Home care billing · TX
Home care billing in Texas
Short answer
Home care billing in Texas runs through two systems at once: the EVV Aggregator at TMHP, which must hold an accepted visit before a personal care or home health claim is matched and forwarded to the payer, and the STAR+PLUS or STAR Kids plan that authorizes long-term services and pays the claim.
Fee-for-service home health visits need a TMHP prior authorization tied to a physician-signed plan of care and are billed on a UB-04 with type of bill 321 inside the 95-day window. A dedicated Remitwright biller clears visit maintenance before claims leave and keeps each plan's rules current, serving Texas agencies remotely. Rules for other states are on the home care billing by state page.
Last reviewed by the Remitwright billing team. Editorial policy
Key facts for Texas home care billing
| Fact | In Texas | Source |
|---|---|---|
| Programs that pay | STAR+PLUS Home and Community-Based Services (HCBS) program; Medically Dependent Children Program (MDCP) through STAR Kids; HHSC intellectual and developmental disability waivers (CLASS, DBMD, HCS, TxHmL); Community First Choice (CFC) and Personal Care Services (PCS) | 6 |
| How it is delivered | Managed care and fee-for-service | 9 |
| Medicare home health and hospice | Palmetto GBA, Jurisdiction M | 10 |
Programs that pay for home care in Texas6
STAR+PLUS Home and Community-Based Services (HCBS) program
Long-term services and supports for adults with a disability and people 65 and older, including those dually eligible for Medicare and Medicaid, delivered through STAR+PLUS managed care organizations alongside acute care.
Enrollment in STAR+PLUS is required for Medicaid clients who receive SSI or SSI-related Medicaid, qualify for STAR+PLUS HCBS waiver services, are 21 or older and live in a nursing facility, or qualify for Medicaid for Breast and Cervical Cancer. Adults 21 and older in HCS, CLASS, TxHmL, DBMD or a community ICF-IID enroll in STAR+PLUS for acute care only, unless they are dual eligible.
Medically Dependent Children Program (MDCP) through STAR Kids
MDCP waiver services for children and young adults 20 and younger with disabilities, together with their acute care, through STAR Kids MCOs in 13 service areas.
STAR Kids clients with an assessed need for LTSS, identified by the STAR Kids Screening and Assessment Instrument, may receive those services through their STAR Kids MCO. Children who receive SSI, SSI-related Medicaid or MDCP get all of their Medicaid services through STAR Kids.
HHSC intellectual and developmental disability waivers (CLASS, DBMD, HCS, TxHmL)
1915(c) waiver long-term services for people with intellectual and developmental disabilities; the waiver program keeps the LTSS while the STAR Kids or STAR+PLUS plan covers basic Medicaid health services.
Community First Choice services are carved out for STAR Kids clients who receive services through CLASS, DBMD, HCS or TxHmL, so the payer for an attendant visit depends on which waiver the client is in.
Community First Choice (CFC) and Personal Care Services (PCS)
Attendant and personal care services that the Medicaid Managed Care Handbook lists in its table of services split between TMHP and the MCOs, with the responsible payer shown for each managed care program.
Clients 20 and younger may also be eligible for private duty nursing and personal care services under Texas Medicaid policies, which the home health handbook, cited below, points to when a skilled nursing visit is requested mainly for activities of daily living.
How the program is delivered
Both. CMS's 2024 state tables list STAR+PLUS and STAR Kids as statewide managed care programs whose program type combines an MCO with managed long-term services and supports (MLTSS); STAR+PLUS runs under 1115(a) authority and STAR Kids under 1115(a) and 1915(b)/1915(c). The STAR+PLUS plans in the tables are Wellpoint, Superior HealthPlan, UnitedHealthcare Community Plan and Molina Healthcare of Texas.9 Fee-for-service still applies to the acute care home health nursing benefits described in the home health handbook, cited below, and to managed care carve-out services, which are administered as fee-for-service benefits through TMHP.
Electronic visit verification
HHAeXchange is the single, state-funded EVV vendor system, under a TMHP partnership that began October 1, 2023. New program providers and financial management services agencies that have not onboarded with HHAeXchange or become an approved Proprietary System Operator submit the HHAeXchange Provider Onboarding Form to start.2 The model is a state vendor with a proprietary-system alternative: a program provider or FMSA may instead use an EVV proprietary system it bought or built, after submitting the EVV Proprietary System Request Form in the EVV Portal and passing an Operational Readiness Review session, as the proprietary systems page cited below sets out. Every system feeds the EVV Aggregator, a centralized database run by TMHP that accepts or rejects visit transactions with standardized edits, matches EVV claim line items to accepted visits and sends the result to the payer.
Services under EVV5
- Medicaid personal care services (PCS) that require an in-home visit, under EVV since January 1, 2021
- Medicaid home health care services (HHCS) that require an in-home visit, including services delivered through the consumer directed services option and the service responsibility option, under EVV since January 1, 2024
Authorizations
Fee-for-service home health skilled nursing and home health aide visits require prior authorization from TMHP. The agency needs a physician or allowed practitioner order, an RN initial assessment in the client's home and a Texas Medicaid home health services plan of care signed by the RN and the physician. Authorization must be obtained within three business days of the start of care for an initial request and within seven business days of the new start of care for a recertification, and visits are authorized for no more than 60 days at a time, with the physician reviewing the plan of care at least every 60 days.7 Requests go to the TMHP Prior Authorization Department by mail, fax or the electronic portal. Skilled nursing visits requested mainly for respite, child care, activities of daily living, housekeeping or routine teaching are not authorized. In STAR+PLUS, the Medicaid Managed Care Handbook, cited above, requires the MCO to furnish a service coordinator, who holds primary responsibility for service coordination and care management, so plan authorizations run through that coordinator rather than TMHP.
Where the claims go
All claims for EVV services, fee-for-service and managed care alike, must be submitted electronically to TMHP; paper claims for EVV services are not accepted. The EVV Aggregator performs the claims match and TMHP forwards the claim with its EVV match code to the applicable payer for adjudication. Other claims for managed care clients go to the MCO that administers the client's benefits, and only carve-out services go to TMHP.8 Home health skilled nursing and aide claims use type of bill 321 on the UB-04 (or the CMS-1500), with the prior authorization number in Block 23 of the CMS-1500 or Form Locator 63 of the UB-04, and the plan of care certification dates must coincide with the dates of service. Prior authorization does not waive the 95-day filing deadline, as the home health handbook, cited above, states.
Medicare home health and hospice in Texas
Palmetto GBA, LLC, the A/B MAC for Jurisdiction M, processes Medicare home health and hospice claims for Texas, alongside Alabama, Arkansas, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Mississippi, New Mexico, North Carolina, Ohio, Oklahoma, South Carolina and Tennessee.10 For Texas Medicaid, the home health handbook, cited above, requires providers to be a licensed and certified home health agency enrolled in Texas Medicaid, pays professional home health services at a statewide visit rate under 1 TAC 355.8021, and tells agencies not to submit home health claims until Medicaid certification is received and a prior authorization number is assigned.
Common rejections in Texas, and the fix
EVV claim submitted on paper or sent straight to the MCO
The fixEvery EVV-required claim goes electronically to TMHP so the aggregator can match it; TMHP forwards the matched claim to the plan. Your biller routes by service code before submission, so an attendant or home health claim never leaves on paper or bypasses the aggregator.
No accepted visit in the EVV Aggregator for the claim line
The fixThe aggregator matches claim lines to accepted visit transactions and sends the result to the payer. Before billing, the biller clears rejected visits in visit maintenance and uses the EVV Portal's view of visit transactions ready for billing, so each line has an accepted visit behind it.
Home health claim denied for an invalid type of bill
The fixSkilled nursing and home health aide claims on the UB-04 carry type of bill 321 only; other types of bill are denied. The biller sets the claim template once per agency and checks the type of bill on every batch before release.
Prior authorization number missing or dates outside the plan of care
The fixThe PA number goes in Block 23 of the CMS-1500 or Form Locator 63 of the UB-04, and the certification or revised request dates on the plan of care must line up with the dates of service. The biller holds the claim until TMHP assigns the number and then bills within the 95-day window.
Initial authorization requested after the three-business-day window
The fixInitial authorization is due within three business days of the start of care and recertification within seven business days of the new start of care, with services delivered from the agreed start date. The biller logs the start-of-care date and files the RN assessment and signed plan of care against that three-business-day clock.
Skilled nursing visit requested for a non-covered purpose
The fixVisits requested mainly for respite, child care, activities of daily living, housekeeping or routine teaching are not authorized. For clients 20 and younger, the biller checks whether private duty nursing or personal care services policies fit instead before the request is built.
Claim filed with TMHP for a STAR+PLUS or STAR Kids member's plan service
The fixClaims for services a managed care client receives from the plan go to that MCO; only carve-outs and EVV claims route through TMHP. The eligibility check records the plan on the date of service and the biller files to the plan's portal within its filing rules.
Remitwright serves Texas home care and home health agencies remotely, inside the agency software you already use, with a dedicated biller.
FAQ
Questions from Texas agencies
Do we have to use HHAeXchange for our Texas attendant visits?
Which of our services fall under EVV in Texas?
Where do our EVV claims actually go, TMHP or the health plan?
What does Texas Medicaid need before it authorizes skilled nursing visits?
Who authorizes long-term services for a STAR+PLUS member?
How do STAR Kids and the IDD waivers fit together for billing?
What claim form do home health agencies use in Texas Medicaid?
Which Medicare contractor pays our home health and hospice claims in Texas?
Which programs pay for home care in Texas?
Is home care in Texas paid through managed care or fee-for-service?
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