Texas emergency department billing services
Professional ER billing for emergency medicine groups in Texas: MDM-based 99281-99285 levels, critical care time, modifier 25, payer enrollment and No Surprises Act claims, built on the Texas payer rules verified below.
What changes an ER claim in Texas.
Every Texas rule on file, each linked to its primary source: state surprise-billing law, Medicaid ER policy, Medicaid managed care, the Blue plan and the Medicare contractor.
| Rule type | Date | What it says | Source |
|---|---|---|---|
| State surprise-billing law | Jan 2020 | Texas (SB 1264) bans balance billing by out-of-network providers for emergency care for TDI-regulated plans for services on/after 1 Jan 2020. ER physician payment disputes go to TDI arbitration via the IDR portal, not the patient. Self-funded plans follow federal NSA. | Source |
| Medicaid ER policy | Aug 2026 | Texas Medicaid FFS (TMPPM): under TEFRA s.104, non-emergent, non-urgent physician ED services are paid at 60% of the Medicaid office-visit rate. Bill ED visits with 99281-99285. | Source |
| Medicaid managed care | May 2026 | Superior HealthPlan (STAR, STAR Kids, STAR Health, STAR+PLUS, CHIP) policy CC.PP.076 from 1 May 2026: professional ED E/M codes above the maximum level supported by the diagnosis and claim data are reduced to that maximum level. | Source |
| Blue plan | Nov 2025 | BCBSTX CPCP042 (eff 14 Nov 2025): professional ED E/M 99281-99285 on CMS-1500 may be reviewed before payment; level is set by MDM only (2 of 3 MDM elements), time does not count. | Source |
| Medicare contractor | Jun 2026 | Medicare Part B (professional) claims are processed by Novitas Solutions, Jurisdiction H (JH). CMS re-awarded JH to Novitas on 25 Jun 2026; implementation in progress. | Source |
How we bill Texas ER visits.
The same four-step workflow we run for emergency medicine and hospitalist groups billing from their hospital system.
Hospital feed and registration
Demographics, insurance and the attending physician arrive from the hospital system daily. Gaps go back to registration as clarification requests, not guesses.
MDM levels and critical care minutes
ED visits 99281-99285 are coded on medical decision making only. Critical care is 99291 for 30 to 74 minutes and 99292 from 104 total minutes, on documented time.
Modifier 25 and enrollment check
A separately identifiable E/M on the day of a procedure carries modifier 25 with its own documentation. The rendering physician is checked against the payer roster before release.
Submission, remit and NSA/IDR
Professional claims go out with place of service 23. Out-of-network ER claims follow the No Surprises Act: in-network cost share only, open negotiation, then federal IDR.
FAQ: ER billing in Texas.
Does Texas have a state surprise billing law for ER care?
Texas (SB 1264) bans balance billing by out-of-network providers for emergency care for TDI-regulated plans for services on/after 1 Jan 2020. ER physician payment disputes go to TDI arbitration via the IDR portal, not the patient. Self-funded plans follow federal NSA.
What does Texas Medicaid require for ED visits?
Texas Medicaid FFS (TMPPM): under TEFRA s.104, non-emergent, non-urgent physician ED services are paid at 60% of the Medicaid office-visit rate. Bill ED visits with 99281-99285.
How do Texas Medicaid managed care plans handle ER claims?
Superior HealthPlan (STAR, STAR Kids, STAR Health, STAR+PLUS, CHIP) policy CC.PP.076 from 1 May 2026: professional ED E/M codes above the maximum level supported by the diagnosis and claim data are reduced to that maximum level.
What is the Texas Blue plan policy on ER claims?
BCBSTX CPCP042 (eff 14 Nov 2025): professional ED E/M 99281-99285 on CMS-1500 may be reviewed before payment; level is set by MDM only (2 of 3 MDM elements), time does not count.
Which Medicare contractor processes Texas ER professional claims?
Medicare Part B (professional) claims are processed by Novitas Solutions, Jurisdiction H (JH). CMS re-awarded JH to Novitas on 25 Jun 2026; implementation in progress.
Nearby ER billing state guides.
Neighbouring state pages with their own verified ER payer rules.