2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter J. Payment of Claims to Physicians and Providers › Section 843.337. Time for Submission of Claim; Duplicate Claims; Acknowledgment of Receipt of Claim

Sec. 843.337.  TIME FOR SUBMISSION OF CLAIM;  DUPLICATE CLAIMS;  ACKNOWLEDGMENT OF RECEIPT OF CLAIM.  (a)  A physician or provider must submit a claim to a health maintenance organization not later than the 95th day after the date the physician or provider provides the health care services for which the claim is made.  A health maintenance organization shall accept as proof of timely filing a claim filed in compliance with Subsection (e) or information from another health maintenance organization or insurer showing that the physician or provider submitted the claim to the health maintenance organization or insurer in compliance with Subsection (e).
(b)  If a physician or provider fails to submit a claim in compliance with this section, the physician or provider forfeits the right to payment.
(c)  The period for submitting a claim under this section may be extended by:
(1)  contract;
(2)  notice published by the commissioner allowing an extension of prompt payment deadlines to a later date chosen by the commissioner due to a catastrophic event; or
(3)  the department's approval of a physician's or provider's request for an extension due to a catastrophic event that substantially interferes with the normal business operations of the physician or provider.
(c-1)  The commissioner may adopt rules to implement Subsection (c), including rules establishing requirements for a request made under Subsection (c)(3).
(d)  A physician or provider may not submit a duplicate claim for payment before the 46th day after the date the original claim was submitted.  The commissioner shall adopt rules under which a health maintenance organization may determine whether a claim is a duplicate claim.
(e)  Except as provided by Chapter 1213, a physician or provider may, as appropriate:
(1)  mail a claim by United States mail, first class, or by overnight delivery service;
(2)  submit the claim electronically;
(3)  fax the claim; or
(4)  hand deliver the claim.
(f)  If a claim for health care services provided to a patient is mailed, the claim is presumed to have been received by the health maintenance organization on the fifth day after the date the claim is mailed or, if the claim is mailed using overnight service or return receipt requested, on the date the delivery receipt is signed.  If the claim is submitted electronically, the claim is presumed to have been received on the date of the electronic verification of receipt by the health maintenance organization or the health maintenance organization's clearinghouse.  If the health maintenance organization or the health maintenance organization's clearinghouse does not provide a confirmation within 24 hours of submission by the physician or provider, the physician's or provider's clearinghouse shall provide the confirmation.  The physician's or provider's clearinghouse must be able to verify that the filing contained the correct payor identification of the entity to receive the filing.  If the claim is faxed, the claim is presumed to have been received on the date of the transmission acknowledgment.  If the claim is hand delivered, the claim is presumed to have been received on the date the delivery receipt is signed.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.  Amended by Acts 2003, 78th Leg., ch. 214, Sec. 7, eff. June 17, 2003.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2E.049, eff. April 1, 2009.
Acts 2023, 88th Leg., R.S., Ch. 90 (S.B. 1286), Sec. 1, eff. September 1, 2023.