HB 4549

relating to the prompt payment of health insurance claims.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1.  Section 843.338, Insurance Code, is amended to
Sec. 843.338.  DEADLINE FOR ACTION ON CLEAN CLAIMS.  Except
as provided by Sections 843.3385, 843.3405, and 843.339, not later
than the 45th day after the date on which a health maintenance
organization receives a clean claim from a participating physician
or provider in a nonelectronic format or the 30th day after the date
the health maintenance organization receives a clean claim from a
participating physician or provider that is electronically
submitted, the health maintenance organization shall make a
determination of whether the claim is payable and:
(1)  if the health maintenance organization determines
the entire claim is payable, pay the total amount of the claim in
accordance with the contract between the physician or provider and
the health maintenance organization;
(2)  if the health maintenance organization determines
a portion of the claim is payable, pay the portion of the claim that
is not in dispute and notify the physician or provider in writing
why the remaining portion of the claim will not be paid; or
(3)  if the health maintenance organization determines
that the claim is not payable, notify the physician or provider in
writing why the claim will not be paid.
SECTION 2.  Section 843.3405, is amended to read as follows:
Sec. 843.3405.  INVESTIGATION AND DETERMINATION OF PAYMENT.
(a)  Except as provided by Subsection (b), the [The] investigation
and determination of payment, including any coordination of other
payments, does not extend the period for determining whether a
claim is payable under Section 843.338 or 843.339 or for auditing a
(b)  An investigation and determination of payment shall
extend the period for determining whether a claim is payable or for
(1)  the health maintenance organization suspects that
the claim was submitted fraudulently or based on a
(2)  the investigation and determination are made in
SECTION 3.  Section 843.3385(e), Insurance Code, is amended
(e)  If a health maintenance organization requests an
attachment or other information from a person other than the
participating physician or provider who submitted the claim, the
health maintenance organization, not later than the 30th calendar
day after the insurer receives a clean claim, shall provide notice
containing the name of the physician or provider from whom the
health maintenance organization is requesting information to the
physician or provider who submitted the claim.  A health
maintenance organization that requests an attachment under this
subsection shall determine whether the claim is payable on or
before the later of the 15th day after the date the insurer receives
the requested attachment or the latest date for determining whether
the claim is payable under Section 1301.103 or 1301.104. [The
health maintenance organization may not withhold payment pending
receipt of an attachment or information requested under this
subsection.  If on receiving an attachment or information requested
under this subsection the health maintenance organization
determines that there was an error in payment of the claim, the
health maintenance organization may recover any overpayment under
SECTION 4.  Section 843.343, Insurance Code, is amended to
Sec. 843.343.  ATTORNEY'S FEES.  A physician or provider may
recover reasonable attorney's fees and court costs in an action to
recover payment under this subchapter only when a health
maintenance organization has acted in bad faith in making the
SECTION 5.  Section 843.350, Insurance Code, is amended by
amending Subsection (a) and adding Subsection (c) to read as
(a)  Except as provided by Subsection (c), a [A] health
maintenance organization may recover an overpayment to a physician
(1)  not later than the one year [the 180th day] after
the date the physician or provider receives the payment, the health
maintenance organization provides written notice of the
overpayment to the physician or provider that includes the basis
and specific reasons for the request for recovery of funds; and
(2)  the physician or provider does not make
arrangements for repayment of the requested funds on or before the
45th day after the date the physician or provider receives the
(c)  A health maintenance organization may recover an
overpayment to a physician or health care provider at any time if
the claim was submitted fraudulently or based on a
SECTION 6.  Section 843.342, Insurance Code, is amended by
amending Subsections (h) and (n) to read as follows:
(h)  A health maintenance organization is not liable for a
(1)  if the failure to pay the claim in accordance with
this subchapter is a result of a catastrophic event and:
(A)  the commissioner published a notice allowing
an extension of the applicable prompt payment deadlines due to the
(B)  the department approved the health
maintenance organization's request for an extension due to the
substantial interference of the catastrophic event with the normal
business operations of the health maintenance organization; or
(2)  if the claim was not paid or paid in accordance
with this subchapter, but for less than the contracted rate, and:
(A)  the physician or provider notifies the health
maintenance organization of the underpayment after the 270th day
after the date the underpayment was received; and
(B)  the health maintenance organization pays the
balance of the claim on or before the 30th day after the date the
health maintenance organization receives the notice.
(1)  "Institutional [, "institutional] provider" means
a hospital or other medical or health-related service facility that
provides care for the sick or injured or other care that may be
covered in an evidence of coverage; and
(2)  "Billed charges" means the lowest rate the
preferred provider will accept directly from a patient as payment
SECTION 7.  Section 1301.103, Insurance Code, is amended to
Sec. 1301.103.  DEADLINE FOR ACTION ON CLEAN CLAIMS.  Except
as provided by Sections 1301.104, 1301.1053, and 1301.1054, not
later than the 45th day after the date an insurer receives a clean
claim from a preferred provider in a nonelectronic format or the
30th day after the date an insurer receives a clean claim from a
preferred provider that is electronically submitted, the insurer
shall make a determination of whether the claim is payable and:
(1)  if the insurer determines the entire claim is
payable, pay the total amount of the claim in accordance with the
contract between the preferred provider and the insurer;
(2)  if the insurer determines a portion of the claim is
payable, pay the portion of the claim that is not in dispute and
notify the preferred provider in writing why the remaining portion
of the claim will not be paid; or
(3)  if the insurer determines that the claim is not
payable, notify the preferred provider in writing why the claim
SECTION 8.  Section 1301.1053, Insurance Code, is amended to
Sec. 1301.1053.  DEADLINES NOT EXTENDED.  (a)  Except as
provided by Subsection (b), the [The] investigation and
determination of payment, including any coordination of other
payments, does not extend the period for determining whether a
claim is payable under Section 1301.103 or 1301.104 or for auditing
a claim under Section 1301.105.
(b)  An investigation and determination of payment shall
extend the period for determining whether a claim is payable or for
(1)  the insurer suspects that the claim was submitted
fraudulently or based on a misrepresentation; and
(2)  the investigation and determination are made in
SECTION 9.  Section 1301.1054(d), Insurance Code, is amended
(d)  If an insurer requests an attachment or other
information from a person other than the preferred provider who
submitted the claim, the insurer, not later than the 30th calendar
day after the insurer receives a clean claim, shall provide notice
containing the name of the physician or health care provider from
whom the insurer is requesting information to the preferred
provider who submitted the claim.  An insurer that requests an
attachment under this subsection shall determine whether the claim
is payable on or before the later of the 15th day after the date the
insurer receives the requested attachment or the latest date for
determining whether the claim is payable under Section 1301.103 or
1301.104. [The insurer may not withhold payment pending receipt of
an attachment or information requested under this subsection.  If
on receiving an attachment or information requested under this
subsection the insurer determines that there was an error in
payment of the claim, the insurer may recover any overpayment under
SECTION 10.  Section 1301.108, Insurance Code, is amended to
Sec. 1301.108.  ATTORNEY'S FEES.  A preferred provider may
recover reasonable attorney's fees and court costs in an action to
recover payment under this subchapter only when an insurer has
acted in bad faith in making the payment determination.
SECTION 11.  Section 1301.132, Insurance Code, is amended by
amending Subsection (a) and adding Subsection (c) to read as
(a)  Except as provided by Subsection (c), an [An] insurer
may recover an overpayment to a physician or health care provider
(1)  not later than one year [the 180th day] after the
date the physician or provider receives the payment, the insurer
provides written notice of the overpayment to the physician or
provider that includes the basis and specific reasons for the
request for recovery of funds; and
(2)  the physician or provider does not make
arrangements for repayment of the requested funds on or before the
45th day after the date the physician or provider receives the
(c)  An insurer may recover an overpayment to a physician or
health care provider at any time if the claim was submitted
fraudulently or based on a misrepresentation.
SECTION 12.  Section 1301.137, Insurance Code, is amended by
amending Subsection (h) and adding Subsection (m) to read as
(h)  An insurer is not liable for a penalty under this
(1)  if the failure to pay the claim in accordance with
Subchapter C is a result of a catastrophic event and:
(A)  the commissioner published a notice allowing
an extension of the applicable prompt payment deadlines due to the
(B)  the department approved the insurer's
request for an extension due to the substantial interference of the
catastrophic event with the normal business operations of the
(2)  if the claim was not paid or paid in accordance
with Subchapter C, but for less than the contracted rate, and:
(A)  the preferred provider notifies the insurer
of the underpayment after the 270th day after the date the
(B)  the insurer pays the balance of the claim on
or before the 30th day after the date the insurer receives the
(m)  In this section, "billed charges" means the lowest rate
the preferred provider will accept directly from a patient as
payment in full for the services.
SECTION 13.  This Act takes effect immediately if it
receives a vote of two-thirds of all the members elected to each
house, as provided by Section 39, Article III, Texas Constitution.
If this Act does not receive the vote necessary for immediate
effect, this Act takes effect September 1, 2025.