The Texas Prompt Pay Act (TPPA) is a relatively new piece of legislation that is still undergoing many changes. Texas prompt pay attorneys have to be on their toes to follow how these changes will impact on the rights of their clients and the outcome of arbitration or litigation. However, one of the primary requirements of protection under the TPPA is that there is a “clean” claim.

The elements of a TPPA clean claim are not at all easy for a law person to follow as it is stated in the Texas Administrative Code but essentially it is a claim that is properly and completely filled out in the proper forms with all the Ts crossed and Is dotted. Simple enough? Not by a long shot.

The Centers for Medicare and Medicaid Services have developed different forms for physicians, hospitals, and pharmacies. Specifically, claims for outpatient services (typically filled out by physicians for reimbursement) make use of CMS-1500 while hospitals (for inpatient services) fill out the UB-04 form. The CMS-1500 has about 33 fields while the UB-04 has 79. It is important that each of these fields is filled out in compliance with the rules governing the TPPA to activate its protection. In one case, for instance, a physician consistently failed to fill out field 17 and 17a in the CMS-1500 and when it turned out that he had been underpaid by the insurance company for years (which the company admitted) he was unable to claim interest payments for the unpaid balances under the TPPA because his claim was not “clean.”

Texas prompt pay attorneys can only act effectively if there is a clean claim. It is easy enough to establish the requisite steps if the claimant makes the effort to make sure that the original claim for reimbursement from the health insurance company is accomplished in compliance with the established rules and regulations. If you have a clean claim and still it is denied or delayed unreasonably without explanation, then it is time to find Texas prompt pay attorneys in your area to file a complaint.

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