Automated Inquiry System (AIS)

vii

TMHP Electronic Data Interchange (EDI)

3-1

CMS-1500 Claim Filing Instructions

5-22

UB-04 CMS-1450 Claim Filing Instructions

5-30

TMHP Electronic Claims Submission

5-13

Communication Guide

A-1

DME Certification and Receipt Form

B-35

External Insulin Pump

B-39

Medicaid Certificate of Medical Necessity for Chest Physiotherapy Devices (High-Frequency Chest Wall Compression System [HFCWCS]; Intrapulmonary Percussive Ventilation Device [IPV]; Cough-Stimulating Device [Cofflator]- Initial Request)

B-52

Medicaid Certificate of Medical Necessity for Chest Physiotherapy Devices (High-Frequency Chest Wall Compression System [HFCWCS); Intrapulmonary Percussive Ventilation Device [IPV]; Cough-Stimulating Device [Cofflator]-Extended Request)

B-53

Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form Instructions (2 Pages)

B-42

Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form

B-44

Home Health Services Plan of Care (POC)

B-46

Home Health Services Plan of Care (POC) Instructions

B-47

Home Health Services Prior Authorization Checklist

B-48

Wheelchair Seating Evaluation Form (THSteps-CCP/Home Health Services) (next six pages)

B-117

Home Health Services DME/Medical Supplies Claim Example

D-16

Home Health Services SN Visit Claim Example

D-16

Home Health Services SN Visit and Physical Therapy Claim Example

D-17

Acronym Dictionary

F-1