Texas Codes

Tex. Ins. Code § 843.338 (2026)

Deadline For Action On Clean Claims

✓ current as of May 2026

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Sec. 843.338. DEADLINE FOR ACTION ON CLEAN CLAIMS. Except as provided by Sections 843.3385 and 843.339, not later than the 45th day after the date on which a health maintenance organization receives a clean claim from a participating physician or provider in a nonelectronic format or the 30th day after the date the health maintenance organization receives a clean claim from a participating physician or provider that is electronically submitted, the health maintenance organization shall make a determination of whether the claim is payable and:

(1) if the health maintenance organization determines the entire claim is payable, pay the total amount of the claim in accordance with the contract between the physician or provider and the health maintenance organization;

(2) if the health maintenance organization determines a portion of the claim is payable, pay the portion of the claim that is not in dispute and notify the physician or provider in writing why the remaining portion of the claim will not be paid; or

(3) if the health maintenance organization determines that the claim is not payable, notify the physician or provider in writing why the claim will not be paid.

Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003. Amended by Acts 2003, 78th Leg., ch. 214, Sec. 8, eff. June 17, 2003.

Amended by:

Acts 2011, 82nd Leg., R.S., Ch. 798 (H.B. 2292), Sec. 2, eff. September 1, 2011.

Notes of Decisions

Cited in 6 cases, 2011–2017 · leading case: North Cypress Med. Ctr. Operating Co. v. Cigna Healthcare, 782 F. Supp. 2d 294 (S.D. Tex. 2011).

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North Cypress Med. Ctr. Operating Co. v. Cigna Healthcare, 782 F. Supp. 2d 294 (S.D. Tex. 2011). · cites it 3× “North Cypress also alleges that CIGNA failed to promptly pay benefits in violation of Texas Insurance Code §§ 843.338 and 843.351, and that it breached contracts with North Cypress.”

North Cypress Med. Ctr. Operating Co. v. Cigna Healthcare, 781 F.3d 182 (5th Cir. 2015). “First, we address the dismissal of North Cypress’s claims under Texas Insurance Code sections 843.338 and 843.”

Houston Methodist Hosp. v. Humana Ins. Co., 266 F. Supp. 3d 939 (S.D. Tex. 2017). · cites it 2× “Tex. Ins. Code §§ 843.338, 1301.103. The parties do not dispute that the claims at issue in this action are “clean claims.”

Christus Health Gulf Coast v. Aetna, Inc., 347 S.W.3d 726 (Tex. App. 2011). “Laws 3658 , 3793-95 (current version at Tex. Ins. Code § 843.338). Consistent with the parties' briefing, and unless otherwise specified, citations to the Insurance Code will be to the 2000 version of the code.”

South Texas Health Sys. v. Care Improvement Plus of Texas Ins., 159 F. Supp. 3d 763 (S.D. Tex. 2016). “Tex. Ins. Code § 843.338. .With respect to this language, the Court notes that for the purposes of this Order "Medicare + Choice” is effectively synonymous with “Medicare Advantage.”

Christus Health Gulf Coast, Christus Health Se. Texas, Gulf Coast Div., Inc., Mem'l Hermann Hosp. Sys. & Baptist Hospitals of Se. Texas v. Aetna, Inc. & Aetna Health, Inc. (Tex. App. 2011). “Laws 3658 , 3793–95 (current version at Tex. Ins. Code § 843.338). Consistent with the parties’ briefing, and unless otherwise specified, citations to the Insurance Code will be to the 2000 version of the code.”

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