What is the Texas Prompt Pay Act deadline for paying medical claims?
Under Texas Insurance Code Chapters 843 (HMOs) and 1301 (preferred provider plans), Texas-licensed insurers must pay or deny an electronically submitted clean claim within 30 calendar days of receipt (or 45 calendar days for paper claims). If a clean claim is not paid within this statutory window, the insurer is legally required to pay statutory interest and penalties starting at 18% per annum or the billed charges depending on how late the claim is.
1. Understanding Texas Insurance Code Chapters 843 and 1301
The Texas Prompt Pay statute was designed by the Texas Legislature to prevent health maintenance organizations (HMOs) and preferred provider insurers from stalling physician payments.
Unlike generic federal regulations, Texas law establishes clear statutory timelines, defines what constitutes an unalterable 'clean claim', and enforces self-executing financial penalties when plans violate deadlines.
2. What Constitutes an Irrefutable 'Clean Claim' in Texas?
Texas Department of Insurance (TDI) standard data requirements
To trigger prompt pay protections, your claim must contain all required TDI clean claim data elements, including:
• Complete subscriber and patient identifiers, policy number, and group ID.
• Accurate diagnosis codes (ICD-10-CM) to highest specificity, with appropriate CPT/HCPCS and modifiers.
• Provider billing NPI, rendering NPI, physical service location address, and Texas Medical Board license numbers.
• Prior authorization numbers clearly populated in Loop 2300 / Box 23 when pre-service approval was required.
- Clearinghouse 277CA acceptance confirms initial receipt date for prompt pay calculation.
- If a payer requests additional documentation within 30 days, the prompt pay clock pauses until your practice responds.
- Practices must provide requested clinical records within 45 days, after which the payer has only the remaining statutory days to pay.
3. How to File Prompt Pay Complaints with the Texas Department of Insurance
When major Texas payers consistently violate the 30-day window, healthcare practices can submit provider complaint forms to the TDI Consumer Protection Division.
Systematic TDI complaints often lead to state compliance audits, forcing payers to disburse backlogged payments plus accumulated 18% statutory penalty interest directly to your bank account.