Chiropractic insurance billing in Texas.

Original Medicare Part B covers medically necessary manual spinal manipulation to correct a subluxation (CPT 98940 to 98942). Use the AT modifier for active or corrective treatment; the modifier alone does not establish medical necessity.

For a usually covered service expected to be denied in a particular case, such as spinal manipulation that has become maintenance care, a valid ABN is required before treatment to transfer potential financial liability to the patient. Exams, X-rays and therapies performed by a chiropractor are statutorily excluded from this benefit; an ABN for those services is voluntary. Medicare Advantage uses separate plan coverage and notice procedures, not the Original Medicare ABN. See CMS guidance on advance notices and our chiropractic Medicare billing guide.

Original Medicare Part B claims in Texas are processed by Novitas Solutions (JH). Check its applicable Local Coverage Determination and documentation requirements for the date of service.

Carriers listed for Texas include Blue Cross Blue Shield of Texas (HCSC); UnitedHealthcare; Aetna (CVS Health); Cigna; Humana; Ambetter (Centene). Check the member’s product, network, claim destination and applicable chiropractic policy.

In Texas, chiropractic and physical-medicine benefits may be administered DIRECTLY by the health plan or ‘carved out’ to a delegated specialty network manager — and which one determines where credentialing, prior auth/treatment plans, and CLAIMS must go.

• American Specialty Health (ASH / ashlink.com, ashcompanies.com) operates in Texas and is delegated by CIGNA for chiropractic (and acupuncture), handling network management, credentialing, contract administration, utilization management, medical-necessity review, and claims processing for Cigna members; ASH and Cigna also launched a delegated freestanding physical-therapy/occupational-therapy network in Texas. ASH likewise manages chiropractic nationally for plans such as Aetna and Anthem lines, where ASH administers the benefit, confirm network participation under the provider agreement and use the current Client Summary for review requirements and the claim destination: View source. Confirm the claim destination and review requirements in the applicable ASH Client Summary: View source.
• Optum / Optum Physical Health (a UnitedHealth Group company) manages the chiropractic/physical-health network for UnitedHealthcare. For dates of service from October 1, 2026, UHC removes prior authorization for spinal CMT 98940-98942 on its Medicare Advantage code list, subject to plan-specific exceptions. The separate D-SNP list does not include these CMT removals; other products and therapy codes have separate requirements.
• CONTRAST — Blue Cross and Blue Shield of Texas (BCBSTX) generally administers chiropractic IN-HOUSE under its own clinical payment/coding policy (CPCP016, Chiropractic Care Services) rather than carving out to ASH, so for most BCBSTX plans claims and medical-necessity review stay with BCBSTX. ALWAYS confirm on the member’s card/portal whether chiropractic is delegated (ASH or Optum) or handled by the plan, because that determines where authorizations and claims go.

What actually trips up chiropractic billing in Texas:

• Delegation routing — Cigna chiropractic typically runs through ASH and UnitedHealthcare through Optum Physical Health, while BCBSTX usually keeps chiropractic in-house (CPCP016); confirm the destination for each claim or authorization request under the member’s current product instructions. Confirm the delegate before submitting.
• Texas chiropractic NONDISCRIMINATION mandate — Texas Insurance Code Chapter 1451 (Access to Certain Practitioners) lets an insured select a chiropractor for covered services within the chiropractor’s license, bars insurers from paying or reimbursing LESS for a covered service simply because a chiropractor (rather than another practitioner) performed it, and bars denying covered physical modalities/procedures solely because a chiropractor performed them within scope. This is a real billing lever in Texas — but it equalizes covered services; it does NOT create new benefits, override plan visit caps/medical-necessity rules, or guarantee payment for non-covered/maintenance care.
• Visit caps + treatment-plan/medical-necessity gating — check the member’s benefit terms for covered codes, visit allowances and any unit limits. For ASH benefits, confirm whether review is required and whether a Clinical Performance System allowance applies under the current Client Summary and provider agreement: View source. Document acute medical necessity, functional goals, and measurable progress.
• UHC/Optum Medicare Advantage PA — Medicare-covered manipulation (98940-98942 with the AT modifier) no longer requires prior authorization under UHC’s MA code list effective October 1, 2026, subject to plan-specific exceptions (initial evaluation exempt; maintenance excluded). The separate D-SNP list does not include these CMT removals. Check the member’s product and CPT; commercial and other therapy authorization rules remain product- and code-specific.
• Modifiers and Medicare coverage rules — expect the AT (active/corrective treatment) modifier on Medicare/MA spinal CMT, correct GA/GY/GZ and -59/-XU usage for distinct services, and remember traditional Medicare covers ONLY manual spinal manipulation to correct a subluxation (exams, x-rays, and therapy modalities are statutorily excluded under Medicare chiropractic).
• Texas Medicaid: the standard CMT benefit allows 98940-98942 with the AT modifier for acute care, up to 12 visits over 12 consecutive months starting with the first treatment, and at most one visit per day. TMHP does not require prior authorization for this benefit. Maintenance and adjunctive services furnished by chiropractors are excluded. Check the member’s Medicaid program and MCO instructions separately. Source: TMHP handbook, sections 2.2-2.3: View source.
• Auto/PIP friction — $2,500 minimum PIP is quickly exhausted, carriers commonly apply ‘reasonable and necessary’ bill review and may demand records, and chiropractors cannot use the Texas hospital-lien statute — so use letters of protection/assignments and bill PIP/Med-Pay promptly. Not legal advice — verify benefits and current rules per payer.

Texas is unusual: it sets a STATUTORY 95-DAY filing floor for state-regulated commercial plans, so commercial here is NOT purely contract-set. Under Texas Insurance Code Sec. 1301.102 (PPO/preferred-provider benefit plans) and Sec. 843.337 (HMOs), and the prompt-pay rules in 28 TAC Chapter 21, Subchapter T, a physician/provider must submit a clean claim within 95 DAYS after the date the service was provided; a provider who fails to file within 95 days generally FORFEITS the right to payment (and may not bill the enrollee), with a limited catastrophic-event exception.

A carrier and provider may agree BY CONTRACT to a LONGER (never a shorter) filing window, so the practical initial-filing window runs from the 95-day statutory minimum up to the longer period in your participating-provider agreement (for example, 180 days or up to a year) — confirm per payer/contract.

CRITICAL SCOPE LIMIT: the Texas prompt-pay statute and its 95-day rule apply to TDI-regulated HMOs, PPO/EPO preferred-provider plans — they do NOT govern self-funded ERISA plans, out-of-state plans, Medicare/Medicare Advantage, Medicaid HMOs, CHIP, or government/school/church plans, which set their own (often different) deadlines.

Texas prompt-pay context (how fast the PLAN must pay YOU): on a clean claim a carrier must pay/deny within 30 days for ELECTRONIC claims and 45 days for paper/non-electronic claims after receipt, with statutory penalties for late payment (Ins.

Code Sec. 843.338, Sec. 1301.103; 28 TAC Subch. T). As of 2025-2026; verify the exact window per payer and contract.

Federal limit: generally 12 months (one calendar year) from the date of service to submit an initial Medicare fee-for-service claim. Set by the Social Security Act (Sec. 1842(b)(3)) and CMS, not by Texas (Texas’s Part A/B MAC is Novitas Solutions, Jurisdiction H).

Medicare Advantage plans set their own contractual deadlines (often similar, up to ~12 months) — confirm per plan.

Texas Medicaid (traditional fee-for-service): TMHP must RECEIVE the claim within 95 DAYS of the date of service — one of the tightest Medicaid filing limits in the country — per the Texas Medicaid Provider Procedures Manual (TMPPM), Vol. 1, Claims Filing section, and 1 TAC Sec. 354.1003.

A separate FEDERAL backstop of 365 days (12 months) from the date of service also applies (42 CFR 447.45), and exceptions to the 95-day deadline (e.g., catastrophic event, retroactive eligibility) are only considered for claims still within the 365-day federal window.

Special timing: for retroactive eligibility the 95 days runs from the eligibility ‘add date’ (but the 365-day federal limit still applies); when another insurer is primary the limit is 95 days from the other resource’s date of disposition;

Medicare crossover claims must reach TMHP within 95 days of the Medicare disposition date. Appeals are due within 120 days of the disposition date. IMPORTANT: most Texas Medicaid recipients are in MANAGED CARE (STAR, STAR+PLUS, STAR Kids, STAR Health) and CHIP; under the HHSC Uniform Managed Care Manual the MCO must receive the initial claim within 95 DAYS of the date of service and must allow at least 120 days to appeal — always bill the member’s specific MCO to its own deadline.

Texas Workers’ Comp: a health care provider must submit the medical bill no later than the 95th DAY after the date the services were provided, per 28 TAC Sec. 133.20(b) and Texas Labor Code Sec. 408.0272. Missing this window is HIGH-STAKES — a provider who does not bill timely loses the right to reimbursement for that bill (limited statutory exceptions in Labor Code Sec. 408.0272(b)-(d), e.g., for an erroneous-carrier submission, give 95 days from notice of the error).

On the carrier side, the insurance carrier must take final action (pay, deny, or audit) on a complete medical bill not later than the 45th day after receipt (28 TAC Sec. 133.240). Provider remedies after a denial/reduction: request reconsideration with the carrier (28 TAC Sec. 133.250), and a Medical Fee Dispute Resolution (MFDR) request to the TDI Division of Workers’ Compensation must generally be filed within ONE YEAR of the dates of service in dispute (DWC Form-060).

Submit promptly on the correct standardized form and follow the carrier/TPA e-billing instructions.

Texas is an AT-FAULT (tort) state with NO no-fault system, but it does have PIP (Personal Injury Protection) — and unlike Florida there is NO fixed statutory bill-submission look-back deadline for PIP. Under Texas Insurance Code Sec. 1952.151-1952.152, insurers must OFFER at least $2,500 of PIP with every auto liability policy (higher limits, commonly $5,000/$10,000, are available); coverage applies regardless of fault and is not subject to subrogation.

The submission/notice timeframe for PIP and for first-party Medical Payments (Med-Pay) is POLICY-DRIVEN, not set by statute — submit bills (typically on a CMS-1500 or the carrier’s form) promptly per the policy’s notice/proof-of-loss terms.

Practical norms: bill PIP/Med-Pay promptly to preserve the benefit; for third-party (at-fault liability) and UM/UIM claims, charges are usually presented on a list at release from care and resolved at settlement (often on a letter-of-protection/lien basis — note the Texas hospital-lien statute, Property Code Ch. 55, does NOT extend to chiropractors and does not attach to PIP/Med-Pay/UM benefits).

The underlying bodily-injury tort claim is governed by Texas’s 2-year personal-injury statute of limitations (Civ. Prac. & Rem. Code Sec. 16.003); a PIP breach-of-contract suit follows the 4-year contract limitations period. Confirm each policy’s notice/submission terms.