Medical billing services in Texas

Billing in Texas: what's different

The rules below change how a claim is filed and paid in Texas. Each line links to the official page it was read from, and the date at the top of this page is when it was last checked.

Rules that change how Texas claims are billed

• Surprise billing runs through Texas Insurance Code Chapter 1467¹³

  CMS recognizes Chapter 1467 and 28 TAC Chapter 21, Subchapter PP as the specified state law for emergency care in a hospital or freestanding emergency room, out-of-network facility-based providers at in-network facilities, and out-of-network imaging or lab tied to in-network care, for fully insured PPO, EPO and HMO plans regulated by TDI and for the state employee and teacher plans. Facilities use mediation; non-facility providers use arbitration. Air ambulance claims go to the federal process.

• Texas Medicaid telemedicine uses modifiers 95, 93 and FQ⁷

  Distant site providers bill modifier 95 for synchronous audiovisual visits, 93 for audio-only services and FQ for audio-only behavioral health, unless the code already describes remote delivery. Texas Medicaid MCOs may not deny reimbursement for a covered service solely because it was delivered remotely, are not required to pay for text-only email or fax, and may choose whether to pay for voicemail-style asynchronous audio, so each MCO's policy is checked before the claim leaves.

• Enrollment and revalidation live in PEMS⁴

  Providers enroll, re-enroll and revalidate through the Provider Enrollment and Management System. Most providers have a five-year enrollment period; revalidation opens 180 days before the due date and must reach Closed-Enrolled status within a 45-day grace period or the provider is disenrolled. Providers can keep filing claims while a revalidation is in process, still within 95 days of the date of service.

• MCO claims carry the same 95-day clock and a wrong-plan rule⁵

  Claims to a Medicaid MCO or dental plan must arrive within 95 days of the date of service or they are denied. If you filed with the wrong plan inside that window, the correct MCO must honor the original filing date when you resubmit within 95 days of the R&S Report from the wrong carrier with proof of the first submission. After another insurer pays, the MCO claim is due within 95 days of that disposition. Prior authorization, referral and claims procedures differ from MCO to MCO.

• EVV visits must clear the TMHP aggregator before claims pay⁸

  TMHP, the Medicaid claims administrator, manages the EVV Aggregator, the claims matching process and the EVV Portal. EVV electronically verifies that a service visit happened and records the start and end times, replacing paper timesheets for EVV-required services, so a visit that is missing, rejected or outside its visit maintenance window becomes a claim denial rather than a documentation note.

• Texas Medicaid MCOs pay clean claims on a 30-day standard¹⁶

  UnitedHealthcare Community Plan's Texas manual states a 30-day clean claim payment standard for professional and institutional claims, with interest on claims processed after day 30 according to HHSC, and points providers to the HHSC Uniform Managed Care Manual claims chapter. Clean claims must carry the taxonomy code, NPI and address exactly as enrolled with Texas Medicaid; a mismatch as small as an abbreviated street name results in a denial.

Services for Texas practices

Remitwright serves Texas practices remotely, inside the practice management or EHR system the practice already uses. A dedicated biller works the account; nothing is pooled. Each service below explains what that biller does.

• Medical billingClaims worked by one named biller
• CredentialingEnrollment, CAQH and PECOS kept current
• Eligibility verificationCoverage and benefits checked before visits
• Prior authorizationAuths requested, tracked, attached to claims
• Denial managementEvery denial read, worked and appealed
• A/R follow-upUnpaid claims chased before filing limits