Sample Letter (SB 418): Paper Claim in Process Over 45 Days

____________________

____________________

____________________

____________________

RE:  Request for Claim Resolution  

Patient: _______________________

Member ID: ____________________

Insured: _______________________

Date of Service: _________________

Amount: _______________________

Dear Payer:

Please be advised that this letter is to request final resolution of the claim/services in question.

It is believed that your organization has had the paper-submitted clean claim(s) in question pending and in your possession for 45 or more calendar days. All data elements required by Texas Law were present on the claim(s) when submitted.

We believe that failure to release payment may be a violation of Texas law. We are aware that the Texas Prompt Payment law (28 TAC §§21.2801 - 21.2824) prohibits insurers from unnecessarily delaying claims processing. Payers have 45 days to (1) pay the total amount of a clean claim in accordance with its provider contract, (2) pay the undisputed portion and notify the provider in writing why the rest won't be paid or (3) notify the provider in writing why the claims will not be paid.  If a carrier is unable to pay or deny a paper claim within 45 days, in whole or in part, and audits the claim to determine whether the claim is payable, the payer must notify the physician that the claim is being audited and pay 100% of the contracted rate.

Payers that violate these requirements are liable to a provider a graduated penalty in addition to the contracted rate and may be subject to an administrative penalty by the Texas Department of Insurance.

Since the paper claim(s) in question were received by your company over 45 days ago, we are requesting the following at this time: 

  1. For claims paid up to 45 days late, the contracted rate plus the lesser of 50% of the difference between the billed charges and the contracted rate or $100,000; or,
  2. For claims paid 46-90 days late, the contracted rate plus the lesser of 100% of the difference between the billed charges and the contracted rate or $200,000; or,
  3. For claims paid more than 90 days late, the contracted rate plus the lesser of 100% of the difference between the billed charges and the contracted rate or $200,000, plus 18% annual interest on the penalty amount.

Thank you for your prompt attention to this matter. Should you have any questions, please contact our office at ____________________________.

Sincerely,