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.
Section: Previous 32.039 32.0391 32.040 32.042 32.0421 32.0422 32.0423 32.0424 32.04242 32.0425 32.043 32.044 32.045 32.046 32.0461 NextLast modified: September 28, 2016