A medical billing company for a Texas practice has to know Texas's own rules: Texas Medicaid enrollment through the state's Provider Enrollment and Management System (PEMS), separate contracting and credentialing with Medicaid managed care plans, and the Texas prompt pay rules enforced by the Texas Department of Insurance, which set a 95-day filing deadline and 30 or 45 day payment deadlines for HMO and PPO claims. Sterling Global Solution LLC works for Texas practices from inside their own EHR and practice management system, so the 95-day clock and the payment deadlines are watched on every claim.
Texas Medicaid enrollment
Texas Medicaid programs are run by the Texas Health and Human Services Commission (HHSC), and the Texas Medicaid & Healthcare Partnership (TMHP) supports providers enrolling in them. TMHP explains that applicants use PEMS to enroll in, or revalidate as, a Texas Medicaid provider, and that several state health care programs also enroll, re-enroll and revalidate through PEMS.
Enrollment with the state does not by itself put you in a Medicaid managed care network. TMHP notes, for example, that to serve a STAR+PLUS member, long-term services and supports providers must complete the contracting and credentialing process through the member's STAR+PLUS managed care organization. Federal rules (42 CFR 438.602(b)) also require states to screen and enroll all network providers of their Medicaid managed care plans, so state enrollment and plan credentialing are both needed.
Texas prompt pay rules for HMO and PPO claims
The Texas Department of Insurance (TDI) explains the prompt pay requirements of the Texas Insurance Code for health maintenance organizations and preferred provider benefit plans. In summary, from TDI's Prompt Pay FAQ:
- Filing deadline: a provider is required to file a claim within 95 days of the date of service, absent a catastrophic event (Texas Insurance Code 1301.102(a) and 843.337). TDI notes the 95-day deadline applies to Texas-licensed physicians and providers, regardless of contracting status.
- Payment deadline: Texas Insurance Code 843.338 and 1301.103 provide for payment not later than the 45th day after a non-electronic clean claim is received, and not later than the 30th day after an electronic clean claim is received.
- Electronic means electronic at receipt: an electronic claim received at the payer's designated claim address in a HIPAA-compliant electronic format is subject to the 30-day timeframe.
- Penalties: when a carrier misses the statutory claims payment period, Texas rules (28 TAC 21.2815) add penalties on top of the contracted amount owed.
- Mailed claims: TDI notes that a mailed claim is presumed received on the fifth day after it is mailed (Texas Insurance Code 1301.1021).
The 95-day rule is the one that costs Texas practices the most. Claims held for coding questions, eligibility problems or missing authorizations can run out of time before they are ever sent.
Eligibility verification (EV), benefits verification (BV), prior authorizations, and denial management at no cost for your first 30 days.
30-Day Free TrialWhat this means for a Texas practice
- Submit clean claims electronically to the payer's designated address, so the 30-day clock applies.
- Track every claim against the 95-day filing deadline, and keep proof of submission.
- Keep each provider's PEMS enrollment and revalidation current, and credential separately with each Medicaid managed care plan.
- Check whether a late payment from an HMO or PPO owes a statutory penalty, and request it.
- Check whether a plan is state-regulated before escalating a late payment to TDI.
Specialties we bill for Texas practices
We work with Texas ABA providers, behavioral health practices, cardiology, fertility clinics, orthopedic and OB-GYN practices, and with private and small practices across specialties.
How Sterling Global Solution LLC works with Texas practices
Each claim is checked for eligibility and authorization before the visit and sent electronically the day it is coded. Our follow-up calendar is built on the 95-day filing limit and the 30 and 45 day payment periods, and we ask for statutory penalties when a plan pays late. New providers are enrolled in PEMS and credentialed with each Medicaid plan before their first visit; new billing clients get free credentialing for 3 insurance payers. Start with our 30-Day Free Trial.
Frequently asked questions
Do you provide medical billing services for Texas practices?
What is the timely filing deadline for Texas HMO and PPO claims?
How fast must Texas HMOs and PPOs pay a clean claim?
How do providers enroll in Texas Medicaid?
What happens if a Texas plan pays a clean claim late?
Sources
Texas Medicaid & Healthcare Partnership, Provider Enrollment: PEMS enrollment and revalidation, STAR+PLUS contracting and credentialing.
Texas Department of Insurance, Prompt Pay FAQ: Texas Insurance Code 843.337, 843.338, 1301.102(a), 1301.1021 and 1301.103, and 28 TAC 21.2815.
Code of Federal Regulations, 42 CFR 438.602(b): state enrollment of managed care network providers.
This summarizes official sources and is not legal advice; check the full text and your contracts. How we verify this guidance.
Related reading
- Insurance companies not paying claims. Payment deadlines by state and how to escalate.
- AR recovery services. Recovering claims before filing limits close.
- ABA credentialing services. Getting ABA providers in network.
- How to get credentialed with insurance companies. Medicare, Medicaid and commercial enrollment.
- Medical billing for California practices. How California's claim payment rules compare.
Billing for your Texas practice
Eligibility verification (EV), benefits verification (BV), prior authorizations, and denial management at no cost for your first 30 days.
30-Day Free TrialNo setup fee. No long-term contract.