1a

Insured's ID No. (for program checked above, include all letters)

Enter the client's nine-digit CSHCN Services Program client number.

2

Patient's name

Enter the client's last name, first name, and middle initial as printed on the CSHCN Services Program identification form.

If the insured uses a last name suffix (e.g., Jr., Sr.) enter it after the last name and before the first name.

3

Patient's date of birth

Patient's sex

Enter numerically the month, day, and year (MM/DD/YYYY) the client was born. Indicate the client's sex by checking the appropriate box.

Only one box can be marked.

5

Patient's address

Enter the client's complete address as described (street, city, state, and ZIP+4 Code).

9

Other insured's name

For special situations, use this space to provide additional information such as:

•If the client is deceased, enter "DOD" in block 9 and the time of death in 9a if the services were rendered on the date of death. Enter the date of death in block 9b.

10a

10b

10c

Is the patient's condition related to:

Check the appropriate box. If other insurance is available, enter appropriate information in Blocks 11, 11a, and 11b.

11

11a

11b

Other health insurance coverage

•If another insurance resource has made payment or denied a claim, enter the name and information of the insurance company. The other insurance EOB or denial letter must be attached to the claim form.

•If the client is enrolled in Medicare attach a copy of the Medicare Remittance Notice to the claim form.

11c

Insurance plan or program name

Enter the benefit code, if applicable, for the billing or performing provider.

12

Patient's or authorized person's signature

Enter "Signature on File," "SOF," or legal signature. When legal signature is entered, enter the date signed in eight digit format (MMDDYYYY).

TMHP will process the claim without the signature of the client.

14

Date of current

If the client has chronic renal disease, enter the date of onset of dialysis treatments.

Indicate the date of treatments for PT and OT.

17

17b

Name of referring physician or other source

Enter the complete name (Block 17) and the NPI (Block 17b) of the attending, referring, ordering, designated, or performing (freestanding ASCs only) provider.

Refer to specific sections for requirements in the following situations:

•The attending physician for:

•Clinical pathology consultations to hospital inpatients or outpatients

•The referring physician for:

•Consultation services

•The ordering physician for:

•Laboratory and radiology services

•Speech-language pathology

•Physical therapy

•Occupational therapy

•In-home TPN services

•The performing provider (surgeon) for freestanding ASCs.

19

Reserved for local use

Transfers of multiple clients

If the claim is part of a multiple transfer, indicate the other client's complete name and CSHCN Services Program number.

Ambulance Hospital-to-Hospital Transfers

Indicate the services required from the second facility and unavailable at the first facility.

20

Outside lab?

Check the appropriate box. The information may be requested for retrospective review.

If "yes," enter the name and address or provider identifier of the facility that performed the service in Block 32.

Note: The CSHCN Services Program regulations require a provider bill only for those laboratory services that he or she actually performed. Any services performed outside of the provider's office must be billed by the performing laboratory or radiology center.

21

Diagnosis or nature of illness or injury

Enter up to four ICD-9-CM diagnosis codes to the highest level of specificity available. ACS providers are not required to enter diagnosis codes.

23

Prior authorization number

Enter the PAN issued by TMHP, if applicable.

24

(Various)

General notes for Blocks 24a through 24j:

•Unless otherwise specified, all required information should be entered in the unshaded portion.

•If more than 6-line items are billed for the entire claim, a provider must attach additional claim forms with no more than 28-line items for the entire claim.

•For multipage claim forms, indicate the page number of the attachment (for example, page 2 of 3) in the top right-hand corner of the claim form.

24a

Date(s) of service

Enter the date of service for each procedure provided in a MM/DD/YYYY format.

Grouping is allowed only for services on consecutive days. The number of days must correspond to the number of units in 24g.

If grouping services, the place of service, procedure code, charges, and individual provider for each line must be identical for that service line.

National Drug Code (NDC)

In the shaded area, enter the NDC qualifier of N4 and the 11-digit NDC number (number on package or container from which the medication was administered).

Do not enter hyphens or spaces within this number.

Example: N400409231231

Refer to: "National Drug Codes (NDC)" .

24b

Place of service

Select the appropriate POS code for each service from the table under "Place of Service (POS) Coding" .

24d

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.

Note: ASC providers should enter only one CPT procedure code for the inclusive global fee.

National Drug Code (Optional)

In the shaded area, enter a 1- through 12-digit NDC quantity of unit.

A decimal point must be used for fractions of a unit.

Refer to: "National Drug Codes (NDC)" .

24e

Diagnosis pointer

Enter the line item reference (1, 2, 3, or 4) of each diagnosis code identified in Block 21 for each procedure.

Indicate the primary diagnosis code only. Do not enter more than one diagnosis code reference per procedure. This can result in denial of the service.

24f

Charges

Indicate the usual and customary charges for each service listed. Charges must not be higher than fees charged to private-pay clients.

24g

Days or units

If multiple services are performed on the same day, enter the number of services performed (such as the quantity billed).

National Drug Code (Optional)

In the shaded area, enter the NDC unit of measurement code.

Refer to: "National Drug Codes (NDC)" .

24j

Rendering provider ID # (performing)

Enter the provider identifier of the individual rendering services unless otherwise indicated in the provider specific section of this manual. Do not enter the performing identifier in Block 33.

Enter the TPI in the shaded area of the field.

Enter the NPI in the unshaded area of the field.

26

Patient's account number

Optional

Any alphanumeric characters (up to 15) in this block are referenced on the Remittance and Status (R&S) Report.

27

Accept assignment

Required

All providers of the CSHCN Services Program Services must accept assignment to receive payment by checking Yes.

28

Total charge

Enter the total charges.

For multi-page claims enter "continue" on initial and subsequent claim forms. 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.

29

Amount paid

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 11. If the client makes a payment, the reason for the payment must be indicated in Block 11.

30

Balance due

If appropriate, subtract Block 29 from Block 28 and enter the balance.

31

Signature of physician or supplier

The physician, supplier or an authorized representative must sign and date the claim.

Billing services may print "Signature on File" in place of the provider's signature if the billing service obtains and retains on file a letter signed by the provider authorizing this practice.

Refer to: "Provider Signature on Claims" on page 5-22.

32

Service facility location information

If services were provided in a place other than the client's home or the provider's facility, enter name, address, and ZIP+4 Code of the facility where the service was provided.

32A

NPI

Enter the NPI of the service facility location.

33

Billing provider info & PH #

Enter the billing provider's name, street, city, state, ZIP+4 Code, and telephone number.

33A

NPI

Enter the NPI of the billing provider.

33B

Other ID #

Enter the TPI of the billing provider.