1. (a) A physician or provider must submit a claim to an HMO or preferred provider carrier not later than the 95th day after the date the physician or provider provides the medical care or health care services for which the claim is made. An HMO or preferred provider carrier and a physician or provider may agree, by contract, to extend the period for submitting a claim. For a claim submitted by an institutional provider, the 95-day period does not begin until the date of discharge. For a claim for which coordination of benefits applies, the 95-day period does not begin for submission of the claim to the secondary payor until the physician or provider receives notice of the payment or denial from the primary payor.
2. (b) If a physician or provider fails to submit a claim in compliance with this section, the physician or provider forfeits the right to payment unless the physician or provider has certified that the failure to timely submit the claim is a result of a catastrophic event in accordance with §21.2819 of this title (relating to Catastrophic Event).
3. (c) A physician or provider may submit claims via United States mail, first class, overnight delivery service, electronic transmission, hand delivery, facsimile, if the HMO or preferred provider carrier accepts claims submitted by facsimile, or as otherwise agreed to by the physician or provider and the HMO or preferred provider carrier. An HMO or preferred provider carrier shall accept as proof of timely filing a claim filed in compliance with this subsection or information from another HMO or preferred provider carrier showing that the physician or provider submitted the claim to the HMO or preferred provider carrier in compliance with this subsection.
4. (d) §21.2816 of this title (relating to Date of Receipt) determines the date an HMO or preferred provider carrier receives a claim.
5. (e) A physician or provider may not submit a duplicate claim prior to the 46th day, the 31st day if filed electronically, or the 22nd day if a claim for prescription benefits, after the date the original claim is received according to the provisions of §21.2816 of this title. An HMO or preferred provider carrier that receives a duplicate claim prior to the 46th day after receipt of the original claim, a duplicate electronic claim prior to the 31st day after receipt of the original claim, or a duplicate claim for prescription benefits prior to the 22nd day after receipt of the original claim is not subject to the provisions of §§21.2807 of this title (relating to Effect of Filing a Clean Claim) or 21.2815 of this title (relating to Failure to Meet the Statutory Claims Payment Period) with respect to the duplicate claim.

Source Note:The provisions of this §21.2806 adopted to be effective October 5, 2003, 28 TexReg 8647.