Prior Authorization in Texas

What is specific to Texas

Texas Medicaid runs through TMHP with its own enrollment and its own claim submission rules, separate from commercial payers.

Texas’s Medicaid program is Texas Medicaid. Practices with a meaningful Texas Medicaid mix usually need it worked as its own queue rather than mixed into commercial follow-up, because the submission path, the timely filing window and the appeal route are all different.

Medicare here is adjudicated by Novitas Solutions, jurisdiction JH — shared with Arkansas, Louisiana, New Mexico and Oklahoma. CMS publishes the jurisdictions; checked September 2026.

What a prior authorization seat does in Texas

Submitted before the date of service and chased through the payer's decision window.

An authorisation found after the visit is a write-off, not a denial to appeal. In Texas the work is submitting ahead of scheduling and chasing the decision, against a payment clock that starts only once a clean claim lands.

• Authorizations submitted ahead of scheduling, not after
• Status chased rather than waited on
• Peer-to-peer reviews scheduled when required
• Clinical documentation gathered before submission
• Expiring authorizations flagged before they lapse
• Worked during Texas business hours, not queued overnight

For the statute behind all of this — Texas’s prompt-pay deadline, its Medicaid filing limit, and the wrinkle that catches people out here — see the Texas billing page.

Texas Medicaid, in practice

Predominantly managed care: TMHP states 'The majority of Texas Medicaid benefits are delivered through Managed Care Organizations,' delivered through STAR (largest program), STAR+PLUS (21+ with disabilities or 65+, includes LTSS), STAR Kids (under 21 with disabilities), and STAR Health (foster care, administered statewide by Superior HealthPlan), plus dental maintenance organizations; a traditional fee-for-service (Traditional Medicaid) segment remains. Source: tmhp.com

Texas attaches unusually punitive statutory damages to late clean-claim payment, calculated off billed charges rather than the contracted rate. Under Insurance Code 843.342, an HMO that pays 1–45 days late owes the contracted rate plus a penalty of the lesser of '50 percent of the difference between the billed charges ... and the contracted rate' or $100,000; 46–90 days late, the lesser of '100 percent of the difference between the billed charges ... and the contracted rate' or $200,000; and beyond 90 days, that penalty 'plus 18 percent annual interest on that amount.' This makes prompt-pay demand letters a genuine revenue line in Texas, unlike states that only add single-digit interest. Separately, a provider must enroll in Texas Medicaid through the PEMS portal before contracting and credentialing separately with each MCO. Source: Texas statutes (Public.Law)

For authorisations it decides who you ask. A carve-out means the rules, the portal and the turnaround belong to a different administrator from the one handling the rest of the member’s care, and an authorisation obtained from the wrong one is not an authorisation.

How long you have to file a Texas Medicaid claim

95 days from each date of service (or from the TPI issue date, if later). All claims must be finalized within 24 months of the date of service.

“Claims from all other providers delivering services reimbursed by the Texas Medicaid acute care program must be received by HHSC or its designee within 95 days from each date of service on the claim or 95 days from the date the Texas Provider Identifier (TPI) Number is issued, whichever occurs later.” 1 Tex. Admin. Code § 354.1003 — Time Limits for Submitted Claims

A claim past that date is not late, it is unpayable, and no appeal recovers it. It is the one queue where a week of nobody working it is money that does not come back — which is the argument for working Texas Medicaid as its own queue rather than mixing it into commercial follow-up. Every state’s limit is listed here.

That date is also the outer edge of what a retrospective authorisation is worth. Payers will sometimes grant one after the fact, and practices treat that as the problem solved — but the claim still has to be filed inside the window above. An authorisation granted after it has closed is an administrative victory attached to money nobody can bill, which is why the authorisation queue and the filing clock have to be watched on the same screen rather than by two different people.

Working Texas hours

Texas runs on Central time, 11 hours behind our floor in Rawalpindi. To be at a desk for your nine to five, the shift here runs 8pm to 4am, and 7pm to 3am once the clocks go forward. Pakistan does not observe daylight saving, so the shift moves on this side rather than yours.

One wrinkle worth naming: El Paso and Hudspeth counties run on Mountain time. If your practice sits on that side of the line, say so on the call and the shift is set to your clock rather than the one most of the state keeps.

That is the part that decides whether follow-up happens at all: a payer’s phone lines are open on Texas hours and nobody else’s.

What it costs in Texas

$1,900

Per seat, per month, in US dollars — $22,800 a year for one full-time person, forty hours a week, on Texas hours. No annual contract, no percentage of collections, no setup fee and no software to buy. Seat prices across all roles in Texas run $1,500 to $2,500; the full list is published.

That is the entire invoice. Run your own figures against a percentage vendor or a hire rather than take ours.

Getting started in Texas

About a week from a signed agreement to a person working your queue, and that week of training is not billed on top. The week, step by step, and what is signed before anyone has access.

If working with staff outside the United States is new to your practice, see how a medical billing company structures that seat and why offshore medical billing does not have to mean losing visibility into the work.

Questions