Texas Medicaid billing rules start with one routing decision and one deadline. In short, fee-for-service claims go to TMHP, and managed care claims go to the member’s health plan. In both lanes, the payer must receive the claim within 95 days of the date of service, unless a specific exception starts a new clock.
This guide is for billing managers and practice teams that bill Texas Medicaid. It covers where each claim goes, what data TMHP requires, how to count the 95 days, and which exceptions really apply. It also explains where the Texas prompt pay law fits. All rules reflect the October 2026 Texas Medicaid Provider Procedures Manual (TMPPM).
Key Takeaways
Routing: Fee-for-service and carve-out claims go to TMHP. STAR, STAR+PLUS, STAR Kids, and STAR Health claims go to the member’s health plan.
95-day limit: TMHP and Medicaid health plans must receive a claim within 95 days of the date of service.
Exceptions: Retroactive eligibility, new enrollment, and claims that another payer processed first get a later start date. Most of them still must meet the 365-day federal limit.
Submission: TexMedConnect is free. Vendors send ANSI X12 5010 837P, 837I, or 837D files, and TMHP still accepts paper claims except for EVV services.
Prompt pay: The Insurance Code prompt pay rules cover fully insured HMO and PPO plans. They do not cover Medicaid, CHIP, Medicare, or self-funded ERISA plans.
Who Processes Texas Medicaid Claims?
Texas splits Medicaid claims into two lanes, so the first billing decision is the payer. In practice, the member’s enrollment on the date of service decides the lane. As a result, a wrong lane costs days that the 95-day clock does not give back.
Fee-for-Service Claims Go to TMHP
The Texas Medicaid & Healthcare Partnership (TMHP) is the state’s claims administrator. It processes traditional fee-for-service claims. In addition, it handles services carved out of managed care.
New clients start in fee-for-service. According to the TMPPM, every person found eligible for Texas Medicaid is first enrolled as a fee-for-service client. As a result, early dates of service for a new client often belong to TMHP.
Managed Care Claims Go to the Member’s Health Plan
Claims for services that a managed care organization (MCO) or dental maintenance organization (DMO) administers must go to that plan. Each plan also sets its own portal, clearinghouse, and paper rules. The Medicaid Managed Care Handbook describes four managed care programs:
- STAR: acute care for children, newborns, pregnant women, and some families.
- STAR+PLUS: acute care plus long-term services and supports for adults 65 and older and adults 21 and older with a disability.
- STAR Kids: acute care plus long-term services and supports for people 20 and younger with a disability.
- STAR Health: one statewide plan for most children in foster care.
However, CHIP is a separate program from Medicaid. Even so, CHIP claims follow the same pattern: they go to the member’s CHIP health plan, not to TMHP.
| Claim lane | Who processes it | How to submit | Filing limit |
|---|---|---|---|
| Traditional Medicaid fee-for-service and carve-out services | TMHP | TexMedConnect, an approved vendor or billing agent, or paper | 95 days from the date of service |
| STAR, STAR+PLUS, STAR Kids, STAR Health | The member’s MCO (dental: the DMO) | The plan’s portal, clearinghouse, or paper address | 95 days from the date of service |
| CHIP | The member’s CHIP health plan | The plan’s own methods | Set in the plan’s CHIP provider manual |
| EVV services (fee-for-service and managed care) | TMHP, which forwards matched claims to the payer | Electronic only | 95 days from the date of service |
What the TMHP Clean Claim Requirements Cover
TMHP’s manual does not offer one short definition of a clean claim. Instead, Section 6 of the TMPPM lists the data every claim needs, on paper or electronically. As a result, missing items lead to rejections, denials, or claims TMHP cannot process.
Medicaid health plans apply the clean claim definition in HHSC’s Uniform Managed Care Manual. By contrast, commercial plans use the elements in 28 TAC §21.2803. In practice, the TMHP items below stop the most claims.
- Billing provider’s complete name and physical address with ZIP+4.
- NPI and taxonomy code for the billing and performing provider, plus the benefit code when one applies.
- The performing provider’s NPI whenever a group practice bills.
- The ordering or referring provider’s NPI for services that need an order or referral. That provider must be enrolled in Texas Medicaid.
- Client name, date of birth, sex, and nine-digit Medicaid number that exactly match TMHP’s eligibility file.
- The facility NPI when the place of service is not the home or office.
- Valid diagnosis and procedure codes, with any modifier that sets the type of service.
- One prior authorization number per claim when the service requires authorization.
Paper claims must carry every required item in the correct block. In addition, TMHP does not key information from attachments, and it does not accept superbills or itemized statements as claim supplements.
How the Texas Medicaid 95-Day Timely Filing Limit Works
Under the TMPPM, TMHP must receive a claim within 95 days of each date of service. Claims received later are not payable, because Texas Medicaid does not cover late claims. Inpatient hospital claims count from the discharge date or the last date of service on the claim.
In other words, the clock measures receipt, not creation. For that reason, a claim that waits in a clearinghouse edit queue still uses up days.
How to Count the 95 Days
First, add 95 calendar days to the date of service. If day 95 falls on a weekend or a holiday that TMHP recognizes, the deadline moves to the next business day. TMHP lists every 2026 deadline in its 2026 filing deadline calendar.
A January 1, 2026 date of service must reach TMHP by Monday, April 6, 2026. A July 1, 2026 date of service reaches day 95 on Sunday, October 4, 2026, so the deadline moves to Monday, October 5. Leap years matter too. February 2028 has 29 days, so a January 1, 2028 date of service runs out on Wednesday, April 5, 2028.
Pick a scenario and a start date to see the TMHP filing or appeal deadline, including the weekend and holiday rollover. Without JavaScript, use the table below and TMHP’s annual filing deadline calendar.
Exceptions That Start a New 95-Day Clock
Some situations move the start date. However, most still sit inside a 365-day outer limit counted from the date of service.
| Situation | Clock starts on | Outer limit |
|---|---|---|
| Retroactive eligibility, or eligibility lost and later restored | The date eligibility was added to TMHP’s file (add date) | 365 days from the date of service |
| Patient applied but had no Medicaid number on the date of service | The add date | 365 days from the date of service or discharge |
| First-time enrollment, or a change that issues a new taxonomy and benefit code | The date the taxonomy and benefit code is issued | 365 days from the date of service |
| Re-enrolling with previous enrollment information, or revalidating | No new clock: 95 days from the date of service | None beyond 95 days |
| Medicare processed the claim first | The date of Medicare’s disposition | 365 days from the date of service for paper crossover claims |
| Other insurance billed first | The date of the other payer’s disposition | If no response, wait 110 days, then file within 365 days of service |
| Out-of-state provider | The date of service | 365 days from the date of service |
| Appeal of a denied or adjusted claim | The date of the R&S Report showing the disposition | 120 days from that date |
Retroactive eligibility does not waive the federal rule. In fact, the TMPPM quotes 42 CFR 447.45(d)(1): claims must be filed within 12 months of the date of service. While eligibility is pending, TMHP tells providers to file with 999999999 or 000000000 as the client number and keep the denial or rejection report as proof.
When HHSC Grants an Exception to the 95-Day Rule
Outside those built-in clocks, only HHSC can excuse a late claim. The TMPPM appeals section sends these requests to HHSC Claims Administrator Operations Management, not to TMHP. Providers file them, and a billing company needs the provider’s signed authorization with each request. In addition, HHSC reviews them only when the claim met the 365-day federal deadline.
- A catastrophic event, or damage to business records, beyond the provider’s control.
- A delay or error in the client’s eligibility determination, or wrong written information from HHSC or another state agency.
- Electronic claim or system implementation problems at HHSC, its designee, or the provider.
- A service that became a Medicaid benefit with a retroactive effective date.
- Retroactive eligibility when the provider was never notified of the coverage.
In addition, each request needs proof, such as a police or fire report, the incorrect notice, or a system error report. Otherwise, HHSC has no basis to approve the exception.
Managed Care Claims Follow the Same 95-Day Rule
The 95-day limit is not only a TMHP rule. In fact, the Managed Care Handbook applies it to MCO and DMO claims, and a plan denies a claim it receives after day 95.
- Correct plan: 95 days from the date of service.
- Wrong plan: refile with the correct plan within 95 days of the wrong carrier’s R&S Report date, with proof of the first filing. The correct plan must honor that first date.
- Other insurance first: 95 days from that insurer’s disposition.
- Newborns: file with the mother’s or the newborn’s plan within 95 days of the date of service.
Appeal windows, portals, and attachment rules still vary by plan. Therefore, check each plan’s current provider manual before you build work queues.
How to Submit a Claim Under Texas Medicaid Billing Rules
A clean submission routine protects the 95 days. The five steps below follow the TMPPM workflow for fee-for-service claims.
Step 1: Verify Eligibility and the Payer
Always check eligibility for the date of service, not the billing date. TMHP offers TexMedConnect, the Medicaid Client Portal for Providers, and the Automated Inquiry System (AIS) at 1-800-925-9126. The check also confirms managed care enrollment, which decides the lane.
Then keep a copy of each check with the claim record. That copy shows coverage on the date of service if a denial later needs an appeal. Our guide to preventing eligibility verification errors covers front-desk habits that support this step.
Step 2: Choose the Submission Channel
TexMedConnect is TMHP’s free web application. According to TMPPM Section 3, practices use it to submit claims, check eligibility and claim status, file appeals, and download electronic R&S Reports.
In addition, approved vendors and billing agents send files through the TMHP EDI Gateway in the ANSI ASC X12 5010 format. They use 837P for professional claims, 837I for institutional claims, and 837D for dental claims.
TMHP also still accepts paper claims on original CMS-1500, UB-04 CMS-1450, or ADA forms. However, claims for Electronic Visit Verification (EVV) services must go in electronically.
Step 3: Confirm the Claim Was Accepted
A rejected claim does not count as filed. After each batch, check the claim response report (the 27S file) and the accepted and rejected reports. Only claims accepted on the 27S report move on to processing.
Next, watch the weekly R&S Report. If a claim does not appear within 30 days, TMHP tells providers to resubmit it within the 95-day window.
Step 4: Fix Rejections and Zero-Paid Claims Quickly
First, correct rejections in the same week. A zero-paid claim that is still within 95 days should go back as a new claim, because TMHP processes new claims faster than appeals.
After day 95, the claim can still go back electronically if the NPIs, Medicaid number, dates of service, and billed amount stay the same. Otherwise, file a paper appeal with a copy of the R&S Report within 120 days.
Step 5: Keep Proof of Timely Filing
Finally, store batch reports, acceptance files, and R&S pages for every claim. For paper claims, TMHP accepts certified mail receipts as proof when the receipt number appears on a detailed claim listing. That evidence also supports a CO-29 timely filing appeal with other payers.
What the Texas Prompt Pay Law Means for Medical Claims
The Texas prompt pay law sits in Insurance Code Chapter 843 for HMOs and Chapter 1301 for preferred and exclusive provider plans. It protects claims to fully insured plans that the Texas Department of Insurance (TDI) regulates.
However, coverage is narrower than many billers assume. TDI’s Prompt Pay FAQ says the rules do not apply to self-funded ERISA plans, Medicare Advantage plans, federal employee plans, TRICARE, or workers’ compensation. Medicaid and CHIP are exempt as well, under Insurance Code §1211.001.
Deadlines Under the Prompt Pay Law
- Provider filing: submit by the 95th day after the date of service, unless a contract or a certified catastrophic event extends it. A late claim forfeits payment.
- Plan decision: pay, partly pay, or deny a clean claim within 30 days if it was filed electronically and 45 days if it was filed on paper.
- Pharmacy claims: pay within 18 days (electronic) or 21 days (nonelectronic) after the plan affirmatively adjudicates the claim.
- Extra information: the plan may send one written request to the treating provider within 30 days of receiving the clean claim. The decision is then due by the later of 15 days after the information arrives or the original deadline.
- Audits: the plan must still pay 100% of the contracted rate on time and finish the audit within 180 days.
Penalties for Late Payment
Under Insurance Code §843.342, a late HMO payment triggers a penalty on top of the contracted rate. Similarly, Section 1301.137 sets a parallel penalty rule for preferred provider plans.
| When the plan pays | Penalty owed with the contracted rate |
|---|---|
| Late, up to 45 days after the deadline | The lesser of 50% of billed charges minus the contracted rate, or $100,000 |
| 46 to 90 days after the deadline | The lesser of 100% of that difference, or $200,000 |
| 91 days or more after the deadline | The 100% penalty plus 18% annual interest |
The often-quoted $1,000 figure is different. Instead, it is an administrative penalty that TDI can impose on a plan that breaks the payment rules on more than 2% of clean claims. Also, that penalty cannot exceed $1,000 per day for each claim that remains unpaid. TDI also states that late-payment penalties cannot be waived by contract.
How Medicaid Managed Care Payment Timing Works Instead
Medicaid health plans follow HHSC contract rules rather than the prompt pay statute. Their claims policies point to Chapter 2.0 of HHSC’s Uniform Managed Care Manual (UMCM). For example, one plan’s claims processing policy (Texas Children’s Health Plan, version 6, May 2025) commits to adjudicate 98% of clean claims within 30 days of receipt. The same policy pays 18% annual interest, calculated daily, on clean claims still open after that 30-day deadline.
Complaints follow a different path, too. Providers start with the plan’s own complaint process and can then escalate to HHSC, not TDI.
Texas Medicaid vs. Commercial Claims: Deadline Comparison
The Texas medical billing timely filing limit is 95 days for all three claim types below. However, the payer-side clocks and remedies differ, so each lane needs its own tracking rules. Our 2026 guide to timely filing limits compares Medicare and other national payers.
| Rule | TMHP fee-for-service | Medicaid MCO (STAR programs) | Fully insured commercial plan |
|---|---|---|---|
| Provider filing limit | 95 days from the date of service | 95 days from the date of service | 95 days from the date of service, unless the contract extends it |
| After another payer processes first | 95 days from that payer’s disposition | 95 days from that payer’s disposition | 95 days after notice of the primary payment or denial |
| Payer decision deadline | Not set by the prompt pay law | Set by HHSC contract; plan policies citing UMCM 2.0 use 98% of clean claims within 30 days | 30 days electronic, 45 days paper |
| Appeal window | 120 days from the R&S Report date | Set by each plan’s manual | Set by the contract and plan |
| Late-payment remedy | Not applicable | 18% annual interest under plan policies citing UMCM 2.0 | Statutory penalties, plus 18% annual interest when paid 91 or more days late |
Why Texas Medicaid Claims Reject or Deny
TMHP lists the most common electronic rejections for professional claims. In practice, most come from data that does not match TMHP’s files.
- Client name, date of birth, sex, or Medicaid number that does not exactly match the eligibility file.
- Blank or invalid referring or ordering physician NPIs for consultations, laboratory, or radiology.
- No performing provider NPI when a group bills.
- A missing facility NPI when the place of service is not the home or office.
- An invalid type of service, or a procedure code that needs a modifier to set the type of service.
Denials also follow eligibility gaps, missing prior authorization, and duplicate claims. For that reason, run a weekly rejection sweep and work any claim older than 60 days without an R&S entry first.
Keep Texas Medicaid Claims on Schedule With MedXpert Services
Texas Medicaid billing rules reward practices that route claims correctly, file early, and track every response. In contrast, a wrong lane or an unworked rejection can turn a payable service into a write-off.
MedXpert Services supports Texas practices with claim submission, rejection follow-up, and timely filing tracking. Explore our Texas medical billing services or learn about our denial management services to review your current Medicaid workflow.
