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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.
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 More| Texas Regulation | The Generic Billing Trap | The MD Revenue Group Approach |
|---|---|---|
| SB 1264 Surprise Billing | Billing out-of-network claims under SB 1264 rules when the patient has a federal ERISA self-funded plan. | We verify regulation type (state vs federal) during intake and route disputes to the correct arbitration process. |
| Novitas MAC Billing | Failing to verify credentialing and EDI status holds during Medicare MAC contract transitions. | We monitor Novitas portal guidelines and confirm all clearinghouse enrollments hold during transitions. |
| STAR vs STAR+PLUS Medicaid | Using identical coding and auth workflows for basic STAR and complex STAR+PLUS/STAR Kids programs. | We map plan rules by specific patient MCO type (Amerigroup, Superior, Molina) at the county level. |
| BCBS of Texas Dominance | Accepting low out-of-network rates or standard contract terms from dominant regional payers without negotiation. | We track historical reimbursement benchmarks and negotiate or appeal BCBSTX claims to maximize collections. |
We analyze your last 90 days of claims for denial patterns, underpayments, and coding gaps specific to Novitas and STAR Medicaid MCO rules.
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.
Our local Texas payer specialists identified a systematic STAR MCO authorization mismatch and appealed under SB 1264 rules to force payout.
See What We Can Recover For YouThe Texas Department of Insurance (TDI) has increased audits on out-of-network claims to enforce SB 1264 balance-billing bans. While balance-billing is restricted, providers must submit disputes to the TDI mediation/arbitration portal within strict statutory windows. Incorrectly routing self-funded ERISA claims here causes immediate dismissals.
CMS finalized the renewal of Novitas Solutions' contract for Jurisdiction H. While the administrative contractor name remains the same, backend claim clearinghouse interfaces and EDI protocols are undergoing security upgrades. Incomplete clearinghouse re-enrollment will lead to silent claim rejections.
HHSC has tightened authorization verification for specialized STAR Medicaid programs (STAR+PLUS, STAR Kids). A prior-authorization approved under standard STAR rules will be rejected under STAR+PLUS, even if managed by the same payer organization, requiring distinct billing modifier and taxonomy configurations.
We check specifically for SB 1264 compliance gaps, ERISA plan routing errors, and Novitas MAC anomalies.
