5 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 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 Inactive Provider Termination 5-4

5.1.6 Claims Filing Deadlines 5-5

5.1.7 Exception to Claim Filing Deadline 5-6

5.1.8 Fiscal Agent Payment Deadline 5-7

5.2 Third-Party Resource (TPR) 5-8

5.2.1 Health Maintenance Organization (HMO) 5-8

5.2.2 CSHCN Services Program Eligibility Form 5-9

5.2.3 Claims Filing Involving a TPR 5-9

5.2.4 Verbal Denials by a TPR 5-9

5.2.5 Filing Deadlines Involving a TPR 5-10

5.2.6 Blue Cross Blue Shield (BCBS) Nonparticipating Physicians 5-11

5.2.7 Refunds 5-11

5.2.8 Refunds to TMHP Resulting From Other Insurance 5-12

5.2.9 Accident-Related Claims 5-12

5.2.9.1 Accident Resources and Refunds Involving Claims for Accidents 5-13

5.2.9.2 Third-Party Liability for Claims Involving Accidents 5-13

5.3 Multipage Claim Forms 5-14

5.4 Tips on Expediting Paper Claims 5-15

5.4.1 General requirements 5-15

5.4.2 Data Fields 5-15

5.4.3 Attachments 5-15

5.5 Correction and Resubmission (Appeal) Time Limits 5-15

5.5.1 Claims with Incomplete Information 5-15

5.5.2 Other Insurance Appeals 5-16

5.5.3 Resubmission of TMHP EDI Rejections 5-16

5.5.3.1 TMHP EDI Batch Numbers, Julian Dates 5-16

5.5.4 Authorization and Filing Deadline Calendar for 2012 5-17

5.5.5 Authorization and Filing Deadline Calendar for 2013 5-18

5.6 Coding 5-19

5.6.1 Diagnosis Coding 5-19

5.6.2 Procedure Coding 5-19

5.6.2.1 Healthcare Common Procedure Coding System (HCPCS) 5-19

5.6.2.2 National Correct Coding Initiative (NCCI) Guidelines 5-19

5.6.2.3 Level I 5-20

5.6.2.4 Level II 5-21

5.6.2.5 Determining Reimbursement Rates for New HCPCS Procedure Codes 5-21

5.6.2.6 National Drug Codes (NDC) 5-22

5.6.2.7 Modifiers 5-23

5.6.2.8 Type of Services (TOS) 5-23

5.6.2.9 Place of Service (POS) Coding 5-24

5.6.3 Benefit Code 5-24

5.7 Claims Filing Instructions 5-24

5.7.1 Claim Details 5-25

5.7.2 Provider Types and Selection of Claim Forms 5-25

5.7.2.1 Providers and Services Billable on CMS-1500 5-25

5.7.2.2 CMS-1500 Claim Form Provider Definitions 5-26

5.7.2.3 CMS-1500 Electronic Billing 5-26

5.7.2.4 CMS‑1500 Paper Claim Form Instructions 5-27

5.7.2.5 CMS‑1500 Paper Claim Form Example 5-31

5.7.2.6 UB-04 CMS-1450 Paper Claim Form Instructions 5-32

5.7.2.7 UB-04 CMS-1450 Electronic Billing 5-32

5.7.2.8 Instructions for Completing the UB-04 CMS-1450 Paper Claim Form 5-32

5.7.2.9 Client Status (for block 17) 5-40

5.7.2.10 Occurrence Codes (for blocks 31 through 34) 5-41

5.7.2.11 POA Indicators (for blocks 67 and 72) 5-42

5.7.2.12 UB-04 CMS-1450 Paper Claim Form Example 5-43

5.7.2.13 Dental Claim Filing 5-44

5.7.2.14 2006 ADA Dental Claim Electronic Billing 5-44

5.7.2.15 Instructions for Completing the Paper ADA Dental Claim Form 5-44

5.7.2.16 Electronic Claims Submission 5-47

5.7.2.17 Taxonomy Codes 5-47

5.7.2.18 Dates on Claims 5-47

5.7.2.19 Span Dates 5-48

5.7.2.20 Hospital Billing 5-48

5.7.2.21 Group Billing 5-48

5.7.3 Supervising Physician Provider Number Required on Some Claims 5-48

5.7.4 Ordering/Referring Provider NPI 5-49

5.8 Reimbursement 5-49

5.8.1 Electronic Funds Transfer (EFT) 5-49

5.8.1.1 Advantages of EFT 5-49

5.8.1.2 Enrollment Procedures 5-50

5.8.1.3 One-day Payment Window Reimbursement Guidelines 5-50

5.8.2 Texas Medicaid Reimbursement Methodology (TMRM) 5-50

5.8.3 Maximum Allowable Fee Schedule 5-50

5.8.4 Manual Pricing 5-51

5.8.5 Physician Services in Hospital Outpatient Setting 5-51

5.8.6 Fees 5-51

5.8.6.1 Provider-Specific Rates for Procedure Codes with Modifiers and
Age-Range Criteria 5-51

5.8.7 CSHCN Services Program Reimbursement Information for Clients 5-52

5.9 CSHCN Services Program Accounts Receivables (Using Medicaid Funds to Satisfy
the AR) 5-52

5.10 TMHP-CSHCN Services Program Contact Center 5-53