The Service Is Verified; Do I Need to Send a Clean Claim?


 

Q: If my office receives verification from an insurer that it will pay for a medical service, do we still have to file a clean claim to receive payment under the Texas prompt pay rules?

A: Yes, even if you’ve received verification for services, you still must submit a clean claim in a timely manner to get paid for the services under these rules. Here’s why:

  • Nothing in Senate Bill 418, the prompt pay legislation, indicates that the verification and claim filing processes are mutually exclusive, and nothing exempts a verified service from the clean claim requirements.

 

  • Under the rules, the verification number is a required element of a clean claim.

 

  • An insurer may not deny or reduce payment for a claim for verified services that you provided in a timely manner, except in the case of material misrepresentation or substantial failure to perform the services. The information on a claim form may help the insurer clarify that neither of these situations exist.

For more information about the prompt pay rules, go to the Texas Department of Insurance website.


 

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    When my staff ask specifically for "Verification" of benefits, the typical response is that the insurer cannot do that, that it only applies to INPATIENT benefits, that the plan is "sel-funded." It is amazing how mnay plans are said to be "self-funded" now.
    After obtaining benefits and delivering care accordingly, I still have demands for "overpayments" beyond 180 days.

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