Questions & answers · Health insurance
I have an HMO. The clinic filed my claim late and the plan would not pay. Can the clinic bill me?
Health insuranceWho paysTexasChecked Nov 6, 2026
From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-06 · Source: Texas Insurance Code · Chapter 843 · § 843.337(a) (Time for Submission of Claim) View original ↗
In short
What this means
Texas puts the clock on the provider. A physician or provider must submit a claim to a health maintenance organization not later than the 95th day after the date the care was given [1]. Miss that, and the provider forfeits the right to payment [2]. What is lost there is the provider's right to be paid by the plan.
Now the part that protects you. A contract between a health maintenance organization and a provider must specify that the provider will hold an enrollee harmless for payment of the cost of covered health care services if the plan does not pay the provider for those services [3]. So a bill at your door for covered care is the thing to question. Do it in writing, and name that rule.
Two details decide a real case. The care has to be covered health care services under your plan. And the provider has to be one with a contract or other agreement with the plan [3]. Ask the plan to confirm both in writing before you argue about the bill.
A claim that looks late is not always late. The plan must accept proof of timely filing filed in compliance with the statute, or information from another plan or insurer showing the claim went in that way [1]. The 95 days can also be extended by contract, by a notice the commissioner publishes after a catastrophic event, or by the department approving a provider's request after such an event [4]. These sections are the HMO chapter. A preferred provider plan, or a self-funded plan at work, runs on other rules.
Your next step
Write to the clinic and the plan. Ask the plan to confirm two things: that the service was covered, and that the clinic had a contract or other agreement with it on that date [3]. Ask the clinic to point to the hold-harmless term in that contract [3]. Keep the bill and both letters, and date them. These sources set no deadline for either answer, so send yours with proof of the date. The deadline these sources give is the provider's: the claim must go in within 95 days of the care [1].
Check it yourself
Open your evidence of coverage and check that the service is listed as covered. Then look at your plan directory for the clinic on the date of service. Compare the visit date with the 95-day rule [1]. Whether the clinic contract wording matches the rule: "Don't know yet" here, so ask to see it.
Where this comes from (4)
[1] Texas Insurance Code · Chapter 843 · § 843.337(a) (Time for Submission of Claim) · checked 2026-11-06
A physician or provider must submit a claim to a health maintenance organization not later than the 95th day after the date the physician or provider provides the health care services for which the claim is made. A health maintenance organization shall accept as proof of timely filing a claim filed in compliance with Subsection (e) or information from another health maintenance organization or insurer showing that th…
[2] Texas Insurance Code · Chapter 843 · § 843.337(b) (Time for Submission of Claim) · checked 2026-11-06
If a physician or provider fails to submit a claim in compliance with this section, the physician or provider forfeits the right to payment.
[3] Texas Insurance Code · Chapter 843 · § 843.361 (Enrollees Held Harmless) · checked 2026-11-06
A contract or other agreement between a health maintenance organization and a physician or provider must specify that the physician or provider will hold an enrollee harmless for payment of the cost of covered health care services if the health maintenance organization does not pay the physician or provider for those services.
[4] Texas Insurance Code · Chapter 843 · § 843.337(c) (Time for Submission of Claim) · checked 2026-11-06
The period for submitting a claim under this section may be extended by: (1) contract; (2) notice published by the commissioner allowing an extension of prompt payment deadlines to a later date chosen by the commissioner due to a catastrophic event; or (3) the department's approval of a physician's or provider's request for an extension due to a catastrophic event that substantially interferes with the normal busines…
How we found this
We matched your question to 4 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.
Related answers
- If Medicare denies a surgery claim, do I have to pay the surgeon?
- Can my Medigap plan pay a claim that Original Medicare denied?
- Do I have to apply for Medicaid before a hospital will give me financial assistance?
- I have both Medicare and Medicaid. Who pays first, and what do I still pay?
Answer id CQ2172. Spotted an error? Tell us.