Your practice should always question outstanding clean claims filed to HMOs and PPOs that are not processed within 45 calendar days.
Texas' clean claims laws mandate that HMOs and PPOs process clean claims within 45 days from receipt, or the physician is entitled to receive 85 percent of the contracted rate until claim processing has been completed. Upon final payment of the claim, the physician is entitled to receive up to the full billed amount
Send inquiries concerning over-45-day claims to carriers with a request for appropriate action. TMA's sample letter incorporates appropriate statutory language.
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