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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