CSHCN 2009 > Claims Filing, Third-Party Resources, and Reimbursement

Claims Filing, Third-Party Resources, and Reimbursement

5.1 TMHP Claims Information 5-3

5.1.1 Claims Processed by TMHP 5-3

5.1.2 Claims Processed by the Department of State Health Services (DSHS)-CSHCN Services Program 5-3

5.1.3 TMHP Processing Procedures 5-4

5.1.4 Claims Processed by Date of Service 5-4

5.1.5 Claims Filing Deadlines 5-4

5.1.6 Exception to Claim Filing Deadline 5-5

5.1.7 Fiscal Agent Payment Deadline 5-7

5.2 Third-Party Resource (TPR) 5-7

5.2.1 Health Maintenance Organization (HMO) 5-8

5.2.2 CSHCN Services Program Eligibility Form 5-8

5.2.3 Claims Filing Involving a TPR 5-8

5.2.4 Verbal Denials by a TPR 5-9

5.2.5 Filing Deadlines Involving a TPR 5-9

5.2.6 Blue Cross Blue Shield (BCBS) Nonparticipating Physicians 5-10

5.2.7 Refunds 5-10

5.2.8 Refunds to TMHP Resulting From Other Insurance 5-11

5.2.9 Accident-Related Claims 5-11

5.2.9.1 Accident Resources and Refunds Involving Claims for Accidents 5-12

5.2.9.2 Third-Party Liability for Claims Involving Accidents 5-12

5.3 Multipage Claim Forms 5-13

5.4 Tips on Expediting Paper Claims 5-13

5.4.1 General requirements 5-14

5.4.2 Data Fields 5-14

5.4.3 Attachments 5-14

5.5 Correction and Resubmission (Appeal) Time Limits 5-14

5.5.1 Claims with Incomplete Information 5-14

5.5.2 Other Insurance Appeals 5-14

5.5.3 Authorization and Filing Deadline Calendar for 2009 5-15

5.5.4 Authorization and Filing Deadline Calendar for 2010 5-16

5.6 Coding 5-17

5.6.1 Diagnosis Coding 5-17

5.6.2 Procedure Coding 5-17

5.6.2.1 Healthcare Common Procedure Coding System (HCPCS) 5-17

5.6.2.2 Level I 5-17

5.6.2.3 Level II 5-18

5.6.2.4 Determining Benefits for New HCPCS Procedure Codes 5-18

5.6.2.5 National Drug Codes (NDC) 5-19

5.6.2.6 Modifiers 5-20

5.6.2.7 Place of Service (POS) Coding 5-20

5.6.2.8 Benefit Code 5-20

5.7 Claims Filing Instructions 5-20

5.7.1 Provider Types and Selection of Claim Forms 5-20

5.7.1.1 Providers and Services Billable on CMS-1500 5-20

5.7.1.2 CMS-1500 Electronic Billing 5-21

5.7.1.3 CMS-1500 Claim Form Instructions 5-21

5.7.1.4 CMS-1500 Example 5-25

5.7.1.5 UB-04 CMS-1450 Claim Form Instructions 5-26

5.7.1.6 UB-04 CMS-1450 Electronic Billing 5-26

5.7.1.7 Instructions for Completing the UB-04 CMS-1450 Claim Form 5-26

5.7.1.8 Occurrence Codes 5-32

5.7.1.9 Client Status 5-33

5.7.1.10 UB-04 CMS-1450 Example 5-35

5.7.1.11 Dental Claim Filing 5-36

5.7.1.12 2006 ADA Dental Claim Electronic Billing 5-36

5.7.1.13 Instructions for Completing the ADA Dental Claim Form 5-36

5.7.1.14 Electronic Claims Submission 5-39

5.7.1.15 Taxonomy Codes 5-39

5.7.1.16 Dates on Claims 5-39

5.7.1.17 Span Dates 5-39

5.7.1.18 Hospital Billing 5-40

5.7.1.19 Group Billing 5-40

5.8 Reimbursement 5-40

5.8.1 Electronic Funds Transfer (EFT) 5-40

5.8.1.1 Advantages of EFT 5-40

5.8.1.2 Enrollment Procedures 5-40

5.8.2 Texas Medicaid Reimbursement Methodology (TMRM) 5-41

5.8.3 Maximum Allowable Fee Schedule 5-41

5.8.4 Manual Pricing 5-41

5.8.5 Physician Services in Hospital Outpatient Setting 5-41

5.9 TMHP-CSHCN Services Program Contact Center 5-42