Tex. Ins. Code § 1301.105 · Subchapter C. PROMPT PAYMENT OF CLAIMS
AUDITED CLAIMS.
Text — Current through the 89th 2nd Called Legislative Session, 2025
(a) Except as provided by Section 1301.1054, an insurer that intends to audit a claim submitted by a preferred provider shall pay the charges submitted at 100 percent of the contracted rate on the claim not later than:
(1) the 30th day after the date the insurer receives the clean claim from the preferred provider if the claim is submitted electronically; or
(2) the 45th day after the date the insurer receives the clean claim from the preferred provider if the claim is submitted nonelectronically.
(b) The insurer shall clearly indicate on the explanation of payment statement in the manner prescribed by the commissioner by rule that the clean claim is being paid at 100 percent of the contracted rate, subject to completion of the audit.
(c) If the insurer requests additional information to complete the audit, the request must describe with specificity the clinical information requested and relate only to information the insurer in good faith can demonstrate is specific to the claim or episode of care. The insurer may not request as a part of the audit information that is not contained in, or is not in the process of being incorporated into, the patient's medical or billing record maintained by a preferred provider.
(d) If the preferred provider does not supply information reasonably requested by the insurer in connection with the audit, the insurer may:
(1) notify the provider in writing that the provider must provide the information not later than the 45th day after the date of the notice or forfeit the amount of the claim; and
(2) if the provider does not provide the information required by this section, recover the amount of the claim.
Notes and commentary — not statutory text
History
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(a), eff. September 1, 2005.
Source of truth
- Edition
- Current through the 89th 2nd Called Legislative Session, 2025
- Official file
- https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1301.htm
- Text hash
- sha256 e9133f8dc11532862502628ba97002d4c46d737f2075be5a1eca00265ab61d07
- Composed by
- compose_tx.py 2026-10-05: the Legislative Council's chapter files read in document order; verify_tx.py's independent reading (lxml DOM walk) agrees character for character
This section cites
Provisions in this library that the text above cites, as it prints each citation. A range cited as “ss. 61.13-61.16” links its first and last provisions.
Cited by 5 provisions
Provisions in this library whose text cites Tex. Ins. Code § 1301.105. Each shows the citation as that text prints it.
Insurance Code
- Tex. Ins. Code § 1301.1051COMPLETION OF AUDIT.Printed as Section 1301.105
- Tex. Ins. Code § 1301.1052PREFERRED PROVIDER APPEAL AFTER AUDIT.Printed as Section 1301.105
- Tex. Ins. Code § 1301.1053DEADLINES NOT EXTENDED.Printed as Section 1301.105
- Tex. Ins. Code § 1301.134COORDINATION OF PAYMENT.Printed as Section 1301.105
- Tex. Ins. Code § 1301.137VIOLATION OF CLAIMS PAYMENT REQUIREMENTS; PENALTY.Printed as Section 1301.103, 1301.104, or 1301.105 | Section 1301.105
Procedural information only. Not legal advice and not a substitute for the advice of an attorney. Confirm the current text with the official publisher before relying on it.