What is the timely filing deadline for Texas Medicaid (TMHP) claims?
Under Texas Administrative Code (TAC) and TMHP rules, initial claims for Texas Medicaid must be received within 95 days from the date of service. If a claim is denied or requires appeal, providers have 120 days from the date of the Remittance and Status (R&S) Report to resubmit or appeal. Missing the 95-day window results in an irrecoverable denial.
1. The Complexity of the Texas Medicaid Landscape
Administered by the Texas Health and Human Services Commission (HHSC) and operated operationally by the Texas Medicaid & Healthcare Partnership (TMHP), Texas Medicaid is the second-largest Medicaid program in the nation.
Because Texas transitioned almost all beneficiaries into managed care programs, billing is not uniform: providers must contract with and bill multiple regional health plans depending on the patient's Service Delivery Area (SDA).
2. The Big 4 Texas Medicaid Managed Care Programs
Where Texas claims must be directed
Understanding the specific program dictates your billing rules:
• STAR: Covers children, pregnant women, and low-income adults. Primary payers include Texas Children's Health Plan, Community Health Choice, Parkland Community Health Plan, Superior HealthPlan, and Molina Healthcare of Texas.
• STAR+PLUS: Covers adults who have disabilities or are age 65 or older. Requires coordination of benefits with Medicare (Dual Eligibles).
• STAR Kids: Specialized program for children and youth with disabilities or complex medical needs.
• Traditional Fee-for-Service (FFS): Billed directly to TMHP via TexMedConnect for non-managed specialty populations and retroactive eligibility periods.
3. Conquering the 95-Day Timely Filing Rule
Unlike Medicare (365 days) or commercial plans (typically 90-180 days), Texas enforces a stringent 95-day rule. If you submit on day 96 without an approved disaster exception, payment is forfeited.
Med Billing Solution LLC utilizes automated 48-hour submission triggers and daily clearinghouse acknowledgement tracking (999 and 277 files) to guarantee clean proof of timely submission.