My doctor filed the claim late, my HMO refused it, and now the office is billing me. Do I have to pay that?

Start with the sentence that answers your question. Texas law is short here. A contract between an HMO and a physician or provider must specify that the provider will hold an enrollee harmless for payment of the cost of covered health care services if the HMO does not pay the provider for those services [1]. Read the two conditions in it. The service has to be a covered health care service. And the HMO has to be the one not paying [1]. That is the law on the contract, so ask for that contract term by its name: hold harmless.

Next, the clock that caused this. A physician or provider must submit a claim to the HMO not later than the 95th day after the date the services were provided [2]. If the provider fails to submit a claim in compliance with that section, the provider forfeits the right to payment [3]. Read that carefully. What is forfeited is the provider's right to be paid by the plan. These sources do not say the office may move that amount to you. In fact the hold harmless rule above points the other way [1].

The filing window can be longer than 95 days, so do not assume the claim was late. The period may be extended by contract [4]. It may be extended by a notice the commissioner publishes after a catastrophic event [4]. And it may be extended if the department approves the provider's own request after such an event [4]. So ask both sides which date they are using, and whether any extension applied.

Then check the plan's own clock, because a refusal is not always a filing problem. After a clean claim, the HMO has until the 45th day for a paper claim, or the 30th day for one submitted electronically, to decide whether the claim is payable [5]. It must pay the whole claim, or pay the part that is not in dispute and tell the provider in writing why the rest is not paid, or tell the provider in writing why none of it is paid [5]. Ask the HMO for that written reason. These sections are the HMO ones. Is your coverage a preferred provider policy, or a plan your employer pays itself? Then these are not the rules that apply to you.

Compare the date of your care with the date the office says it filed, and count 95 days [2]. Then read your own plan papers for the words hold harmless, or for a line saying you are not responsible when the plan does not pay a network provider [1]. Then ask whether any extension applied to that filing window [4]. Whether your provider's contract with the plan says more than the law requires: "Don't know yet" here, so ask the office for the clause itself.