TX HMO Affidavit – Untimely Payment
Last Updated: May 5, 2021 | Letter Type: Affidavits | Jurisdiction: TX HMO
AFFIDAVIT OF COMPLIANCE Prompt Payment to Providers Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met the provisions of 6... View more
TX HMO Appeal – Interest Owed on Late Claims
Last Updated: November 21, 2021 | Letter Type: Appeals | Jurisdiction: TX HMO
URGENT- IMPERATIVE ACTION Dear Director of : This office has been asked to file a formal complaint with the Texas Department of Insurance for ’s failure to remit automatic interest accrued on this claim as required by state law. Our investigation has concluded the following: Per 6 TIC §843.338, was required to reimburse this claim... View more
TX HMO Appeal – Maternity Coverage
Last Updated: November 21, 2021 | Letter Type: Appeals | Jurisdiction: TX HMO
URGENT- IMPERATIVE ACTION Dear Director of : This office has been asked to file a formal complaint with the Texas Department of Insurance for ’s failure to provide coverage for maternity services and care as required by state law. Our investigation has concluded the following: As you may know, 6 TIC §843.002(7)(E) states: (7) “Emergency... View more
TX HMO Appeal – Medical Necessity – Qualified Reviewers
Last Updated: November 21, 2021 | Letter Type: Appeals | Jurisdiction: TX HMO
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Texas Department of Insurance for ’s failure to reimburse medically necessary services as required by State law. Our investigation has concluded the following: Please be advised that our treating physician was a . However, your reviewer was... View more
TX HMO Appeal – No Authorization for ER Services and Care
Last Updated: November 20, 2021 | Letter Type: Appeals | Jurisdiction: TX HMO
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the for ’s failure to reimburse emergency services as required by State law. Our investigation has concluded the following: 6 TIC §843.002(7) defines “emergency services and care” as: (7) “Emergency care” means health care services provided in a... View more
TX HMO Appeal – Non-urgent Authorization Timeframes
Last Updated: November 21, 2021 | Letter Type: Appeals | Jurisdiction: TX HMO
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Texas Department of Insurance for ’s failure to meet the timeframe and notice requirements for non-urgent authorization requests as required by state law. Our investigation has concluded the following: THIS REQUEST IS NOW DAYS IN VIOLATION OF... View more
TX HMO Appeal – Notice Requirements for Adverse Determinations
Last Updated: November 20, 2021 | Letter Type: Appeals | Jurisdiction: TX HMO
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Texas Department of Insurance for ’s failure to reimburse medically necessary services as required by state law. Our investigation has concluded the following: On , denied this claim as not medically necessary. To date, we have not... View more
TX HMO Appeal – Poststabilization Timeframe
Last Updated: November 20, 2021 | Letter Type: Appeals | Jurisdiction: TX HMO
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Texas Department of Insurance for ’s failure to reimburse emergency and/or statutorily authorized post-stabilization services and care as required by state law. Our investigation has concluded the following: TO DATE, HAS FAILED TO REIMBURSE EMERGENCY AND STATUTORILY... View more
TX HMO Appeal – Refund Recoupment
Last Updated: November 20, 2021 | Letter Type: Appeals | Jurisdiction: TX HMO
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Texas Department of Insurance for ’s failure to properly reimburse medically necessary services as required by State law. Our investigation has concluded the following: Please be advised that must meet the written requirements set forth in 6... View more
TX HMO Appeal – Retroactive Denial for Authorized Care
Last Updated: November 20, 2021 | Letter Type: Appeals | Jurisdiction: TX HMO
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Texas Department of Insurance for ’s failure to reimburse authorized health services as required by State law. On , authorization number was issued by . Please be advised 6 TIC §843.348(g) states: (g) If the health maintenance... View more