My coverage is an HMO, and it says it never got my doctor's claim. What does Texas law say about the date a claim is received?

Start with the provider's clock. A physician or provider must submit a claim to an HMO. The deadline is the 95th day after the date the services were provided [1]. The same sentence binds the HMO too. It must accept as proof of timely filing a claim filed in one of the allowed ways [1]. It must also accept word from another HMO or insurer showing the claim went in that way [1]. Those allowed ways are four: mail, electronic submission, fax, or hand delivery [2]. And the office cannot keep sending copies. No duplicate claim may go in before the 46th day after the original [2].

Now the received date. A mailed claim is presumed received on the fifth day after it was mailed [3]. Sent overnight, or return receipt requested? Then the date is the day the delivery receipt is signed [3]. An electronic claim is presumed received on the date of the electronic verification of receipt [3]. That verification can be by the HMO or by its clearinghouse [3]. Does neither one confirm within 24 hours of submission? Then the provider's clearinghouse must provide the confirmation [3]. A faxed claim is presumed received on the date of the transmission acknowledgment [3]. A hand delivered claim is presumed received on the date the delivery receipt is signed [3].

Then the HMO's own clock runs, and it carries a condition. The section speaks of a clean claim from a participating physician or provider [4]. For such a paper claim the HMO has until the 45th day. For one submitted electronically it has until the 30th day. By then it must decide whether the claim is payable [4]. Was your doctor outside the network? Then this clock may not be the one that applies. Then it must do one of three things. Pay the whole claim [4]. Or pay the part not in dispute and tell the provider in writing why the rest is not paid [4]. Or tell the provider in writing why none of it is paid [4].

One stall has its own rule. Does the HMO need more information to decide? It must ask in writing no later than the 30th calendar day after it gets a clean claim [5]. The request must describe with specificity the clinical information it wants [5]. And it must relate only to information the HMO can show is specific to that claim, or to the claim's related episode of care [5]. Your doctor need not provide an attachment that is not in, or being put into, your medical or billing record [5]. The HMO must then decide by the later of two dates: the 15th day after it gets the attachment, or the normal deadline [5]. And it may not make more than one such request for a claim [5]. These sections are the HMO ones. Is your coverage a preferred provider policy, or a plan your employer pays itself? Then ask which rule it is applying.

Ask which of the four ways the claim was sent, because each has its own received date [2][3]. Then count 30 or 45 days from that date [4]. The section ties those days to a clean claim from a participating physician or provider [4]. Then ask the office whether it got a written request for records, and whether a second one came, which the law does not allow [5]. Whether your claim was a clean claim: "Don't know yet" here, because the chapter defines that term and the HMO applies it.