Medical Billing Services in Texas

Medicare

Texas Part B claims are processed by Novitas Solutions in Jurisdiction JH. Medicare's filing limit is 12 months from the date of service, and appeals start with a redetermination within 120 days of the initial decision.

Texas Medicaid

Texas Medicaid and CHIP, overseen by the Texas Health and Human Services Commission (HHSC). Managed care programs are STAR (most children, pregnant women and low-income families), STAR+PLUS (adults with disabilities and adults 65 and older), STAR Kids (children and young adults with disabilities) and STAR Health (children in foster care).

Portal: Texas Medicaid & Healthcare Partnership (TMHP), the state's claims administrator, handles provider enrollment through the TMHP Provider Enrollment and Management System (PEMS) and processes fee-for-service claims

Medicaid managed care

Most Medicaid members are enrolled in an MCO chosen by service area. Plans include national carriers such as Superior HealthPlan, Wellpoint (formerly Amerigroup), Molina, UnitedHealthcare Community Plan and Aetna Better Health, and regional plans such as Texas Children's Health Plan, Cook Children's Health Plan, Driscoll Health Plan and Community First. The plans available differ by program and service area.

Timely filing

95 days from the date of service for TMHP fee-for-service claims (1 Tex. Admin. Code Section 354.1003), with all claims to be finalized within 24 months; Medicaid MCOs generally apply the same 95-day limit.

Commercial and Medicare Advantage

Blue Cross and Blue Shield of Texas is the largest commercial payer, followed by UnitedHealthcare, Aetna and Cigna, with Baylor Scott & White Health Plan strong in Central Texas. Humana, UnitedHealthcare, Wellcare and BCBSTX are major Medicare Advantage carriers.

Prompt pay law

Texas prompt pay law for fully insured HMO plans (Tex. Ins. Code Chapter 843) and PPO plans (Chapter 1301) requires payment of clean claims within 30 days for electronic claims and 45 days for paper claims. Providers must submit claims within 95 days of the date of service (Section 843.337 for HMOs) or forfeit payment, and late-paying plans owe tiered penalties based on the difference between billed charges and the contracted rate, plus interest on claims paid very late.

Nurse practitioners

Texas NPs need a prescriptive authority agreement with a delegating physician to prescribe, and the delegating physician's information is part of most payer credentialing files. NPs enroll with TMHP and Medicaid MCOs under their own NPI and bill Medicare under their own NPI at 85% of the physician fee schedule.

Credentialing

Texas Medicaid enrollment starts in TMHP PEMS, and the provider must be enrolled with TMHP before any Medicaid MCO can credential them. Each STAR, STAR+PLUS and STAR Kids MCO then credentials separately by service area, and Texas requires health plans to use the Texas Standardized Credentialing Application. BCBSTX and most commercial plans pull from CAQH ProView, and TMHP enrollment must be revalidated on the state's schedule.