Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter T - SUBMISSION OF CLEAN CLAIMS › Section 21.2806 - Claims Filing Deadline

Current through Reg. 49, No. 28; July 12, 2024
(a) Claim
				  submission deadline. A physician or a provider must submit a claim to an MCC
				  not later than the 95th day after the date the physician or the provider
				  delivers the medical care or health care services for which the claim is made.
				  An MCC and a physician or a provider may agree, by contract, to extend the
				  period for submitting a claim. For a claim submitted by an institutional
				  provider, the 95-day period does not begin until the date of discharge. For a
				  claim for which coordination of benefits applies, the 95-day period does not
				  begin for submission of the claim to the secondary payor until the physician or
				  the provider receives notice of the payment or the denial from the primary
				  payor.
(b) Failure to meet claim
				  submission deadline. If a physician or a provider fails to submit a claim in
				  compliance with this section, the physician or the provider forfeits the right
				  to payment unless the physician or the provider has certified that the failure
				  to timely submit the claim is a result of a catastrophic event in compliance
				  with §
										21.2819 of
				  this title (relating to Catastrophic Event).
(c) Manner of claim submission. A physician
				  or a provider may submit claims by United States mail, first class; United
				  States mail, return receipt requested; overnight delivery service; electronic
				  transmission; hand delivery; facsimile, if the MCC accepts claims submitted by
				  facsimile; or as otherwise agreed to by the physician or the provider and the
				  MCC. An MCC must accept as proof of timely filing a claim filed in compliance
				  with this subsection or information from another MCC showing that the physician
				  or the provider submitted the claim to the other MCC in compliance with this
				  subsection.
(d) Determining date of
				  submission. Section
				  21.2816 of this
				  title (relating to Date of Receipt) determines the date an MCC receives a
				  claim.
(e) Duplicate claims.
(1) A physician or a provider may not submit
				  a duplicate claim before the 46th day, or the 31st day if filed electronically,
				  after the date the original claim is received according to the provisions of
				  §
											21.2816 of this
				  title, except as provided in paragraph (2) of this subsection for prescription
				  benefit claims.
(2) A physician or
				  a provider may not submit a duplicate claim for prescription benefits before
				  the 22nd day, or the 19th day if filed electronically, after the date the
				  original claim is received according to the provisions of §
											21.2816 of this
				  title.
(3) An MCC that receives a
				  duplicate claim before the applicable date specified in paragraphs (1) and (2)
				  of this subsection is not subject to the provisions of §
											21.2807
				  of this title (relating to Effect of Filing a Clean Claim) or §
											21.2815
				  of this title (relating to Failure to Meet the Statutory Claims Payment Period)
				  with respect to the duplicate claim.