6.1 R&S Report Information

The R&S Report provides information on pending, paid, denied, adjusted, and incomplete claims. TMHP provides R&S Reports to give providers detailed information about the status of claims submitted to TMHP. The R&S Report also identifies receivables resulting from inappropriate payments. These receivables are recouped from payments of subsequent claim submissions.

Providers receive an R&S Report for each 9-digit provider identifier with claim activity.

Providers can determine the program associated with the R&S Report by looking at the top center of the R&S Report. The line below Texas Medicaid & Healthcare Partnership identifies the program associated with the R&S Report.

Online R&S Reports are available as a PDF every Monday morning at 6 a.m., Central Time, following the claims processing cycle. Providers must have a provider administrator account on the TMHP website at www.tmhp.com to receive online R&S Reports.

Refer to:

Section 39, “TMHP Electronic Data Interchange (EDI),” on page 39‑1, for information about electronic billing.

Providers must retain copies of all R&S Reports for a minimum of 5 years. Do not send original R&S Reports back to TMHP; instead, submit copies of the R&S Reports when submitting a corrected claim or when resubmitting a previously incomplete claim.

Samples of the R&S Report are provided at the end of this chapter. The R&S Report provides information using the following general formatting guidelines:

•	Information is displayed in rows rather than columns

•	Incomplete claims appear in the “Claims — Paid or Denied” section

•	Explanation of benefits (EOB) and explanation of pending status (EOPS) codes are five characters in length (up to four messages can be displayed at the claim level and up to five at the detail level)

•	Descriptions of EOBs and EOPS are in an appendix at the end of the R&S Report

•	Financial transactions appear in one of the following categories: accounts receivable, Internal Revenue Service (IRS) levies, claim refunds, payouts (system and manual), claim reissues, and claim voids

•	The internal control number (ICN) is 24 digits

•	The primary diagnosis submitted on the claim appears with the claim header information