What is the Texas prompt-pay deadline for dental claims, and what interest applies to late payment?

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Split regime for dental · Last verified 2026-08-31

Texas prompt-pay law for dental claims

Texas runs more than one prompt-pay regime for dental claims. Which deadline and interest rate apply depends on the payer type, set out below.

Tex. Ins. Code §1301.002; §843.338; §843.342; Ch. 542 Subch. B

Read the statute text

Payment deadlines

Electronic claims: 30 days — electronic clean claim from a participating provider, dental HMO only (§843.338)
Paper claims: 45 days — paper clean claim from a participating provider, dental HMO only (§843.338)

Texas's famous clean-claim regime does not apply to dental insurance: §1301.002 says Chapter 1301 "does not apply to a provision for dental care benefits in a health insurance policy." The 30-day electronic / 45-day paper clean-claim deadlines reach dental only through dental HMOs under §843.338, and only for a claim from a participating physician or provider. Chapter 843 defines an HMO to include single-service plans, and the clean-claim payment deadlines (§843.338) and penalties (§843.342) carry no dental exception — the only dental-specific carve-outs in Subchapter J are from verification (§843.347(c)) and preauthorization (§843.348(f)), and their existence is itself proof that single-service dental HMOs are otherwise inside the subchapter. Capitated payments are outside Subchapter J entirely (§843.345). A dental PPO or indemnity claim billed by the dentist has no Texas provider prompt-pay deadline. Chapter 542 Subchapter B is a first-party act running to the patient — §542.051(2) defines the claim as one made by an insured, policyholder or named beneficiary that "must be paid by the insurer directly to the insured or beneficiary" — so the dentist's access depends on assignment doctrine the statute does not settle. On the patient's own claim that act runs 15 days to acknowledge (§542.055), 15 business days to accept or reject after all requested items arrive (§542.056(a)), and 5 business days to pay after acceptance (§542.057) — but §542.056(d) lets the insurer notify inside that period that it needs more time and then "accept or reject the claim not later than the 45th day after the date the insurer notifies a claimant under this subsection," so 15 business days can lawfully become 15 business days plus 45 more.

Interest and penalties

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.

Does it apply to dental? Split regime for dental

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.

Self-funded (ERISA) plans: A self-funded private-employer (ERISA) dental plan is generally beyond a state prompt-pay statute's reach: 29 U.S.C. § 1144(b)(2)(B) bars a state from deeming such a plan an insurer, and the courts have read that to keep state insurance regulation off it. The statute itself never uses the words self-funded or prompt pay, and the rule is not categorical — a self-funded governmental or church plan is not an ERISA plan at all, so state law can reach it; § 1144(b)(6) leaves multiple employer welfare arrangements open to state insurance law; and nothing in § 1144 addresses state enforcement against the third-party administrator or the network contract. Where the plan is a self-funded ERISA group health plan, the federal claims-procedure deadlines apply instead: a post-service benefit determination within 30 days (one 15-day extension), at least 180 days to appeal, and an appeal decision within 60 days (or two 30-day levels), under 29 CFR 2560.503-1.

Estimate the late-payment interest

Uses the verified Texas rule (Tex. Ins. Code §1301.002; §843.338; §843.342; Ch. 542 Subch. B). Estimate only — the statute's own accrual triggers control.

How the claim was submitted

Texas sets a different deadline for each, so this decides which day the field below counts from.

Electronic— 30 days — electronic clean claim from a participating provider, dental HMO only (§843.338)Paper— 45 days — paper clean claim from a participating provider, dental HMO only (§843.338)

Claim amount (allowed)Interest statutes run on the payable claim amount, not billed charges.Days past the deadlineDays after the statutory deadline for a electronic claim (30 days — electronic clean claim from a participating provider, dental HMO only (§843.338)), not days since submission.

No single formula applies

Two different regimes apply depending on the entity, and the late-stage 18% in the dental HMO regime is not the dentist's money — see the detail on this page before estimating anything.

How we calculate this

The calculator does not show a payable amount for this result; the explanation above states the controlling limitation. The rate and deadline come from Tex. Ins. Code §1301.002; §843.338; §843.342; Ch. 542 Subch. B, read against the statute text linked in the sources on this page (last verified 2026-08-31). Accrual start dates, clean-claim status, safe harbors, and plan funding all affect the real figure — treat this as an estimate for the payer conversation, not a demandable amount.

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Also in the statute

The clean-claim deadlines run to participating providers. Out-of-network dental reaches them only through §843.351 — emergency care, or specialty or other health care services requested by the HMO or by a physician or provider inside the delivery network because they are not reasonably available in-network. Do not cite §1301.069: it sits in Chapter 1301, which §1301.002 disapplies to dental care benefits entirely.
The Chapter 843 clean-claim deadlines are non-waivable: "Except as provided by Sections 843.336(f) and 843.337(c), the provisions of this subchapter may not be waived, voided, or nullified by contract" (§843.353). Note the contrast — §843.346's general 45-day payment rule can be varied by written agreement, but §843.338's clean-claim clock cannot.
Capitated DHMO payments sit outside the regime entirely: "This subchapter does not apply to a capitated payment required to be made to a physician or provider under an agreement to provide health care services" (§843.345). That matters in dental, where capitation is common.
A dental HMO provider has its own fee right: "A physician or provider may recover reasonable attorney's fees and court costs in an action to recover payment under this subchapter" (§843.343).
The reciprocal deadline on the practice: a claim must reach the HMO no later than the 95th day after the services are provided, and a provider who misses it "forfeits the right to payment" (§843.337(a)–(b), (d)).
Chapter 542 Subchapter B does not apply to an HMO except as to prompt payment to an enrollee (§542.053(c); §1271.005(c)), and its damages clock is a separate 60-day trigger rather than the 15/15/5 schedule (§542.058(a)).
Medicaid and CHIP dental are outside the SB 418 regime by commissioner rule, per TDI's own FAQ rather than the statute; those claims run on 42 CFR parts 447/438.

Sources (statute text)