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I have an HMO, I paid the bill myself, and I want the plan to pay me back. What clocks does it have to keep?

Health insuranceHow to fileTexasChecked Nov 6, 2026

From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-06 · Source: Texas Insurance Code · Chapter 1271 · § 1271.005(c) «Applicability of Other Law» View original ↗

In short

  1. An HMO must keep the prompt payment clocks when it pays you [1].
  2. Send a written notice with the facts, and keep that date [4].
  3. It has 15 days to answer, then 15 business days, then 5 [5] [6] [8].

What this means

Two sentences decide which rules apply to you. An HMO shall comply with Subchapter B, Chapter 542, with respect to prompt payment to an enrollee [1]. And that subchapter says it does not apply to an HMO except as that section provides [2]. So read the limit with the duty. These clocks run on money the plan owes you. The clocks for money it owes a clinic sit in another chapter.

What kind of claim is yours? A claim there means a first-party claim, made by an insured, a policyholder, or a named beneficiary [3]. And it must be one the insurer pays directly to that person [3]. You paid the bill and want the plan to pay you, so that is the kind. Starting it is simple. A notice of claim means any written notification from you that reasonably apprises the plan of the facts relating to the claim [4]. Write what happened, with dates and amounts, attach the receipt and the itemized bill, and keep the date you sent it.

Then three clocks run in order. Not later than the 15th day after it receives notice of your claim, the plan must acknowledge receipt, start any investigation, and request every item, statement and form it reasonably believes it will need [5]. It may ask for more later if the investigation needs it [5]. Then it must tell you in writing whether it accepts or rejects the claim, no later than the 15th business day after it has all those items [6]. If it rejects the claim, that notice must state the reasons [7]. If it says it will pay, it must pay no later than the fifth business day after that notice [8]. If the payment waits on something you must do, those five business days start when you do it [8].

So the dates on your own letters are what hold the plan to this. Send one package, dated, with everything on its list. Keep a copy. These are the Texas rules for an HMO paying an enrollee. Does your coverage pay its own claims through your employer instead? Then ask the plan administrator which rule applies to your reimbursement.

Your next step

Send one written notice with the facts, the dates and the amounts, and attach the receipt and the itemized bill [4]. Write on your copy the date you sent it. Count 15 days for the acknowledgment and for the plan's list of what it needs [5]. Send everything on that list in one dated package. Then count 15 business days for a written accept or reject [6]. Is it a reject with no reasons? Then ask for the reasons in writing, because the notice must state them [7]. If it says yes, count five business days to payment [8]. The sources give no deadline for your own first letter, so send it as soon as you have the receipt.

Check it yourself

Find the member reimbursement form and address in your own plan papers. Then check your copy for the date you sent the notice and for the plan's acknowledgment [5]. Then compare any reject letter with what it must state [7]. Whether your own evidence of coverage sets a filing window for member claims: "Don't know yet" here, so read the proof of loss part and ask the plan in writing.

Where this comes from (8)

  1. [1] Texas Insurance Code · Chapter 1271 · § 1271.005(c) «Applicability of Other Law» · checked 2026-11-06

    A health maintenance organization shall comply with Subchapter B , Chapter 542 , with respect to prompt payment to an enrollee.

  2. [2] Texas Insurance Code · Chapter 542 · § 542.053(c) «Exception» · checked 2026-11-06

    This subchapter does not apply to a health maintenance organization except as provided by Section 1271.005 (c).

  3. [3] Texas Insurance Code · Chapter 542 · § 542.051(2) «Definitions» · checked 2026-11-06

    Claim" means a first-party claim that: (A) is made by an insured or policyholder under an insurance policy or contract or by a beneficiary named in the policy or contract; and (B) must be paid by the insurer directly to the insured or beneficiary.

  4. [4] Texas Insurance Code · Chapter 542 · § 542.051(4) «Definitions» · checked 2026-11-06

    Notice of claim" means any written notification provided by a claimant to an insurer that reasonably apprises the insurer of the facts relating to the claim.

  5. [5] Texas Insurance Code · Chapter 542 · § 542.055(a)-(b) «Receipt of Notice of Claim» · checked 2026-11-06

    Not later than the 15th day or, if the insurer is an eligible surplus lines insurer, the 30th business day after the date an insurer receives notice of a claim, the insurer shall: (1) acknowledge receipt of the claim; (2) commence any investigation of the claim; and (3) request from the claimant all items, statements, and forms that the insurer reasonably believes, at that time, will be required from the claimant. (b…

  6. [6] Texas Insurance Code · Chapter 542 · § 542.056(a) «Notice of Acceptance or Rejection of Claim» · checked 2026-11-06

    an insurer shall notify a claimant in writing of the acceptance or rejection of a claim not later than the 15th business day after the date the insurer receives all items, statements, and forms required by the insurer to secure final proof of loss.

  7. [7] Texas Insurance Code · Chapter 542 · § 542.056(c) «Notice of Acceptance or Rejection of Claim» · checked 2026-11-06

    If the insurer rejects the claim, the notice required by Subsection (a) or (b) must state the reasons for the rejection.

  8. [8] Texas Insurance Code · Chapter 542 · § 542.057(a)-(b) «Payment of Claim» · checked 2026-11-06

    if an insurer notifies a claimant under Section 542.056 that the insurer will pay a claim or part of a claim, the insurer shall pay the claim not later than the fifth business day after the date notice is made. (b) If payment of the claim or part of the claim is conditioned on the performance of an act by the claimant, the insurer shall pay the claim not later than the fifth business day after the date the act is per…

How we found this

We matched your question to 8 official sources, quoted the exact lines, and re-checked each quote against its source on 2026-11-06.

What we don’t know yet

Your own plan or notice may say something different. If your letter cites another rule, send it and we will look again.

Every answer is checked against the official rule it quotes.

Information only — not legal advice. Your plan, insurer or agency decides.

This answer quotes the official sources listed above, with the date we checked them. Your own policy, notice and state rules control. We are not your lawyer or your insurer. We don’t file, argue or negotiate claims for you — you send any letter or form yourself.

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