Refer to: Federal Register , Vol. To expedite claims processing, providers must supply all information on the claim form itself and limit attachments to those required by TMHP or necessary to supply information to properly adjudicate the claim.
The following claim form attachments are required when appropriate:. Providers that submit paper crossover claims must submit only one of the approved MRAN formats. If the template and MAP EOB contain conflicting information, the claim will not be processed and will be returned to the provider. Elective abortions are not benefits of Texas Medicaid. The claims must meet the day deadline from the recoupment disposition date. Note: Letter requests for refunds will not be accepted. A recoupment EOB with a disposition date is required.
Claims for clients with a primary care provider or designated provider i. Because each software developer is different, location of fields may vary.
Contact the software developer or vendor for this information. Claims without this information cannot be processed. Each claim form must have the appropriate signatory evidence in the signature certification block. Providers can purchase CMS paper claim forms from the vendor of their choice. TMHP does not supply the forms.
Important: When completing a CMS paper claim form, all required information must be included on the claim in the appropriate block. Information is not keyed from attachments. Superbills or itemized statements are not accepted as claim supplements. The following definitions apply to the provider terms used on the CMS paper claim form:. The referring provider is the individual who directed the patient for care to the provider that rendered the services being submitted on the claim form.
Examples include, but are not limited to the following:. The ordering provider is the individual who requested the services or items listed in Block D of the CMS paper claim form. Examples include, but are not limited to, a provider ordering diagnostic tests, medical equipment, or supplies. The rendering provider is the individual who provided the care to the client. In the case where a substitute provider was used, that individual is considered the rendering provider. An individual such as a lab technician or radiology technician who performs services in a support role is not considered a rendering provider.
The supervising provider is the individual who provided oversight of the rendering provider and the services listed on the CMS paper claim form. A purchased service provider is an individual or entity that performs a service on a contractual or reassignment basis.
In the case where a substitute provider is used, that individual is not considered a purchased service provider. The instructions describe what information must be entered in each of the block numbers of the CMS paper claim form. Block numbers not referenced in the table may be left blank. They are not required for claim processing by TMHP. If the insured uses a last name suffix e. For special situations, use this space to provide additional information such as:.
Enter the date of death in block 9b. Check the appropriate box. If other insurance is available, enter appropriate information in blocks 11, 11a, and 11b. The other insurance EOB or denial letter must be attached to the claim form. Enter the benefit code, if applicable, for the billing or performing provider. For pregnancy enter the date of the last menstrual period. If the client has chronic renal disease, enter the date of onset of dialysis treatments. Enter the name First Name, Middle Initial, Last Name and credentials of the professional who referred, ordered, or supervised the service s or supplies on the claim.
If multiple providers are involved, enter one provider using the following priority order:. Do not use periods or commas within the name. A hyphen can be used for hyphenated names. Enter the applicable qualifier to identify which provider is being reported. If there is a Supervising Physician for the referring or ordering provider that is listed in Block 17, the name and NPI of the supervising provider must go in Block Indicate the services required from the second facility and unavailable at the first facility.
The information may be requested for retrospective review. List no more than 12 diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity.
For Workers Compensation and other property and casualty claims, this is required when prior authorization, referral, concurrent review, or voluntary certification was received. If more than one date of service is for a single procedure, each date must be given on a separate line.
Select the appropriate POS code for each service from the table under subsection 6. Enter the appropriate condition indicator for THSteps medical checkups. Fully describe procedures, medical services, or supplies furnished for each date given.
Enter the appropriate procedure codes and modifier for all services billed. If a procedure code is not available, enter a concise description. In the shaded area, enter a 1- through digit NDC quantity of unit. In 24 E, enter the diagnosis code reference letter pointer as shown in Form Field 21 to relate the date of service and the procedures performed to the primary diagnosis.
The reference letter s should be A-L or multiple letters as applicable. Indicate the usual and customary charges for each service listed. Charges must not be higher than fees charged to private-pay clients. If multiple services are performed on the same day, enter the number of services performed such as the quantity billed. Note: The maximum number of units per detail is 9, Enter the taxonomy code of the individual rendering services unless otherwise indicated in the provider specific section of this manual.
All providers of Texas Medicaid must accept assignment to receive payment by checking Yes. Indicate the total of all charges on the last claim. Note: Indicate the page number of the attachment for example, page 2 of 3 in the top right-hand corner of the form. Enter any amount paid by an insurance company or other sources known at the time of submission of the claim. Identify the source of each payment and date in block If the client makes a payment, the reason for the payment must be indicated in block If appropriate, subtract block 29 from block 28 and enter the balance.
The physician, supplier, or an authorized representative must sign and date the claim. This is a required field for services provided in a facility.
The facility provider number, name, and address are not optional. The following provider types may bill electronically or use the UB CMS paper claim form when requesting payment:. Note: In the case of an audit, facility providers will not be allowed to submit an addendum to the original medical records for finalized claims. Because each software package is different, field locations may vary. Note: The maximum number of electronic claim details that will be accepted electronically is Only 28 details will be processed.
Claims without this information in the appropriate fields cannot be processed. The instructions describe what information must be entered in each of the block numbers of the UB CMS paper claim form. Second Digit—Bill Classification except clinics and special facilities :. Used by providers office to identify internal patient account number.
Providers that receive a transfer patient from another hospital must enter the actual dates the patient was admitted into each facility. Use military time 00 to 23 for the time of admission for inpatient claims or time of treatment for outpatient claims. Providers can refer to the National Uniform Billing Code website at www.
For inpatient claims, enter the hour of discharge or death. Use military time 00 to 23 to express the hour of discharge.
Enter the dates of the previous stay. Accident hour—For inpatient claims, if the patient was admitted as the result of an accident, enter value code 45 with the time of the accident using military time 00 to Use code 99 if the time is unknown.
Usually, this is the difference between the admission and discharge dates. The sum of Blocks 39—41 must equal the total days billed as reflected in Block 6. For inpatient hospital services, enter the description and revenue code for the total charges and each accommodation and ancillary provided.
List accommodations in the order of occurrence. List ancillaries in ascending order. The space to the right of the. Match the appropriate diagnoses listed in Blocks 67A through 67Q corresponding to each procedure. If a procedure corresponds to more than one diagnosis, enter the primary diagnosis. Home Health Services. Outpatient claims must have the appropriate revenue code and, if appropriate, the corresponding HCPCS code or narrative description.
If necessary, combine IV supplies and central supplies on the charge detail and consider them to be single items with the appropriate quantities and total charges by dates of service. Multiple dates of service may not be combined on outpatient claims.
Enter the numerical date of service that corresponds to each procedure for outpatient claims. If applicable, enter the number of pints of blood. When billing for observation room services, the units indicated in this block should always represent hours spent in observation. Indicate the total of all charges on the last claim and the page number of the attachment for example, page 2 of 3 in the top right-hand corner of the form. Enter amounts paid by any TPR, and complete Blocks 32, 61, 62, and 80 as required:.
This section is used for requesting the day rule for a third party insurance. Enter the policy number or group number of the other health insurance. Enter the ICDCM diagnosis code in the unshaded area for the principal diagnosis to the highest level of specificity available.
Enter the ICDCM diagnosis code in the unshaded area to the highest level of specificity available for each additional diagnosis. Enter one diagnosis per block, using Blocks A through J only. Exception: A diagnosis is required when billing for estrogen receptor assays, plasmapheresis, and cancer antigen CA , immunofluorescent studies, surgical pathology, and alphafetoprotein.
Note: The admitting diagnosis is only for inpatient claims. Optional: The PPS code is assigned to the claim to identify the DRG based on the grouper software called for under contract with the primary payer.
Optional: Enter the ICDCM diagnosis code in the unshaded area to the highest level of specificity available for each additional diagnosis. Inpatient claims, services that require an attending provider are defined as those listed in the ICDCM coding manual volume 3, which includes surgical, diagnostic, or medical procedures. Other operating physician—An individual performing a secondary surgical procedure or assisting the operating physician. Required when another operating physician is involved.
Rendering provider—The health-care professional who performed, delivered, or completed a particular medical service or nonsurgical procedure. Note: If the referring physician is a resident, Blocks 76 through 79 must identify the physician who is supervising the resident. The time must be entered in Block Optional: Area to capture additional information necessary to adjudicate the claims.
Important: Services and supplies that exceed the 28 items per claim limitation must be submitted on an additional UB CMS paper claim form and will be assigned a different claim number by TMHP. IV supplies may be combined and billed as one item. Include appropriate quantities and total charges for each combined procedure code used. Using combination procedure codes conserves space on the claim form. Multipage claim forms are processed as one claim for that client if all pages contain 28 or fewer items.
Attachments will only be used for clarification purposes. Because each software package is different, block locations may vary.
These forms may be obtained by contacting the ADA at Claims without a provider name, physical address, and provider identifier cannot be processed.
The following table is an itemized description of the questions appearing on the form. Thoroughly complete the ADA Dental claim form according to the instructions in the table to facilitate prompt and accurate reimbursement and reduce follow-up inquiries. The other two boxes are not applicable. Refer to: Subsection A. May be a parent or legal guardian of the patient receiving treatment.
Enter the contact information for the insurance company providing the non-Medicaid coverage. Leave blank and skip to Item Used by dental office to identify internal patient account number. Enter the letter s from Box 34 that identified the diagnosis code s applicable to the dental procedure. List the primary diagnosis pointer first. Provide a brief description of the service provided e. Enter usual and customary charges for each service listed. Charges must not be higher than the fees charged to private pay clients.
When other changes applicable to dental services provided must be reported, enter the amount here. Charges may include state tax and other charges imposed by regulatory bodies. Identify the source of each payment date in Block If the client makes a payment, the reason for the payment must be identified in Block For identifying missing permanent dentition only.
Enter up to four applicable diagnosis codes after each letter A-D. Providers are required to check the Other Accident box for emergency claim reimbursement. If the Other Accident box is checked, information about the emergency must be provided in Block Do not enter the name and address of a provider employed within a group.
Do not enter the NPI for a provider employed within a group. Enter the area code and number for the billing group or individual Do not enter the telephone number of a provider employed within a group. Enter the taxonomy code assigned to the billing dentist or dental entity. Do not enter the taxonomy code for a provider employed within a group. Enter the NPI for the dentist enrolled as part of a group who treated the patient. The instructions describe what information must be entered in each of the block numbers of the Claim Form.
Check the box for the specific program to which these services are billed:. For DFPP, the eligibility date can be found on the following forms:. This reflects the location where the client lives.
Please use the HHSC county codes. If the client does not have a SSN, or refuses to provide the number, enter Aggregate categories used here are consistent with reporting requirements of the Office of Management and Budget Statistical Direction. Indicate whether the client is of Hispanic descent by entering the appropriate code number in the box. Ethnicity is independent of race and all clients should be counted as either Hispanic or non-Hispanic.
Title XIX: Enter the gross monthly income reported by the client. Be sure to include all sources of income. If income is received in a lump sum, or if it is for a period of time greater than a month e. If income is paid weekly, multiply weekly income by 4. If paid every two weeks, multiply amount by 2.
If paid twice a month, multiply by 2. DFPP: Use the family size reported on the eligibility assessment tool. Enter the number of times this client has been pregnant. If male, enter zero.
Enter the number of live births for this client. Enter the number of living children this client has. This also must be completed for male clients. Enter the amount paid by the other insurance company. Enter the date of the other insurance payment or denial in this block.
Enter the level of practitioner that performed the service. Use this section when billing for complications related to sterilizations, contraceptive implants, or intrauterine devices IUDs. Medicaid does not accept multiple to-from dates on a single-line detail.
Bill only one date per line. If the client is registered at a hospital, the POS must indicate inpatient or outpatient status at the time of service. Note: TOS codes are no longer required for claims submission. In the shaded area, enter the NDC quantity of units administered up to 12 digits, including the decimal point. A decimal point must be used for fractions of a unit. Enter the diagnosis line item reference A-L for each service or procedure as it relates to each ICD diagnosis code identified in Block When multiple services are performed, the primary reference number for each service should be listed first, other applicable services should follow.
Diagnosis codes must be entered in Form Field 29 only. Do not enter diagnosis codes in Form Field 32E. Indicate the charges for each service listed quantity multiplied by reimbursement rate. Members of a group practice except pathology and renal dialysis groups must identify the taxonomy code of the provider within the group who performed the service.
Although not required for DFPP claims, if a claim or encounter that was submitted through DFPP is later determined eligible to be paid under Title XIX, the claim will be denied if the performing provider information is missing. Optional: Members of a group practice except pathology and renal dialysis groups must identify NPI of the provider within the group who performed the service. If the client was assessed a copayment DFPP , enter the dollar amount assessed. Copay cannot be assessed for Title XIX clients.
Enter the total of separate charges for each page of the claim. Enter the total of all pages on last claim if filing a multipage claim. Name and address of facility where services were rendered if other than home or office. For laboratory specimens sent to an outside laboratory for additional testing, the complete name and address of the outside laboratory should be entered. The laboratory should bill Texas Medicaid for the services performed. Enter the NPI of the provider where services were rendered if other than home or office.
Enter the billing provider name, physical address, city, state, ZIP Code, and telephone number. All vision services must be billed on a CMS paper claim form or the appropriate electronic formats. For eyewear claims beyond program benefits, e. Do not submit form to TMHP. The following table shows the blocks required for vision claims on a CMS paper claim form. Name, provider identifiers, and address of prescribing medical doctor or doctor of optometry. Describe procedures, medical services, or supplies furnished for each date given.
These receivables are recouped from claim submissions. All claims for the same provider identifier and program processed for payment are paid at the end of the week, either by a single check or with Electronic Funds Transfer EFT.
The report is available each Monday morning, immediately following the weekly claims cycle. The EDI delivery method is also available. The digit Medicaid ICN for a specific claim. Hospital outpatient crossovers, home health crossovers, RHC crossovers. If the claim is a result of an automatic crossover from Medicare, the last ten digits of the Medicare claim number appears directly under the TMHP claim number. Indicates by code the specific service provided to the client.
A three-digit code represents a hospital accommodation or ancillary revenue code. For claims paid under prospective payment methodology, it is the code of the DRG. Indicates the quantity billed per claim detail. Indicates the charge billed per claim detail. Indicates the quantity TMHP has allowed per claim detail. Indicates the charges TMHP has allowed per claim detail.
For inpatient hospital claims, the allowed amount for the DRG appears. A one-digit numeric code identifying the POS is indicated in this column. Refer to subsection 6. Providers using electronic claims submission should continue using the same POS codes. The final amount allowed for payment per claim detail. The total paid amount for the claim appears on the claim total line. The EOB codes are printed next to or directly below the claim.
The codes explain the status of pending claims and are not an actual denial or final disposition. Up to five EOB codes are displayed. Indicates claim details that have been denied or reduced. Indicates the three digit benefit code associated with the claim.
Modifiers have been developed to describe and qualify services provided. For THSteps dental services two modifiers are printed. The claims are sorted by claim status, claim type, and by order of client names. The following information is provided on a separate line for all inpatient hospital claims processed according to prospective payment methodology:. Claims filed electronically without required information are rejected. Users are required to retrieve the response file to determine reasons for rejections.
TMHP cannot process incomplete claims. Incomplete claims may be submitted as original claims only if the resubmission is received by TMHP within the original filing deadline. Adjustments — Paid or Denied is centered at the top of each page in this section. Adjustments are sorted by claim type and then patient name and Medicaid number. Media types , , , , , , , and appear in this section.
An adjustment prints in the same format as a paid or denied claim. Immediately below is the claim as originally processed. Future payments will be reduced or withheld until such amount is paid in full. Additional subheadings are printed to identify the financial transactions.
The following descriptions are types of financial items. A number to reference when corresponding with TMHP. The amount to be withheld each week. This area is blank if the provider elects to have a percentage withheld each week.
The date the financial transaction was processed originally. The total amount owed TMHP. The date the last transaction on the accounts receivable occurred. A number assigned by the provider, if available. This area is blank for purged claims. The fiscal year end FYE for cost reports. The EOB code that corresponds to the reason code for the accounts receivable. The name of the patient on the claim, if the accounts receivable are claim-specific. The ICN of the original claim, if the accounts receivable are claim-specific.
The date the backup withholding was set up originally. Payments are withheld until the levy is satisfied or released. IRS levies are reported in the following format:. The amount to be withheld periodically. The date the levy was set up originally. The total amount owed to the IRS. The date the last transaction on the levy occurred. The amount still owed on the levy. The claim number of the claim to which the refund was applied this cycle.
The first name, middle initial, and last name of the patient on the applicable claim. The total amount billed for the claim being refunded. The refund amount applied to the claim. Corresponds to the reason code assigned. A control number to reference when corresponding with TMHP. The fiscal year for which this refund is applicable.
Payouts are dollars TMHP owes to the provider. TMHP processes two types of payouts: system payouts that increase the weekly check amount and manual payouts that result in a separate check being sent to the provider. A control number is given, which should be referenced when corresponding with TMHP. The amount of the payout. The fiscal year for which the payout is applicable. Name of the patient if available.
Medicaid number of the patient if available. Date of service if available. The number of the original check.
The amount of the original check. Indicates the number of claims processed for the week and the year-to-date total. The total amount of system payouts made to the provider by TMHP. The total amount of manual payouts made to the provider by TMHP. The amount paid to the IRS for backup withholding. The total amount of the payment that was voided or stopped with no reissuance of payment. The amount of the reissued payment. The total amount of claim-related refunds applied during the weekly cycle.
The total amount of nonclaim-related refunds applied during the weekly cycle. This column will not be used at this time. The total amount billed for claims in process as of the cutoff date for the report. TMHP is listing the pending status of these claims for informational purposes only.
The pending messages should not be interpreted as a final claim disposition. The Following Claims are Being Processed claim prints in the same format as a paid or denied claim. EOBs appear in numerical order.
EOPS appear in numerical order. EOB and EOPS codes may appear on the same pending claim because some details may have already finalized while others may have questions and are pending. TMHP provides several effective mechanisms for researching the status of a claim.
If a claim has not been received by TMHP and must be submitted a second time, the second claim must also meet the day filing deadline. The provider allows TMHP 45 days to receive a Medicare-paid claim automatically transmitted for payment of coinsurance or deductible according to current payment guidelines. Electronic billers may refile the claim electronically.
For claims submitted by a hospital for inpatient services, the filing deadline is 95 days from the discharge date or the last DOS on the claim.
For all other types of providers, the filing deadline is 95 days from each DOS on the claim. When a service is a benefit of both Medicare and Medicaid, the claim must be filed to Medicare first.
Providers should not file a claim with Medicaid until Medicare has dispositioned the claim unless the service is a Medicaid-only service. This includes deductible, coinsurance, and copayments for any Medicaid covered items and services. Note: These guidelines do not apply to services that are rendered to clients who are living in a nursing facility. Refer to: Subsection 2.
Providers should contact their MAC for more information. This electronic crossover process allows providers to receive disposition from both carriers while only filing the claim once. Take advantage of this FREE software. Begin using MREP today! Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories.
You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials. Applications are available at the American Dental Association website.
Please click here to see all U. Government Rights Provisions. CDT-4 is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT The ADA does not directly or indirectly practice medicine or dispense dental services.
The sole responsibility for the software, including any CDT-4 and other content contained therein, is with insert name of applicable entity or the CMS; and no endorsement by the ADA is intended or implied. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.
Talk to someone about your options and have them guide you through the process. You can enroll in person, by phone or online. Covered California Plans. Not sure which plan you qualify for? Shop and Compare. Dental Coverage. Family Dental. Vision Coverage. Adult Vision. Edit this toggle Covered California. Medi-Cal Programs Medi-Cal coverage is available for individuals and families, children and pregnant individuals. Depending on your income, you can get free or low-cost health care.
Children under age 19 can get Medi-Cal, even if their parents don't qualify. Medi-Cal offers free or affordable programs to start pregnancy coverage right away.
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