Texas prompt pay law dental

Sourced answer

Under Tex. Ins. Code §1301.002; §843.338; §843.342; Ch. 542 Subch. B, the Texas payment deadline is 30 days — electronic clean claim from a participating provider, dental HMO only (§843.338) and 45 days — paper clean claim from a participating provider, dental HMO only (§843.338). Dental HMO clean claims: §843.342's tiered penalties — the lesser of 50% of the billed-minus-contracted difference or $100,000 (paid late but before day 46 after the required adjudication date), the lesser of 100% or $200,000 (day 46–90), and beyond day 90 the tier-two penalty plus 18% annual interest on that amount — but §843.342(m) pays that interest to the Texas Health Insurance Risk Pool, not to the dentist; only institutional providers split it. The penalty itself is the provider's, and §843.343 lets a physician or provider recover reasonable attorney's fees and court costs in an action to recover payment under the subchapter. Capitated payments are outside the subchapter entirely (§843.345). Dental PPO/indemnity claims: Chapter 542 Subchapter B provides 18% per year on the claim as damages plus reasonable and necessary attorney's fees (§542.060(a)), triggered where the insurer delays payment more than 60 days after receiving the requested items (§542.058(a)) — but it pays "the holder of the policy or the beneficiary making the claim," and §542.051(2) defines the claim as first-party and requires payment directly to the insured or beneficiary, so the statute does not settle provider standing and reads against it on its face. §542.053(c) also disapplies Subchapter B to an HMO except for prompt payment to an enrollee (§1271.005(c)), so the two regimes do not overlap. §542.060(c)'s indexed rate applies only to Chapter 542A forces-of-nature property claims and never reaches dental. Dental applicability: Split regime. Dental benefits in insurance policies are expressly excluded from the SB 418 clean-claim chapter (§1301.002) — the tiered penalties most billing articles quote never apply to dental PPO or indemnity plans, and a Texas exclusive provider benefit plan may not provide dental care benefits at all (§1301.0042(b)). Dental HMOs are covered by the parallel Chapter 843 clean-claim rules: §843.112(b) applies expressly to "a dental health maintenance organization or another single service health maintenance organization that provides dental benefits," and §843.002(13)(B) makes dental care a health care service, so a dentist is a "provider" for the subchapter. Chapter 542 Subchapter B does reach dental carriers — §542.052(15) names a nonprofit dental service corporation — but it governs only first-party claims payable directly to the insured or a named beneficiary, so it is not a provider prompt-pay statute and gives a dentist no deadline in his own right. TDI's prompt-pay FAQ confirms the CHIP, Medicaid, and out-of-state exclusions from the SB 418 regime. It does not address dental at all; the dental exclusion rests on §1301.002 alone. A self-funded private-employer (ERISA) plan is generally beyond this statute's reach and runs on the federal claims-procedure clock instead — but that comes from the courts reading 29 U.S.C. § 1144, not from its text, and it is not categorical: a self-funded governmental or church plan is not an ERISA plan at all, § 1144(b)(6) leaves multiple employer welfare arrangements open to state insurance law, and nothing in § 1144 bars a state from reaching the third-party administrator or the network contract.