The Texas Department of Insurance (TDI) adopted new prompt pay rules on Sept. 15, 2003, as a result of TMA-backed House Bill 418.
Under the rules, the carrier is allowed one request for additional information within 30 days of clean claims receipt. The request must be written, specific to the claim or a related episode of care, specifically describe the clinical and other information requested, be relevant and necessary for claim resolution, and be for information contained or in the process of being incorporated into the patient's medical or billing record that your office maintains.
The request for additional information stops the claim clock until the carrier receives (1) the requested information or (2) your response that the information is not in your medical or billing record. Upon receiving a response, the carrier must act on the claim on or before the later of the 15th day after receiving response or the latest date for adjudicating an audited claim.
Go to the TMA Web site for more information about the prompt pay rules, including a link to TDI questions and answers and additional details in the "Education" section of the TDI Web page (covers deadlines, adjudication of audited claims, and more).
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