Sec. 1301.104. DEADLINE FOR ACTION ON PHARMACY CLAIMS; PAYMENT. (a) An insurer, or a pharmacy benefit manager that administers pharmacy claims for the insurer under a preferred provider benefit plan, that affirmatively adjudicates a pharmacy claim that is electronically submitted shall pay the total amount of the claim through electronic funds transfer not later than the 18th day after the date on which the claim was affirmatively adjudicated.
(b) An insurer, or a pharmacy benefit manager that administers pharmacy claims for the insurer under a preferred provider benefit plan, that affirmatively adjudicates a pharmacy claim that is not electronically submitted shall pay the total amount of the claim not later than the 21st day after the date on which the claim was affirmatively adjudicated.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.
Amended by:
Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(a), eff. September 1, 2005.
Acts 2011, 82nd Leg., R.S., Ch. 798 (H.B. 2292), Sec. 9, eff. September 1, 2011.
Structure Texas Statutes
Title 8 - Health Insurance and Other Health Coverages
Chapter 1301 - Preferred Provider Benefit Plans
Subchapter C. Prompt Payment of Claims
Section 1301.102. Submission of Claim
Section 1301.1021. Receipt of Claim
Section 1301.103. Deadline for Action on Clean Claims
Section 1301.104. Deadline for Action on Pharmacy Claims; Payment
Section 1301.105. Audited Claims
Section 1301.1051. Completion of Audit
Section 1301.1052. Preferred Provider Appeal After Audit
Section 1301.1053. Deadlines Not Extended
Section 1301.1054. Requests for Additional Information
Section 1301.106. Claims Processing Procedures and Claims Payment Processes
Section 1301.107. Contractual Waiver and Other Actions Prohibited
Section 1301.108. Attorney's Fees
Section 1301.109. Applicability to Entities Contracting With Insurer