Tex. Ins. Code Section 843.338
Deadline for Action on Clean Claims

Except as provided by Sections 843.3385 (Additional Information) and 843.339 (Deadline for Action on Prescription Claims; Payment), not later than the 45th day after the date on which a health maintenance organization receives a clean claim from a participating physician or provider in a nonelectronic format or the 30th day after the date the health maintenance organization receives a clean claim from a participating physician or provider that is electronically submitted, the health maintenance organization shall make a determination of whether the claim is payable and:

(1)

if the health maintenance organization determines the entire claim is payable, pay the total amount of the claim in accordance with the contract between the physician or provider and the health maintenance organization;

(2)

if the health maintenance organization determines a portion of the claim is payable, pay the portion of the claim that is not in dispute and notify the physician or provider in writing why the remaining portion of the claim will not be paid; or

(3)

if the health maintenance organization determines that the claim is not payable, notify the physician or provider in writing why the claim will not be paid.
Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003. Amended by Acts 2003, 78th Leg., ch. 214, Sec. 8, eff. June 17, 2003.
Amended by:
Acts 2011, 82nd Leg., R.S., Ch. 798 (H.B. 2292), Sec. 2, eff. September 1, 2011.

Source: Section 843.338 — Deadline for Action on Clean Claims, https://statutes.­capitol.­texas.­gov/Docs/IN/htm/IN.­843.­htm#843.­338 (accessed Jun. 5, 2024).

843.001
Short Title 843.002
Definitions 843.003
Powers of Insurers and Group Hospital Service Corporations 843.004
Governing Body of Health Maintenance Organization 843.005
Use of Insurance-related Terms by Health Maintenance Organization 843.006
Public Documents 843.007
Confidentiality of Medical and Health Information 843.008
Costs of Administering Health Maintenance Organization Laws 843.009
Appeals 843.010
Applicability of Certain Provisions to Governmental Health Benefit Plans 843.051
Applicability of Insurance and Group Hospital Service Corporation Laws 843.052
Laws Relating to Solicitation or Advertising 843.053
Laws Relating to Restraint of Trade 843.054
Laws Requiring Certificate of Need for Health Care Facility or Service 843.055
Laws Relating to Practice of Medicine 843.056
Inapplicability of Bankruptcy Law 843.072
Authorization Required to Act as Health Maintenance Organization 843.073
Certificate of Authority Requirement: Applicability to Physicians and Providers 843.074
Certificate of Authority Requirement: Applicability to Medical School and Medical and Dental Unit 843.075
Certificate of Authority for Single Health Care Service Plan 843.076
Application 843.077
Eligibility of Foreign Corporation 843.078
Contents of Application 843.079
Contents of Application: Limited Health Care Service Plan 843.080
Modification or Amendment of Application Information 843.082
Requirements for Approval of Application 843.083
Denial of Certificate of Authority 843.084
Duration of Certificate of Authority 843.085
Change in Control: Commissioner Approval 843.101
Providing or Arranging for Care 843.102
Health Maintenance Organization Quality Assurance 843.103
Acquisition and Operation of Facilities 843.104
Contracts for Certain Administrative Functions 843.105
Management and Exclusive Agency Contracts 843.106
Insurance, Reinsurance, Indemnity, and Reimbursement 843.107
Indemnity Benefits 843.108
Point-of-service Rider 843.109
Payment by Governmental or Private Entity 843.110
Corporation, Partnership, or Association Powers 843.111
Group Model Health Maintenance Organizations 843.112
Dental Point-of-service Option 843.113
Specified Powers Not Exclusive 843.151
Rules 843.152
Subpoena Authority 843.153
Authority to Contract 843.154
Fees 843.155
Annual Report 843.156
Examinations 843.157
Rehabilitation, Liquidation, Supervision, or Conservation of Health Maintenance Organization 843.201
Disclosure of Information About Health Care Plan Terms 843.202
Disclosure of Information to Medicare Recipients 843.203
Selection of Primary Care Physician or Provider 843.204
Untrue or Misleading Information 843.205
Member’s Handbook 843.206
Notice of Change in Payment Arrangements 843.207
Notice of Change in Operations 843.208
Cancellation or Nonrenewal of Coverage 843.209
Identification Card 843.210
Terms of Enrollee Eligibility 843.211
Applicability of Subchapter to Entities Contracting with Health Maintenance Organization 843.251
Complaint System Required 843.252
Complaint Initiation and Initial Response 843.253
Complaint Investigation and Resolution 843.254
Appeal to Complaint Appeal Panel 843.255
Composition of Complaint Appeal Panel 843.256
Information Provided to Complainant Relating to Complaint Appeal Panel 843.257
Rights of Complainant at Complaint Appeal Panel Meeting 843.258
Appeal Involving Ongoing Emergency or Continued Hospitalization 843.259
Notice of Decision on Appeal 843.260
Record of Complaints 843.261
Special Provisions for Appeals of Adverse Determinations 843.262
Certain Decisions Binding 843.281
Retaliatory Action Prohibited 843.282
Submitting Complaints to Department 843.283
Posting of Information on Complaint Process Required 843.301
Practice of Medicine Not Affected 843.302
Disclosure of Application Procedures and Qualification Requirements to Physician or Provider 843.303
Denial of Initial Contract to Physician or Provider 843.304
Exclusion of Provider Based on Type of License Prohibited 843.305
Annual Application Period for Physicians and Providers to Contract 843.306
Termination of Participation 843.307
Expedited Review Process on Termination or Deselection 843.308
Notification of Patients of Deselected Physician or Provider 843.309
Contracts with Physicians or Providers: Notice to Certain Enrollees of Termination of Physician or Provider Participation in Plan 843.310
Contracts with Physicians or Providers: Certain Indemnity Clauses Prohibited 843.311
Contracts with Podiatrists 843.312
Physician Assistants and Advanced Practice Nurses 843.313
Economic Profiling 843.314
Inducement to Limit Medically Necessary Services Prohibited 843.315
Payment of Capitation 843.316
Alternative Capitation System 843.317
Exclusion of Physician or Provider Based on Affiliation with Health Maintenance Organization Prohibited 843.318
Certain Contracts of Participating Physician or Provider Not Prohibited 843.319
Certain Required Contracts 843.320
Use of Hospitalist 843.321
Availability of Coding Guidelines 843.323
Contract Provisions Prohibiting Rejection of Batched Claims 843.336
Definition 843.337
Time for Submission of Claim 843.338
Deadline for Action on Clean Claims 843.339
Deadline for Action on Prescription Claims 843.340
Audited Claims 843.341
Claims Processing Procedures 843.342
Violation of Certain Claims Payment Provisions 843.343
Attorney’s Fees 843.344
Applicability of Subchapter to Entities Contracting with Health Maintenance Organization 843.345
Exception 843.346
Payment of Claims 843.347
Verification 843.348
Preauthorization of Health Care Services 843.349
Coordination of Payment 843.350
Overpayment 843.351
Services Provided by Certain Physicians and Providers 843.352
Conflict with Other Law 843.353
Waiver Prohibited 843.354
Legislative Declaration 843.361
Enrollees Held Harmless 843.362
Continuity of Care 843.363
Protected Physician or Provider Communications with Patients 843.401
Fiduciary Responsibility 843.402
Officers’ and Employees’ Bond 843.403
Minimum Net Worth 843.404
Additional Net Worth Requirements 843.405
Deposit with Comptroller 843.406
Hazardous Financial Condition 843.407
Receivership and Delinquency Proceedings 843.408
Insolvency and Allocation to Other Health Maintenance Organizations 843.409
Examination Expenses 843.410
Assessments 843.461
Enforcement Actions 843.462
Operations During Suspension or After Revocation of Certificate of Authority 843.463
Injunctions 843.464
Criminal Penalty 843.2015
Information Available Through Internet Site 843.2071
Notice of Increase in Charge for Coverage 843.3041
Acupuncturist Services 843.3042
Chiropractic Services 843.3045
Nurse First Assistant 843.3115
Contracts with Dentists 843.3385
Additional Information 843.3405
Investigation and Determination of Payment 843.3481
Posting of Preauthorization Requirements 843.3482
Changes to Preauthorization Requirements 843.3483
Remedy for Noncompliance
Green check means up to date. Up to date

Accessed:
Jun. 5, 2024

§ 843.338’s source at texas​.gov