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

Universal Citation: 28 TX Admin Code § 21.2806

Current through Reg. 50, No. 13; March 28, 2025

(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.

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