Section 26.562 - Eligibility of Claims Paid for Reimbursement from the Fund(a) For each health benefit plan eligible for reimbursement from the fund, a participating health benefit plan issuer shall record and aggregate claims paid on a per-covered-person basis. Reimbursement from the fund shall be calculated based on such per-covered-person aggregates.(b) A participating health benefit plan issuer shall be eligible for reimbursement of 80 percent of eligible claims paid within the claims corridor on behalf of each person covered under a qualifying group health benefit plan.(c) A participating health benefit plan issuer shall not be entitled to any reimbursement on behalf of an enrollee if the claims paid on behalf of that person in a given calendar year do not, in the aggregate, reach the claims threshold. Additionally, claims paid on behalf of an enrollee which exceed the claims corridor in a given calendar year shall not be eligible for reimbursement from the fund.(d) Claims paid within a calendar year shall be determined by the date of payment rather than the date of service or date the claim was incurred. A participating health benefit plan issuer may not delay or defer payment of a claim solely for the purpose of causing the date of payment to fall into a subsequent calendar year.(e) Claims paid shall not include interest paid by a participating health benefit plan issuer in connection with any claim.(f) Claims paid that are not submitted for reimbursement prior to April 1 of the calendar year following the calendar year in which they are paid shall not be eligible for reimbursement from the fund and shall not be credited as paid claims in any year for the purpose of determining whether the claims threshold has been reached. (1) If the commissioner determines that the claims data submitted in conjunction with a reimbursement request is insufficient to make a reimbursement determination, the commissioner or the fund administrator shall make a request for clarification of the data or for the submission of additional data.(2) Participating health benefit plan issuers shall comply with all such requests within 15 business days of the date of the request.(3) If a participating health benefit plan issuer fails to comply with such a request from the commissioner or the fund administrator within 15 business days, the commissioner has discretion to deem any affected claims ineligible for reimbursement.(g) Claims paid shall not include claims paid prior to January 1, 2010.28 Tex. Admin. Code § 26.562
The provisions of this §26.562 adopted to be effective March 16, 2010, 35 TexReg 2174