No Clean Claim, No Prompt Pay Protection

Recently, Dr. Jones discovered that one of the managed care companies with which he does business had underpaid him for years. The company agreed it was at fault - it had never entered the terms of his contract correctly into its payment system - and even admitted this to the Texas Department of Insurance (TDI).

But TDI did not order the managed care company to pay penalties to Dr. Jones for underpaying the claims. Why? Because Dr. Jones habitually had not filled out two of the fields on the CMS-1500 claim form. Because he had failed to submit clean claims, Dr. Jones could not collect any penalties from the payer under the Texas prompt pay law.

In Dr. Jones' case, the problem fields were 17 - the name of the referring physician - and 17a - the identification number of the referring physician. As a primary care physician, Dr. Jones generally sees patients without referral; when filing claims for those patients, he left fields 17 and 17a blank. But the clean claim regulations require that these fields not be left blank. For both fields, Dr. Jones should have entered "self-referral" or "none."

The lesson to be learned here is this: For protection of the Texas prompt pay law to apply, you must submit claims according to the letter of the law. The elements of a clean claim are specified in the Texas Administrative Code. For help in filling out a clean CMS-1500 claim form, see TMA's color-coded form and explanations  members only.

Remember, only health plans regulated by TDI are subject to the Texas prompt pay law. Patients with plans regulated by TDI will have ID cards that have the letters "DOI" or "TDI" printed on them.


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