Texas Insurance Code
§ 843.342 — VIOLATION OF CERTAIN CLAIMS PAYMENT PROVISIONS; PENALTIES
IN § 843.342Title 6. ORGANIZATION OF INSURERS AND RELATED ENTITIES · Part C. LIFE, HEALTH, AND ACCIDENT INSURERS AND RELATED ENTITIES · Ch. 843. HEALTH MAINTENANCE ORGANIZATIONS · Art. J. PAYMENT OF CLAIMS TO PHYSICIANS AND PROVIDERS
Statute text
View on source(a)Except as provided by this section, if a clean claim submitted to a health maintenance organization is payable and the health maintenance organization does not determine under this subchapter that the claim is payable and pay the claim on or before the date the health maintenance organization is required to make a determination or adjudication of the claim, the health maintenance organization shall pay the physician or provider making the claim the contracted rate owed on the claim plus a penalty in the amount of the lesser of:
(1)50 percent of the difference between the billed charges, as submitted on the claim, and the contracted rate; or
(2)$100,000.
(b)If the claim is paid on or after the 46th day and before the 91st day after the date the health maintenance organization is required to make a determination or adjudication of the claim, the health maintenance organization shall pay a penalty in the amount of the lesser of:
(1)100 percent of the difference between the billed charges, as submitted on the claim, and the contracted rate; or
(2)$200,000.
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Legislative history
Acts 2007, 80th Leg., R.S., Ch. 435 (S.B. 1884), Sec. 1, eff. September 1, 2007. Acts 2009, 81st Leg., R.S., Ch. 265 (H.B. 2064), Sec. 1, eff. January 1, 2010. Acts 2023, 88th Leg., R.S., Ch. 90 (S.B. 1286), Sec. 2, eff. September 1, 2023.