clean Claim to determine whether it is payable, Cigna Behavioral of Texas will notify PROVIDER that the claim is being audited and Payor shall pay 100% of the Contracted Rate within the applicable Statutory Claims Payment Period. Payment of 100% of the Contracted Rate is not an admission that liability is acknowledged on that claim. Cigna Behavioral of Texas will complete the audit within 180 calendar days from receipt of the Clean Claim. Upon completion of any audit of a Clean Claim, Cigna Behavioral of Texas will notify PROVIDER of the results of the audit and:
    1. If Cigna Behavioral Health Behavioral of Texas determines that additional payment is due to PROVIDER, such additional payment shall be paid by Payor within thirty (30) calendar days after the completion of the audit;
    2. If Cigna Behavioral of Texas determines that a refund is due from PROVIDER, such refund shall be made by PROVIDER within thirty (30) calendar days of the later of notification to PROVIDER of the results of the audit or exhaustion of any Participant appeal rights, if a Participant appeal is filed before the thirty (30) calendar day refund period has expired, and may be made by any method, including charge-back against PROVIDER.
  4. Failure to Meet Statutory Claims Payment Period.
    1. If Cigna Behavioral of Texas determines that a Clean Claim is payable and Payor fails to pay any amount due and owing on the Clean Claim within the statutory time frames, Payor shall pay to PROVIDER, in addition to the Contracted Rate owed, a penalty as follows:
      1. If the claim is paid on or before the 45th day after the end of the applicable Statutory Claims Payment Period, the lesser of:
        1. 50% of the difference between the Billed Charge and the Contracted Rate; or
        2. $100,000.
      2. If the claim is paid on or after the 46th day and before the 91st day after the end of the applicable Statutory Claims Payment Period, the lesser of:
        1. 100% of the difference between the Billed Charge and the Contracted Rate; or
        2. $200,000.
      3. If the claim is paid on or after the 91st day after the end of the applicable Statutory Claims Payment Period, a penalty computed under subsection (1)(b) above plus 18% annual interest on the penalty amount. Interest under this subsection accrues beginning on the date the claim was required to be paid and ending on the date the claim and the penalty are paid in full.
    2. If Cigna Behavioral of Texas determines that a Clean Claim is payable and Payor pays only a portion of the amount of the Clean Claim on or before the applicable Statutory Claims Payment Period and pays the balance of the Contracted Rate owed for the Clean Claim after that date, Payor shall pay to PROVIDER, in addition to the Contracted Rate owed, a penalty as follows:
      1. If the balance of the Clean Claim is paid on or before the 45th day after the applicable Statutory Claims Payment Period, the lesser of:
        1. 50% of the underpaid amount; or
        2. $100,000.
      2. If the balance of the Clean Claim is paid on or after the 46th day and before the 91st day after the end of the applicable Statutory Claims Payment Period, the lesser of:
        1. 100% of the underpaid amount; or
        2. $200,000.
      3. If the balance of the Clean Claim is paid on or after the 91st date after the end of the applicable Statutory Claims Payment Period, a penalty computed under subsection (2)(b) above plus 18% annual interest on the penalty amount. Interest under this subsection accrues beginning on the date the claim was required to be paid and ending on the date the claim and the penalty are paid in full.
      4. For purposes of this subsection 2, the underpaid amount is calculated on the ratio of the amount underpaid on the Contracted Rate as applied to an amount equal to the Billed Charge submitted minus the Contracted Rate
    3. No penalty shall be owed:
      1. If the failure to pay the claim in accordance with the applicable Statutory Claims Payment Period is a result of a catastrophic event that Cigna Behavioral of Texas certified in accordance with Texas law; or
      2. If the claim was paid in accordance with statutory time frames but for less than the Contracted Rate, and
        1. PROVIDER notifies Cigna Behavioral of Texas of the underpayment after the 270th day after the date the underpayment was received; and
        2. Payor pays the balance of the claim on or before the 30th day after the date Cigna Behavioral of Texas received notice of the underpayment.
      3. Subsection 3 above does not relieve Payor of any obligation to pay the remaining unpaid Contracted Rate owed.
  5. Claims Filing Deadline. PROVIDER must submit a claim to Cigna Behavioral of Texas not later than the 95th day after the date of discharge with regard to the medical care or health care services for which the claim is made. For a claim for which coordination of benefits applies, the 95 day period does not begin for sub-mission of the claim to the secondary payor until PROVIDER receives notice of the payment or denial from the primary payor. If PROVIDER fails to submit a claim in compliance with this section, PROVIDER forfeits the right to payment unless PROVIDER has certified in accordance with Texas law that the failure to timely submit is a result of a catastrophic event. The date of receipt of a claim and whether the method of submission of a claim is appropriate shall be determined in accordance with Texas law. PROVIDER may not submit a duplicate claim prior to the date that the applicable Statutory Claims Payment Period has passed. If Cigna Behavioral of Texas receives a duplicate claim prior to such date, such claim shall not be subject to the requirements set forth above relating to the effect of filing a Clean Claim and failure to meet the Statutory Claims Payment Period.
  6. Overpayment of Claims.
    1. A refund due to overpayment or completion of audit may be recovered if:
      1. Cigna Behavioral of Texas notifies PROVIDER of the overpayment not later than the 180th day after the date of receipt of the overpayment; or
      2. Cigna Behavioral of Texas notifies PROVIDER of the completion of an audit in accordance with Section C above.
    2. Notification under this provision shall:
      1. Be in written form and include the specific claims and amounts for which a refund is due and for each claim the basis and specific reasons for the request for refund;
      2. Include notice of the PROVIDER'S right to appeal; and
      3. Describe the methods by which Cigna Behavioral of Texas intends to recover the refund.
    3. PROVIDER may appeal a request for refund by providing written notice of disagreement with the refund request not later than 45 days after receipt of notice under subsection (2) above. Upon receipt of a written notice under this sub-section, Cigna Behavioral of Texas shall begin Cigna Behavioral of Texas's internal appeal process as provided in the Medical Management Program Requirements to the Agreement.
    4. A refund may not be recovered under this section until:
      1. For overpayments, the later of the 45th day after notification under subsection 1 (a) of this section or the exhaustion of any PROVIDER appeal rights under subsection 3 of this section where PROVIDER has not made arrangements for payment with Cigna Behavioral of Texas; or
      2. For audits, the latter of the 30th day after notification under subsection 1(b) of this section or the exhaustion of any PROVIDER appeal rights under subsection 3 of this section where the PROVIDER has not made arrangements for payment with Cigna Behavioral of Texas.
    5. If Payor is a secondary payor and pays a portion of a claim that should have been paid by the primary payor and that was paid to PROVIDER by the primary payor, Payor may recover the amount of overpayment from PROVIDER pursuant to this Section F.
    6. This Section F does not affect Payor’s ability to recover any overpayment in the case of fraud or a material misrepresentation by PROVIDER.
  7. The terms Clean Claim, Statutory Claims Payment Period, Billed Charge and Contracted Rate shall have the same meaning as defined under applicable Texas law.