Providers must submit bills within 95 days from the date of service or risk losing the right to payment.
This rule applies to network and non-network claims.
When Timely Filing Applies
The 95-day timely filing rule applies to all health care services billed under the Texas workers’ compensation system, unless the claim qualifies for a statutory or network exception.
Timely Filing Exceptions
Providers are not subject to the 95-day timely filing rule when one of the following occurs:
- The injured worker or claims administrator misidentified the employer or carrier, causing the bill to go to the wrong payer
- The claims administrator or employer failed to notify the provider of its workers’ compensation coverage
- The provider can show good cause for delay.
In the cases above, the provider must submit the bill as soon as possible after discovering the error.
Texas |
Statute/Rule |
Statute |
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Section |
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Subsection Text |
(a) A health care provider shall submit a claim for payment to the insurance carrier not later than the 95th day after the date on which the health care services are provided to the injured employee. Failure by the health care provider to timely submit a claim for payment constitutes a forfeiture of the provider's right to reimbursement for that claim for payment. |
Section |
408.0272 - Certain Exceptions for Untimely Submission of Claim |
Subsection Text |
(b) Notwithstanding Section 408.027, a health care provider who fails to timely submit a claim for payment to the insurance carrier under Section 408.027(a) does not forfeit the provider's right to reimbursement for that claim for payment solely for failure to submit a timely claim if: (1) the provider submits proof satisfactory to the commissioner that the provider, within the period prescribed by Section 408.027(a), erroneously filed for reimbursement with: (A) an insurer that issues a policy of group accident and health insurance under which the injured employee is a covered insured; (B) a health maintenance organization that issues an evidence of coverage under which the injured employee is a covered enrollee; or (C) a workers' compensation insurance carrier other than the insurance carrier liable for the payment of benefits under this title; or (2) the commissioner determines that the failure resulted from a catastrophic event that substantially interfered with the normal business operations of the provider. (c) Notwithstanding Subsection (b), a health care provider who erroneously submits a claim for payment to an entity described by Subdivision (1) of that subsection forfeits the provider's right to reimbursement for that claim if the provider fails to submit the claim to the correct workers' compensation insurance carrier within 95 days after the date the provider is notified of the provider's erroneous submission of the claim. (d) Notwithstanding any other provision of this section or Section 408.027, the period for submitting a claim for payment may be extended by agreement of the parties.
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