EMS and ambulance billing
Ground ambulance billing in Texas follows its own payment rules for out of network claims, and they work differently from IDR. ZanexMed checks every payment against the rate the plan owes and follows up until it is paid in full.
Updated October 31, 2026
Under Texas SB 2476, a state regulated health plan must pay an out of network ground ambulance claim at the rate set by the local government, if that rate is filed in the Texas Department of Insurance database. If no local rate is filed, the plan pays the lower of the billed charge or 325 percent of the Medicare rate. The patient cannot be balance billed beyond in network cost sharing. These claims do not go through IDR; the rate is set by law. The rules apply to services on or after January 1, 2024, and SB 916 extended them in 2025.
What the law requires from state regulated plans.
| Rule | What it says |
|---|---|
| Payment rate | The local government rate filed with TDI, or if none, the lower of billed charges or 325 percent of Medicare |
| Rate increases | Filed local rates can rise each year only within an inflation based cap |
| Patient protection | No balance billing beyond copay, coinsurance and deductible |
| Dispute process | No IDR; the rate is set by law and the TDI database |
| Start date | Law effective September 1, 2023, for services on or after January 1, 2024 |
| Extension | SB 916 (2025) extended the rules; the bill set the new end date as September 1, 2027 |
Sources: TDI Commissioner Bulletin B-0012-23 and the SB 916 bill analysis. Check TDI for current rules before billing.
Ground ambulance is not covered by the federal No Surprises Act. In Texas, state regulated plans follow the SB 2476 rate rules above. Self funded employer plans are not bound by those state rules, so those claims need normal appeals and negotiation.
Air ambulance is covered by the No Surprises Act. An underpaid out of network air ambulance claim can go to federal IDR after 30 business days of open negotiation. From November 1, 2026, the new federal rules also change how similar claims can be batched.
The first step for any ambulance claim is the same: confirm the plan type, then compare the payment with the amount the plan actually owes.
Most ambulance underpayments are errors, not disputes, so we start with the math.
We confirm whether the plan is state regulated, self funded or federal.
We compare each payment with the filed local rate or 325 percent of Medicare.
Mileage, level of service and origin and destination codes are checked before submission.
Short payments on state regulated plans are appealed with the rate that applies.
Underpaid air ambulance claims move to federal negotiation and IDR.
You see payments, appeals and recoveries by payer each month.
Each of these costs EMS agencies money every month.
Quick answers to the questions providers ask us most.
Send us a month of ambulance remittances. We will compare each payment with the rate the plan owes and show what can be recovered.
Tell us about your practice and a billing specialist will contact you.
