Section 354.11 - Claims Payment(a) Prior authorization is required for all allowable products.(b) The program reimburses program providers for allowable product(s) for eligible clients. Payment may be made only after the allowable product(s) has been dispensed and submission of a valid claim. Claims must be: (1) submitted on the claim form accepted by the program;(2) submitted by a program provider; and(3) filed directly with the program.(c) The program reimburses eligible clients for insurance premium payments made to program approved health plans. Reimbursements may be made after the program's receipt of a valid proof of insurance premium payment.(d) Filing Deadlines. (1) Complete claims must be received by the program within 95 calendar days from the end of the month of the date of service or 95 calendar days from the end of the month for which the premium was paid.(2) Incomplete and ineligible claims will be denied.(3) Denied claims may be considered for payment if the claim is corrected and resubmitted within 30 days following the date of the program notice of denial or within the initial 95 day filing deadline, whichever is later.26 Tex. Admin. Code § 354.11
Adopted to be effective December 14, 2008, 33 TexReg 10036; Amended by Texas Register, Volume 40, Number 15, April 10, 2015, TexReg 2091, eff. 4/16/2015; Amended by Texas Register, Volume 42, Number 08, February 24, 2017, TexReg 764, eff. 3/1/2017; Entire chapter transferred from T. 25, Pt. 1, Ch. 37, Subch. F by Texas Register, Volume 47, Number 08, February 25, 2022, TexReg 0981, eff. 3/15/2022