Texas Billing Rules for Eye Care Practices
Four Texas-specific rules shape how eye care claims are billed in the state. Each one changes how fast claims are filed and how denials are worked.
| Rule | What it requires | How we handle it |
|---|---|---|
| Texas Medicaid filing limit | Claims received by TMHP within 95 days of service | Daily submission and a 60-day aging alert |
| Texas Medicaid appeal limit | Appeals received within 120 days of the R&S report date | Denials worked within 10 days of the report |
| Commercial filing limit | Physicians submit HMO and PPO claims within 95 days of service under the Texas Insurance Code | Same daily workflow for commercial claims |
| Texas Prompt Pay Act | Clean claims paid within 30 days (electronic) or 45 days (paper) | Claim age tracked, late payments flagged for penalty review |
Self-funded employer plans governed by ERISA fall outside the Texas Prompt Pay Act, so we identify plan type during the eligibility check.
Texas Medicare Through Novitas
Novitas Solutions processes Medicare Part B claims for Texas as part of Jurisdiction H. Its local coverage determinations list the diagnosis codes that support tests such as scanning computerized ophthalmic diagnostic imaging (92133, 92134) and visual fields (92083), and they set how often each test is covered. We load the current Novitas LCD rules into claim scrubbing so a test is checked before it is billed, not after it denies.
Texas practices also see a large share of Medicare Advantage patients. Those plans follow Medicare coverage rules but add their own prior authorization lists, especially for anti-VEGF injections and surgery.
Texas Medicaid Eye Claims
Texas Medicaid is administered by the Texas Health and Human Services Commission, with TMHP processing fee-for-service claims and provider enrollment. Most Medicaid patients are in managed care programs such as STAR, STAR Kids and STAR+PLUS, where the managed care organization or its vision vendor processes the claim. We confirm the right payer for each patient because a claim sent to TMHP for a managed care member does not stop the 95-day clock.
Children's vision services under Texas Health Steps have their own benefit limits and eyewear rules. Our pediatric ophthalmology billing page covers the pediatric side in more detail.
Serving All of Texas
We work inside your EHR and practice management system from our own offices, so location inside Texas does not matter. Practices in Houston, Dallas and Fort Worth, San Antonio, Austin, El Paso and smaller markets across the state receive the same service, reporting and account lead.
- Remote access to your EHR, practice management system and clearinghouse
- A monthly KPI call with your practice administrator
- Credentialing with Texas Medicaid, managed care plans and commercial payers through our credentialing services
Services for Texas Practices
Texas practices use the same service set as our clients in other states. That includes coding, claim submission, payment posting, denial management, A/R recovery and patient billing. The difference in Texas is speed, because the filing windows leave little room for rework.
Start With a Free Texas Billing Audit
A free ophthalmology billing audit shows how many of your Texas Medicaid and commercial claims are close to the 95-day limit today, and how many were lost to it in the last year. We send the findings in writing within 10 business days.