Chiropractic insurance billing in Texas.

Medicare’s chiropractic rules are federal — the same in every state. Medicare Part B covers ONLY manual manipulation of the spine to correct a subluxation (CPT 98940–98942), and ONLY when the care is active or corrective — which you signal with the AT modifier. Maintenance care, exams, X-rays, and any therapies performed by a chiropractor are not covered, so a properly executed ABN is essential before non-covered services. The full federal rules are in our chiropractic Medicare billing guide.

Part B claims in Texas are processed by Novitas Solutions (JH) — its Local Coverage Determination and documentation expectations (and its audits of the AT modifier and medical necessity) are the ones your Texas claims are measured against.

A Texas chiropractic or multi-specialty practice spends most of its commercial billing day with: Blue Cross Blue Shield of Texas (HCSC); UnitedHealthcare; Aetna (CVS Health); Cigna; Humana; Ambetter (Centene). Each has its own claim portal, fee schedule, and chiropractic medical-policy quirks.

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, so when a Texas member’s chiropractic is carved out to ASH, network enrollment, the treatment-plan/medical-necessity review, prior authorization, and claims route to ASH — not the health plan. Misrouting to the carrier instead of ASH is a leading denial cause; verify on the member card/portal.
• Optum / Optum Physical Health (a UnitedHealth Group company) manages the chiropractic/physical-health network for UnitedHealthcare. Effective Sept. 1, 2024, UnitedHealthcare Medicare Advantage (excluding certain D-SNP) requires prior authorization — delegated to Optum Physical Health, reviewed under CMS Ch. 15, applicable LCDs and InterQual — for Medicare-covered spinal manipulation billed with the AT modifier; the initial evaluation is exempt, and (per the Jan. 13, 2025 update) the first 6 visits within 8 weeks of the first DOS are covered without clinical review, with only plans exceeding 6 visits / 8 weeks going to medical-necessity review.
• 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); sending the claim or auth to the wrong entity (carrier vs. ASH/Optum) is a top denial. 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 — commercial chiropractic is commonly capped per calendar year (e.g., many BCBSTX/CMT plans run ~12-35 manipulation visits/year depending on the plan), and ASH/Optum front-load documentation: an initial treatment plan, periodic re-evaluation, a clear active/corrective-vs-maintenance distinction (maintenance is non-covered), and per-visit unit/modality limits. Document acute medical necessity, functional goals, and measurable progress.
• UHC/Optum Medicare Advantage PA — Medicare-covered manipulation (98940-98942 with the AT modifier) needs prior auth through Optum for the treatment plan/visit count (initial eval exempt; first 6 visits/8 weeks auto-approved as of 1/13/2025; maintenance excluded).
• 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 scope — adult chiropractic coverage under Texas Medicaid is limited/largely excluded (chiropractic is primarily a benefit for children via Texas Health Steps/EPSDT), so verify the member’s specific Medicaid program before treating and billing.
• 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 (commonly 90-180 days, some 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, Civil Practice & Remedies 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.