Billing and Payors

Resources for accurate billing to reduce claims denials and receive appropriate payment.

An integral part of running a medical practice is billing for health care services that are provided. Below are many helpful guides, tools and information to assist you in navigating various billing requirements by payors.

Appeals and Denials Best Practices
 - PowerPoint presentation on navigating the denial and appeals process successfully.

Audits - AMA resources on payor audit trends, how to respond to an audit, etc. (in Regulatory and legal considerations section)

Bilateral Billing Guide - A guide on the bilateral billing requirements of the major Houston market health plans.

Claim form - A CMS-1500 claim form that can be populated online.

Clean Claim Edits - A guide to assist with avoiding claims rejections and denials using front-end claim editing. 

Chronic Care Management (CCM) - Information on patient eligibility, billing, required documentation, etc.

Coordination of Benefits-Commercial PlansCoordination of Benefits-Medicare - Information on determining primary or secondary payor status when a patient has multiple coverage.

Critical Care Billing and Coding - Two part videos and CMS resource outlining how to bill for these services

Downcoding of E/M codes - AMA resource on payor evaluation and management (E/M) downcoding programs. AAP checklist to identify downcoded claims.

Excludes 1 and Excludes 2 Notations - A guide explaining Excludes 1 and Excludes 2 Notations in diagnosis coding.

Expedited Credentialing - information on the Texas law that allows physicians joining an existing group practice to be paid as in-network while in credentialing.

Evaluation and Management Coding and Documentation 2021-2024 - Information on the new guidelines and revisions to E/M Services effective Jan. 1 of 2021, 2023, and 2024. Use our Documentation Score Sheet to assist with code selection. More information can be found in the TMA webinar 2021 E&M: Ready Set Go!.

HCMS Payment and Practice Help
 - HCMS offers a payment assistance program at no charge to our members to assist them with payment issues.

Hospital Services Billing Guide - A guide on the billing rules for observation and inpatient care services for Medicare and commercial payors. 

Incident-to Billing Guide - Information on billing for Advanced Practice Providers (NPs, PAs, APRNs) along with billing tools, resources, and related links. See the MLN and Medicare Benefit Manual for additional information.

Interpretation Services for the Hearing Impaired

Locum Tenens - Guidance on locum tenens rules and billing protocols.

Modifier 25 Resource - Instructions and guides for the proper use of modifier 25.

Modifier 59 Resource - Instructions and guides for the proper use of modifier 59.

NDC Billing Guidelines - Guidance on billing for physician administered drugs using National Drug Codes (NDC). NDC Billing Units Calculator provides the HCPCS and NDC billing units. 


Prompt Payment Discounts - Prompt payment discounts for patients.

Prompt Pay Penalties - Resources to determine prompt pay penalties and regulations by payor type: Prompt Pay Penalties Fact SheetPrompt Pay Penalty Guide, and Underpayment Penalty Calculator.

Refunds and Recoupments - Rules and information regarding recoupments.

Surprise Billing - Federal 
- An HCMS resource providing information and guidance on the federal No Surprises Act.

Surprise Billing - Texas 
- The Texas Department of Insurance (TDI) provides instruction and resources on the arbitration process for certain billing disputes. For further explanation of and resources on the surprise billing law and arbitration, also refer to TMA information and summary of the bill.

Telemedicine/Telehealth - Rules, legislation, and resources on providing telemedicine services.

Texas Preauthorization Gold Card Rules - A guide to the TDI Preauthorization Exemptions rules to assist with understanding and implementing its provisions. This resource requires your member log in.

Where To File Complaints - Information on where to file complaints against various payors.