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Medical Billing Services in Texas

Texas practices bill a Medicaid program delivered mostly through managed care, with fee-for-service claims processed through the state's Medicaid claims contractor, Medicare through Novitas Solutions, and state laws on balance billing, prior authorization and workers' compensation that work differently from most states. We bill remotely for Texas practices and apply the rules that fit each claim.

  • Medicaid managed care plans and TMHP fee-for-service claims
  • Medicare claims through Novitas Solutions, Jurisdiction H
  • Workers' comp non-subscriber employers identified before billing
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The Texas payer landscape

The Texas Department of Insurance (TDI) regulates the insurance industry in Texas. Two state laws shape how commercial claims are handled. Senate Bill 1264 (86th Legislature, 2019) added protections against certain surprise balance bills, with a state dispute process for payment disagreements.

House Bill 3459 created a prior authorization exemption known as gold carding. Which plans and services it covers is set by TDI rules, so we track the current rules rather than assume a provider is exempt.

Official source: Sunset Advisory Commission: Texas Department of Insurance (external site)

Texas Medicaid billing notes

Most Texas Medicaid services are delivered through managed care, in programs that include STAR+PLUS and STAR Kids, under the oversight of the Health and Human Services Commission (HHSC). Every managed care plan has its own payer ID, authorization rules and portal, so a practice that accepts several plans is effectively billing several different payers.

For fee-for-service Medicaid, HHSC contracts for claims processing and fiscal agent services through the Texas Medicaid & Healthcare Partnership (TMHP), and provider enrollment is also handled through TMHP. Filing deadlines and enrollment requirements are published in the state's current provider manuals, and we track the current rule rather than quote it.

Official source: Texas HHSC Self-Evaluation Report to the Sunset Advisory Commission (external site)

Workers' comp coverage and Division rules

Most private employers in Texas are not required to carry workers' compensation coverage. For employers that are covered, medical billing follows rules and fee guidelines set by the TDI Division of Workers' Compensation, which we check for the current version.

Because a non-subscriber employer has no workers' comp carrier to bill, the first question for any work injury is whether the employer is covered at all.

Official source: Texas Open Data Portal (TDI-DWC): workers' comp non-subscriber employers (external site)

Practices we typically see in Texas

Texas practices that see Medicaid patients mostly bill managed care plans, with fee-for-service and some carved-out claims going through TMHP, and bill Novitas for traditional Medicare. Many also see injured workers whose employers may or may not carry workers' compensation coverage.

How remote billing works for practices in Texas

We work in your systems from outside the practice, so nothing changes in how patients are seen. The practice creates our user accounts and keeps control of them.

  1. Step 1: Payer and enrollment review

    We list every payer you bill, including each Medicaid managed care plan, and confirm your enrollment with each one.

  2. Step 2: Secure system access

    Your team grants role-based access to your practice management system and clearinghouse under a signed business associate agreement.

  3. Step 3: Texas rules set per payer

    Authorization rules, gold-card status where it applies, and Medicaid filing requirements are recorded per payer.

  4. Step 4: Work-injury intake

    Each injury case is checked for whether the employer carries workers' comp before the first bill goes out.

  5. Step 5: Shared reporting

    You see collections, denials and A/R by payer, with each Medicaid plan reported separately.

Official sources for Texas

Rules change. These are the agencies and contractors we check for the current requirements.

Frequently asked questions

Does a billing company need to be located in Texas?

No. Billing is done electronically through your practice management system, clearinghouse and payer portals, so a remote team can bill Texas payers the way an in-house team would. What matters is knowing the Texas payer rules. That is how our team works with practices nationwide.

Which Medicare contractor processes Texas claims?

Novitas Solutions, the Medicare Administrative Contractor for Jurisdiction H, which also covers Arkansas, Colorado, Louisiana, Mississippi, New Mexico and Oklahoma.

Official source: CMS: A/B MAC Jurisdiction H (Novitas Solutions) (external site)

How does workers' compensation billing work in Texas?

Most Texas private employers are not required to carry workers' compensation, so the first step is confirming whether the employer is covered. For covered claims, billing follows the current TDI Division of Workers' Compensation rules.

Official source: Texas Open Data Portal (TDI-DWC): workers' comp non-subscriber employers (external site)

What did Senate Bill 1264 change for out-of-network claims?

It added protections against certain surprise balance bills and a state process for resolving payment disputes. TDI publishes the current rules, which we track.

Where do Texas Medicaid fee-for-service claims go?

Through the Texas Medicaid & Healthcare Partnership (TMHP), which HHSC contracts for fee-for-service claims processing. Managed care claims go to the patient's plan.

Official source: Texas HHSC Self-Evaluation Report to the Sunset Advisory Commission (external site)

Related services and nearby states

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Billing for a Texas practice?

Talk to us about your payer mix, including Medicaid managed care plans and workers' comp cases, or start with a free billing audit.

Request a Free Billing Audit