STAR
Children, pregnant members, and low-income families. The largest program by volume, and the one affected by the 2026 plan transition.
Texas · Remote billing support
Medical billing services for Texas practices, built around the state's own rules.
Four Medicaid programs. Thirteen service delivery areas. A 95-day filing clock that applies to Medicaid and state-regulated commercial plans. We bill to how Texas actually works.
Remote support statewide TMHP & PEMS enrollment STAR / STAR+PLUS / STAR Kids Behavioral health specialists
The Texas clock
Deadlines that decide whether a claim gets paid
95 days
File with Texas Medicaid
From date of service, per TMHP. One of the tightest windows in the country.
120 days
Appeal a denial
Texas Medicaid appeal window. Miss it and the claim is unrecoverable.
95 days
File with TDI-regulated plans
Applies to Texas-licensed providers billing HMOs and PPOs. §843.337
30/45 days
Carrier must pay you
Clean claims, electronic vs. paper, with tiered penalties. §843.338
Why Texas is different
A clinic in Lubbock and a clinic in McAllen can bill the same code and get two different answers.
That is not a coding error. It is Texas. The state runs four separate Medicaid managed care programs across thirteen service delivery areas, and the health plans available in Bexar County are not the plans available in El Paso or the Rio Grande Valley. Add the shortest filing clock in the country and the margin for administrative error narrows fast.
Mental Health Billing remotely supports healthcare providers throughout Texas with billing, coding, credentialing, and revenue cycle management. This page is written for the biller or practice owner who needs to understand what actually drives collections here.
The payer landscape
Four Medicaid programs, thirteen service areas, and a plan mix that changes by region
HHSC administers Texas Medicaid, with TMHP acting as the fee-for-service claims administrator and enrollment gatekeeper. Most members sit inside managed care — and which plan covers them depends on where they live.
STAR+PLUS
Adults 65+ and adults with disabilities, including long-term services and supports. Authorizations flow through the MCO's service coordinator.
STAR Kids
Children with disabilities. Assessment-driven service plans mean authorization detail carries directly into payability.
STAR Health
Children in foster care, with statewide administration and its own eligibility and coordination requirements.
Each program contracts with a different MCO mix by region — Superior HealthPlan, Wellpoint, Molina, and UnitedHealthcare Community Plan alongside regional plans like Community First in San Antonio, El Paso Health, Driscoll in South Texas, Texas Children's Health Plan, Cook Children's, and Parkland Community Health Plan.
On the commercial side, Blue Cross and Blue Shield of Texas holds the largest statewide share, with UnitedHealthcare, Aetna, and Cigna behind it. Meanwhile Texas has not expanded Medicaid and carries the nation's highest uninsured rate — roughly 16.7% overall and about 21.6% among working-age adults. Self-pay balances, sliding-fee scales, and county indigent programs are a real revenue line here, not an afterthought.
Denial drivers
Where Texas claims break down
Six patterns account for most of the revenue Texas practices lose. None of them are national problems.
The 95-day problem, twice over
Texas Medicaid requires clean claims within 95 days of service, with appeals due in 120. Separately, §843.337 and §1301.102 impose a 95-day deadline on Texas-licensed providers billing TDI-regulated plans. Practices carrying a national 180-day habit lose money quietly.
Prompt pay is enforceable — and rarely invoked
Under §843.338 and §1301.103, state-regulated carriers must act on a clean electronic claim in 30 days, 45 for paper, with tiered penalties for late payment. Documented submission dates turn a slow payer into a leverage conversation.
Gold-card exemptions nobody tracks
Texas pioneered gold-carding through HB 3459, and HB 3812 revised the framework effective September 1, 2025, requiring issuers to evaluate eligibility at least annually. Notices arrive in a different format from every carrier, so multi-site practices keep filing authorizations they no longer owe.
Credentialing is two steps, per region
PEMS enrollment is only the beginning. Each MCO credentials and contracts separately, per service delivery area. A provider fully enrolled in Texas Medicaid can still be out-of-network with the exact STAR plan covering the patient in the room.
Behavioral health routes elsewhere
Several Texas MCOs delegate behavioral health to a subcontracted vendor. The claim address, authorization portal, and appeal path differ from the medical side of the same plan card — a setup error that produces silent, repeatable denials.
Nonsubscriber injury claims
Texas is the only state where private employers may decline workers' compensation entirely. Those injuries route through group health or a liability carrier instead of DWC fee guidelines. Billing them as standard comp guarantees a denial.
Our response
How we work these problems
Every process below exists because of a specific Texas rule, not a generic best practice.
Short filing windows
95 days to file, 120 to appeal, and shorter contractual limits inside some MCO agreements.
What we do
Submission cadence is built to the 95-day rule rather than a monthly cleanup cycle. Claims scrub and drop within days of the encounter, and denials route into an appeal queue governed by the 120-day window.
Regional plan fragmentation
Coverage is never just "yes." It is which plan, which service area, which behavioral health vendor.
What we do
Eligibility and MCO assignment are verified before each date of service, with payer ID, taxonomy, and claim routing mapped per plan so behavioral health claims reach the right processor the first time.
Aging commercial A/R
Carriers slow-walk payment because most practices never cite the statute they are subject to.
What we do
Prompt-pay tracking runs against payer receipt dates, so escalations carry a statutory basis and a documented clean-claim date instead of another phone call.
Authorization waste
Staff submit prior authorizations for services the physician has already earned an exemption from.
What we do
We keep a payer-by-payer record of exemption status under the Texas gold-card rules, so exemptions are used rather than filed away in a mailroom.
Enrollment lapses
Missed PEMS revalidation has disenrolled Texas providers outright, turning billed work into unpayable claims.
What we do
Credentialing runs as a calendar: PEMS enrollment and revalidation dates, then MCO contracting for each service delivery area you actually treat in, with CAQH attestation kept current throughout.
Services
What we run, framed for Texas operations
Medical billing and claim submission
Clearinghouse configuration for TMHP and each contracted Texas MCO, with taxonomy and payer ID mapping that reflects regional plan differences.
Medical coding services
Documentation-matched CPT, ICD-10-CM, and HCPCS selection, with modifier discipline for telehealth, supervised services, and time-based psychotherapy codes.
Denial management and appeals
Root-cause categorization across eligibility, authorization, timely filing, and credentialing lag, with corrected claims or reconsiderations filed inside Texas deadlines.
Credentialing services in Texas
PEMS, Medicare, and commercial paneling, plus revalidation tracking so an enrollment lapse never surfaces later as a claims problem.
Revenue cycle management
Charge capture through posting, secondary billing, patient balance workflow, and monthly reporting on Texas-specific denial patterns.
Self-pay and balance recovery
Estimates, statements, and follow-up built for a non-expansion state where a meaningful share of collections comes directly from patients.
Specialties
Specialty pressure points across Texas
The rule that trips up an OB practice in Houston is not the rule that trips up an orthopedic group in Odessa.
Behavioral health
The heaviest state-specific load. Mental health rehabilitative services and targeted case management run through Texas Resiliency and Recovery utilization management, with CANS and ANSA certification required of clinical and supervisory staff and authorizations tied to assessment outcomes. Licensure sits under the Behavioral Health Executive Council, and LPC-Associates and licensed psychological associates generally bill under a supervising clinician's identifier — a supervision-attribution rule that produces avoidable denials when rendering and billing NPIs are configured incorrectly.
Pediatrics
Texas Health Steps checkup components and periodicity requirements, often administered through child-focused plans such as Texas Children's Health Plan, Cook Children's, or Driscoll, each with its own submission and documentation expectations.
OB/GYN and women's health
Claims intersect with Healthy Texas Women and extended postpartum Medicaid coverage, where the eligibility category a patient sits in determines whether a service is payable at all.
Orthopedics, PT, and occupational medicine
Nonsubscriber injury claims that never touch the workers' compensation system, requiring group health or liability billing paths and different documentation than a DWC claim.
Telehealth-heavy practices
Correct place-of-service and modifier combinations under Texas telemedicine rules — and the reminder that licensure follows the patient's physical location at the time of service, not the provider's.
Revenue cycle
The cycle we run for Texas practices
A real sequence, timed against the state's deadlines at every stage.
Verify eligibility and identify the plan
Before the visit: coverage, program, service delivery area, network status, and whether behavioral health routes to a separate vendor.
Review coding against documentation
Code selection and modifiers confirmed against the note, including supervision attribution and telehealth place-of-service.
Scrub and submit inside the window
Claims drop within the 95-day envelope, sized down to the payer's own contractual limit when that limit is shorter.
Post ERAs and EOBs the same week
Underpayments surface against contracted rates immediately rather than months later during a reconciliation.
Work denials by category
Appeals filed inside Medicaid's 120-day window, with prompt-pay escalation for state-regulated carriers that miss their deadline.
Report by Texas payer
Monthly clean claim rate, days in A/R, and denial reasons broken out per payer so the next fix is obvious.
The decision
Why outsourcing adds up in a non-expansion state
A full-time biller in Dallas or Austin costs salary, benefits, software, and clearinghouse fees — and you compete for that hire against hospital systems paying more.
One in-house biller
- Fixed cost regardless of claim volume or seasonality
- Coverage stops during vacation, illness, or turnover
- Texas rule changes get tracked only if someone has time
- Credentialing and revalidation live in one person's memory
- Recruiting competes directly with large health systems
Working with our team
- Cost scales with volume instead of headcount
- Continuous coverage with no single point of failure
- Statute and payer-policy changes monitored as part of the service
- PEMS revalidation and MCO contracting kept on a calendar
- Patient-balance workflow built for a high self-pay mix
Questions from Texas providers
Frequently asked questions
Our claim was submitted on day 92 but denied for timely filing. Is that appealable?
Yes, if you can evidence receipt. TMHP accepts electronic claim reports and 277CA acknowledgments as proof of timely filing. The appeal must be submitted within 120 days.
We enrolled through PEMS. Why are STAR claims still denying as out-of-network?
PEMS enrollment establishes your Texas Medicaid participation. Network status is separate: each MCO credentials and contracts with you individually, in each service delivery area where you practice.
Our members are moving off FirstCare and RightCare this fall. What breaks?
Payer IDs, eligibility responses, authorizations already in progress, and your contract status with whichever plan receives those members. Re-verification and MCO contracting should be underway before the September transition.
Do gold-card exemptions apply to Medicaid managed care?
The exemption framework applies to state-regulated health plans under TDI oversight. Medicaid authorization requirements are governed separately by HHSC and each MCO's utilization management rules, so the two should be tracked apart.
A patient's employer has no workers' compensation. How do we bill the injury?
As a non-occupational claim to the applicable group health plan, or to the employer's liability carrier, depending on the arrangement. DWC fee guidelines do not apply to nonsubscriber employers.
Can our LPC-Associate bill Texas Medicaid directly?
Generally no. Services are billed under the supervising clinician's Medicaid identifier, and most commercial panels in Texas do not credential associate-level licensees independently. Getting the rendering and billing NPI setup right is what keeps these claims payable.
Next step
Let's look at your Texas A/R together
If your denials cluster around timely filing, MCO network status, or behavioral health authorizations, those are solvable with the right process behind them. A consultation includes a review of your current denial mix and credentialing status — no cost, no obligation.