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TPPA Coverage

Posted by on Dec 19, 2014 in Health | 0 comments

The Texas Prompt Pay Act (TPPA) is specific to insurance companies that are styled as Health Managed Organizations (HMOs) and Preferred Provider Organizations (PPO). This means that insurance carriers other than HMOs and PPOs are not covered by the provisions of the TPPA except in very few instances. According to the website of the prompt pay law firm Williams Kherkher, this means it does not apply to claims against Medicare and Medicaid, although the forms used for TPPA clean claim compliance is supplied by the Centers for Medicare and Medicaid Services (Forms CMS-1500 for physicians and UB-04 for hospitals).

It does not mean that these excluded carriers are not addressed in the legislation when it comes to prompt pay issues. It just means that they are not addressed in the provisions of the TPPA.

For example, if you are a dentist contracted by HMO A to provide certain services at a specified rate for a group of employees, you will bill HMO A for whatever services you have rendered using Form CMS-1500 (filling it up completely and according to TPPA regulations). If HMO A fails to pay for the claims within 45 days for a mailed claim, or 30 days for an electronically submitted claim, then HMO A is possibly in violation of TPPA regulations, and you can consult with a prompt pay lawyer for guidance on what you should do. On the other hand, if you rendered dental services to Medicare patients and you are being paid late, you cannot rightly cite the TPPA to claim protection or impose sanctions.

The TPPA is a highly specific subsection of laws enforced by the Texas Department of Insurance which is also embodied in the Texas Administrative Code. For a detailed explanation of the TPPA in preparation for filing a claim, it would be advisable to consult with a prompt pay lawyer to make sure that the TPPA applies to a particular case.

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