info@mdrevenuegroup.com9:00 AM - 5:00 PM | Mon - Fri
Texas has one of the more misunderstood surprise-billing laws in the country, and the misunderstanding costs practices money. Senate Bill 1264 protects patients on state-regulated health plans from balance bills and routes disputes through a baseball-style arbitration process, but state-regulated plans only cover about 16% of Texans. The rest carry self-funded employer coverage governed by federal ERISA law, where the federal No Surprises Act applies instead. A practice that doesn't know which rule applies to which patient is guessing on every out-of-network dispute it files. Add a Medicaid program run entirely through managed care, a Medicare contractor that just won a fresh multi-year recompete, and a legislature that only meets in odd years, and Texas rewards a billing team that actually tracks which system governs which claim.
National RCM playbooks assume every state works the same way. Texas doesn't, and the practices that lose the most revenue are the ones billed like it does.
Senate Bill 1264 protects patients with state-regulated health plans from surprise medical bills, using a Major League Baseball-style final-offer arbitration process to settle payer-provider disputes without involving the patient. But state-regulated plans only cover roughly 16% of Texans. The large majority carry self-funded employer coverage under federal ERISA law, which SB 1264 doesn't reach at all, those disputes go through the federal No Surprises Act's independent dispute resolution process instead. A practice needs to know which category a given patient falls into before assuming which arbitration process, and which set of rules, actually applies.
CMS awarded Novitas Solutions the Medicare Administrative Contractor Jurisdiction H contract again on June 30, 2026, a base year plus six option years, covering Texas, Arkansas, Colorado, Louisiana, Mississippi, New Mexico, and Oklahoma. Novitas has held this jurisdiction since 2012, so there's no name change here the way there was for the Northeast's NGS/Wellpoint Federal transition, but any MAC recompete carries a real risk of backend processing changes, and it's worth confirming your clearinghouse configuration held through the transition.
Texas Medicaid delivers care through STAR for low-income families and children, STAR+PLUS for adults with disabilities and the elderly, STAR Kids for children and young adults with disabilities, and STAR Health for children under state conservatorship in the child welfare system, each with its own MCO roster including Superior HealthPlan, Amerigroup, Molina Healthcare of Texas, and UnitedHealthcare Community Plan. A workflow tuned for STAR's plan rules doesn't automatically carry over to a STAR+PLUS or STAR Kids patient at the same practice.
The Texas Legislature holds regular sessions only in odd-numbered years, meaning any new state health care legislation from the most recent session won't be revisited in a regular session again until 2027. Practices tracking Texas regulatory change need to watch for special sessions and agency rulemaking in the interim rather than assuming the legislative calendar works the way it does in a state with annual sessions.
Blue Cross Blue Shield of Texas, part of Health Care Service Corporation and the only Blue Cross Blue Shield licensee that operates as a for-profit-adjacent mutual across multiple states, dominates the commercial market. HCA Healthcare operates one of the largest hospital footprints in the state, alongside Baylor Scott & White Health, Memorial Hermann, and CHRISTUS Health, each with its own negotiated group contracts that change how a hospital-affiliated practice bills compared to an independent one.
SB 1264's arbitration process only applies to state-regulated health plans, roughly 16% of the Texas market. A practice that files an SB 1264 dispute for a patient actually covered under a self-funded ERISA plan is using the wrong process entirely, the claim needed to go through the federal No Surprises Act's IDR process instead.
Novitas retained the Jurisdiction H contract in the June 2026 recompete, but any MAC transition, even without a name or company change, carries a real risk that a clearinghouse profile or EDI configuration built around the prior contract cycle silently falls out of date. Practices that don't re-verify this after a recompete risk claim rejections that have nothing to do with coding.
A prior-authorization threshold or documentation requirement that holds for a STAR patient doesn't necessarily hold for a STAR+PLUS or STAR Kids patient at the same practice, even under the same MCO. Treating Texas Medicaid as one uniform managed care program generates avoidable denials at the program boundary.
With the Texas Legislature meeting only in odd years, agency rulemaking and interim committee activity in even years often shapes real regulatory change without a session vote. Practices that only track Texas policy during legislative sessions miss changes that take effect between them.
The plan rejects the claim outright. Prior authorization can’t be obtained retroactively, so the practice loses the full claim value.
Authorization rules are mapped at check-in, and booking is locked until the token is validated.
A claim submitted past the filing deadline gets written off as an administrative loss.
Claims are scrubbed, batched, and filed within 24 hours of note lock, well inside any filing deadline.
The payer pays a minimal out-of-network rate, and the underpaid balance is written off to avoid dispute overhead.
Payment outputs are tracked against historical contracts, and an underpaid claim triggers a state or federal dispute automatically.
A free audit checks your last 90 days of claims against the Texas-specific issues above.
Medicaid: Texas Medicaid, delivered entirely through managed care via STAR (low-income families and children), STAR+PLUS (adults with disabilities and the elderly), STAR Kids (children and young adults with disabilities), and STAR Health (children under state conservatorship), with MCOs including Superior HealthPlan, Amerigroup, Molina Healthcare of Texas, and UnitedHealthcare Community Plan
Medicare Administrative Contractor: Novitas Solutions (Jurisdiction H, covering Texas, Arkansas, Colorado, Louisiana, Mississippi, New Mexico, and Oklahoma; contract renewed June 30, 2026)
Senate Bill 1264's baseball-style arbitration process for surprise bills applies only to state-regulated health plans. Self-funded ERISA plans, the majority of Texas commercial coverage, fall under the federal No Surprises Act's dispute process instead. We identify which category a patient's plan falls into before filing any out-of-network dispute.
CMS re-awarded Novitas Solutions the Jurisdiction H A/B MAC contract this year, a base year with six option years. We re-verify clearinghouse and EDI enrollment records after any MAC recompete, even one without a contractor change, since backend configuration issues are a common source of post-transition rejections.
STAR, STAR+PLUS, STAR Kids, and STAR Health each serve a different population with distinct authorization and documentation rules, even where the same MCO administers more than one program. We track these as separate rule sets rather than a single Texas Medicaid assumption.
Texas holds regular legislative sessions only in odd years. We monitor agency rulemaking and interim committee activity in even years specifically, since that is where real regulatory change often happens between sessions.
Book a 15-minute call and we'll walk through exactly how your specific payer mix would be handled.
Every fact on this page, from the Medicaid structure to the regulatory notes, was researched specifically for Texas, not copied from a 50-state boilerplate.
AAPC-certified coders handle your claims directly, with a named point of contact instead of a rotating support queue.
We run your existing vendor in parallel while we credential and rebuild your claim rules, so nothing lapses during the switch.
Claims submission built around which specific STAR Medicaid program, and which surprise-billing framework, actually applies to a given Texas patient.
Learn moreFull-cycle RCM that routes disputes to the correct process, SB 1264 or the federal No Surprises Act, based on the patient's actual plan type.
Learn moreProvider enrollment across Blue Cross Blue Shield of Texas, the major Medicaid MCOs, and the hospital-affiliated networks tied to HCA, Baylor Scott & White, and Memorial Hermann.
Learn moreA free audit that checks specifically for misrouted surprise-billing disputes and STAR-program authorization mismatches.
Learn moreFront-desk and administrative support that scales with a growing Texas practice without new office overhead.
Learn moreBenchmarks your claims data against current Texas payer-specific denial patterns across all four STAR Medicaid programs.
Learn moreLocal visibility support built for a market spanning dense metro corridors and long distances between rural practice areas.
Learn moreTalk to our team about your specific specialty, payer mix, and current billing setup.
We analyze your last 90 days of claims for denial patterns, underpayments, and coding gaps specific to your state and specialty.
A written plan targeting the specific leakage points the audit found, not a generic onboarding checklist.
Your existing vendor keeps running while we credential and build claim rules in parallel, proven on real claims first.
Real-time reporting on collections, denials, and A/R velocity, so you see the recovery as it happens, not at quarter-end.
If we don't find money you're leaving on the table, you don't pay a dime.
No commitment. No sales pressure. Just answers.
