Prompt Pay Claim Eligibility

Medical service providers deserve to be paid fairly for their work. This means that not only should they be fully compensated for their efforts, but that such compensation should be provided in a timely manner. In order to help ensure that medical professionals receive compensation appropriately from insurance providers, the Texas Prompt Pay Act provides a legal mechanism whereby insurance companies that fail to fully compensate medical professionals within a given time-frame may be penalized and held legally accountable for their inaction.

In order for a medical professional to be eligible to pursue a Prompt Pay claim, however, a considerable number of requirements must first be met, some of which may require the assistance of qualified legal counsel. At Williams Kherkher, we know how confusing it can be for Texas medical providers to pursue a Prompt Pay claim; however, taking such action can be worth it when it results in you getting the payments you should have already been provided.

Eligibility Requirements for Prompt Pay Claims

In order to be eligible to pursue a Prompt Pay claim, the following requirements must first be met:

  • The patient must be insured by an entity covered by the Prompt Pay Act (see our covered entities section).
  • The medical care provider must either have a written contract with the insurance company (third party contracts typically qualify), have performed services in an emergency or its attendant episode of care, or have performed services at the request of the insurance company because an in-network doctor could not have reasonably performed the services.
  • The claim initially submitted to the insurance company must have been a “clean claim”; that is, the data contained in the claim must be “complete, legible, and accurate.”
  • The claim must have been submitted within 95 days of services rendered, with rare exceptions.

If all of these requirements are satisfied, and the insurer fails to pay the doctor’s claim, a Prompt Pay claim may be possible.

Talk to a Prompt Pay Attorney in Texas

If you believe that you may be entitled to pursue a Prompt Pay claim for compensation you are owed by an insurance company, our attorneys at Williams Kherkher can help. Call (888) 220-0640 today to learn more about what we can do to help you fight for the compensation you need.

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