Claims data reporting
TDI issues a mandatory data call for managed care carriers (MCCs) doing business in Texas per Title 28 of the Texas Administrative Code (TAC) 21.2821.
TDI requires this data call to determine carriers’ compliance with prompt pay requirements on claims submitted by providers under Texas Insurance Code (TIC) 1301.101, TIC 1301.131, TIC 843.336, and TAC 21.2801.
Senate Bill 418 and House Bill 610 prompt pay data call reports are due as follows:
- First quarter – Due May 15 of each year
- Second quarter – Due August 15 of each year
- Third quarter – Due November 15 of each year
- Fourth quarter – Due February 15 of each year
- SB 418 annual declinations – Due August 15 of the following year
Prompt pay penalty reporting
After the Texas Health Insurance Pool dissolved effective September 1, 2015, TDI assumed the responsibility for collecting the pool’s share of prompt pay penalties. For claims paid late between August 2015 and December 2021, MCCs reported all penalty payments owed to TDI on the Prompt Pay Reporting Form, (FIN593).
MCCs, who paid claims late after January 2022, must submit claims and payment reports through TDI’s Clean Claims portal, Clean claims application and issue all penalty payments owed to TDI. (Click on the following links to learn more about the portal: Webinar showing the features of the portal | Q&A from the webinar).
House Bill 2064, which passed in 2019 and remains in effect, requires that a portion of the statutory prompt pay penalties to the Pool, until its dissolution. The pool's portion of prompt pay penalties payable under TIC 843.342 and TIC 1301.137 are as follows, regardless of the type of underlying insurance coverage associated with the late claim payment:
- Non-Institutional: The 18% interest portion of the penalty associated with claims paid more than 90 days late.
- Institutional Claims: 50% of the entire penalty, including any interest.
Healthcare Providers
If you are a health care provider, who is having claim-related issues, please visit TDI’s Provider Resources page for additional information related to the prompt payment of clean claims and for a link on how to file a complaint with TDI’s Consumer Protection division, Health Providers.
Claim submission delays due to Change Healthcare cybersecurity event
Carriers and providers unable to meet submission deadlines due to the Change Healthcare cybersecurity event must notify TDI by email at PromptPay@tdi.texas.gov.
TDI granted a waiver from rules for a 30-day period from March 18, 2024. The wavier ends on April 18, 2024.
If a carrier or provider needs more time, a new notification must be submitted to PromptPay@tdi.texas.gov.
TDI’s prompt pay FAQ has guidance on catastrophic event notifications.
Prompt pay related links
- Prompt Pay FAQ
- Prompt Pay Guidelines
- TDI adopts rules related to prompt pay deadlines during a catastrophic event to implement Senate Bill 1286, (88R), Subchapter T. Submission of Clean Claims, 28 TAC §21.2819.