Medical billing for Texas practices

Medicaid managed care is most of Texas Medicaid

Most Texas Medicaid members are in a managed care plan: STAR for children and pregnant women, STAR+PLUS for adults with disabilities, STAR Kids for children with disabilities and STAR Health for children in foster care. Which plans operate in your county depends on the HHSC service area, so a Dallas practice and a Rio Grande Valley practice see different rosters even though both bill Texas Medicaid. The STAR and CHIP contracts have been tied up in a contested reprocurement and court challenge since 2024, and two smaller plans exited the program in 2026, so rosters are not stable. We keep the plan list current per location and re-check it when the state announces a change, because a member reassigned to a plan you are not loaded with becomes a denial with a short appeal window.

Texas Medicaid enrollment, credentialing and licensing

Enrollment runs through the Provider Enrollment and Management System, PEMS, on the TMHP portal, which since mid-2026 is reached through the TMHP IAMOnline login with multi-factor authentication. The application asks for the NPI, the Texas Medical Board license, ownership disclosures and a signed HHSC agreement, and a draft left untouched for 180 days expires. TMHP asks for revalidation at least 120 days before the enrollment period ends, and we calendar it at that date for each provider. An active TMHP record is only the state half. Each STAR plan still has to contract and load the provider, and because the plans work from the state file, a lapse in PEMS stops every plan at once. Medicare Part B in Texas is administered by Novitas Solutions as the Jurisdiction H contractor, and its PECOS enrollment runs on its own timeline, from a few weeks for a clean application to a few months for one that needs development. Commercial payers pull from CAQH ProView, so the profile has to be complete and re-attested before contracting starts. The Texas Medical Board registration renews every two years on a fixed quarterly expiration date, and we track it alongside payer revalidations, because an expired registration is a credentialing problem before it is anything else.

Eligibility and the 95-day filing clock

Texas Medicaid fee-for-service claims must reach TMHP within 95 days of the date of service, and the STAR plans set their own limits by contract, several of them the same 95 days. Because members move between plans and out of coverage at redetermination, coverage verified last month is not coverage verified today. Eligibility is checked against the member's current plan before the appointment, which catches the reassignments and retroactive terminations that otherwise surface as a CO-27 or a wrong-payer denial six weeks later, when most of the filing window is already gone.

Workers' compensation billing in Texas

Texas workers' compensation runs under the Division of Workers' Compensation at the Texas Department of Insurance, with fee guidelines built off Medicare rates, its own preauthorization list and its own medical fee dispute process. Two things make Texas different. Employers are not required to carry coverage at all, so the first question is whether the employer subscribes, and if it does, whether the injured worker is in a certified health care network that restricts who can treat and bill. The treating doctor also owes a DWC Form-073 work status report after the first visit and after any change in restrictions, filed within seven days, and carriers must accept medical bills electronically. We confirm carrier, network status and preauthorization before the visit, file the work status reports on schedule, and keep these claims in their own queue with their own follow-up clock, because a comp bill left in a commercial A/R bucket ages out quietly.

BCBSTX, prompt pay and the Texas surprise-billing law

Blue Cross and Blue Shield of Texas is the largest commercial payer in most Texas markets, and its HMO and PPO products do not behave the same way: referral rules, authorization lists and claim edits differ by product even when the card carries the same logo. Texas prompt-pay law requires a contracted payer on a state-regulated plan to pay or deny a clean electronic claim within 30 days and a paper claim within 45, with penalties that grow the later the payment arrives. Clean claims that pass day 30 are worked as late payments, not slow ones. For out-of-network care, Senate Bill 1264 sends disputes on state-regulated plans to Texas mediation or arbitration through TDI, while self-funded employer plans go to the federal No Surprises Act process, so the first step on any out-of-network claim is reading the card to see which regulator applies.

Multi-location practices across the Texas metros

Groups spread across Dallas-Fort Worth, Houston, Austin and San Antonio often carry several tax IDs and several payer contracts, and the STAR roster changes at the service area line. Claims and reporting are separated by location and payer so collections can be read per site, which is the only way to see that one office has a credentialing gap rather than a billing problem. Medicare Advantage has grown fast in Texas, with UnitedHealthcare and Humana carrying much of it, and those plans authorize and appeal like commercial insurers, so we work them against plan policy rather than Medicare rules. Aged A/R can be taken on as a standalone project if you want to see the work before moving the whole cycle, and the free billing audit starts with your own remittances rather than a pitch.

Texas Medicaid

Most Texas Medicaid members are in a managed care plan rather than fee-for-service, so the claim goes to the MCO and follows the MCO’s rules, not TMHP’s. The plan roster differs by service area and has been in flux since the contested STAR and CHIP reprocurement, so the plan a member holds is confirmed before every visit.