5.1.3 TMHP Processing Procedures

The provider who performed the service must file an assigned claim and agree to accept the allowable charge as full payment.

Regulations prohibit providers from charging clients or TMHP a fee for completing or filing claim forms. The cost of claims filing is considered a part of the usual and customary charges for services provided to all CSHCN Services Program clients.

Claims filed with TMHP for reimbursement by the CSHCN Services Program are subject to the following procedures:

•	TMHP verifies that all required information is present on the claim form.

•	The claim is processed using clerical and automated procedures. Claims requiring special consideration are reviewed by medical professionals.

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All claims from the same provider that are ready for disposition at the end of each week are paid by a single check or electronic funds transfer (EFT) sent to the provider with an explanation of each payment or denial. This explanation is called the Remittance and Status (R&S) Report. If no payment is made to the provider, an R&S Report identifying denied or pending claims is sent to the provider. If there is no claim action during that time period, the provider does not receive an R&S Report that week.

Refer to:

Chapter 6, “Remittance and Status (R&S) Reports,” on page 6-1.