6 TIC §843.342(a-b)

August 8, 2021 1:19 am Published by

(a)  …the health maintenance organization shall pay the physician or provider making the claim the contracted rate owed on the claim plus a penalty in the amount of the lesser of:

(1)  50 percent of the difference between the billed charges, as submitted on the claim, and the contracted rate;  or

(2)  $100,000.

(b)  If the claim is paid on or after the 46th day and before the 91st day after the date the health maintenance organization is required to make a determination or adjudication of the claim, the health maintenance organization shall pay a penalty in the amount of the lesser of:

(1)  100 percent of the difference between the billed charges, as submitted on the claim, and the contracted rate;  or

(2)  $200,000.

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