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Claims Filing
5.1 Claims Information 5-4
5.1.1 TMHP Processing Procedures 5-4
5.1.1.1 Fiscal Agent 5-4
5.1.1.2 Payment Error Rate Measurement (PERM) 5-4
5.1.2 Prior Authorization Requests Through the TMHP Website 5-5
5.1.3 Online Radiology Prior Authorizations 5-7
5.1.4 Prior Authorization Requests on Medicaid Secondary Claims 5-7
5.1.5 Authorization for Medicaid HMO Clients 5-7
5.1.6 Claims Filing Instructions 5-7
5.1.6.1 Tips on Expediting Paper Claims 5-8
5.1.7 Claims Filing Deadlines 5-8
5.1.7.1 Claims for Clients with Retroactive Eligibility 5-10
5.1.7.2 Exceptions to the 95-Day Filing Deadline 5-10
5.1.7.3 Appeal Time Limits 5-11
5.1.7.4 Claims with Incomplete Information and Zero Paid Claims 5-11
5.1.7.5 Claims Filing Reminders 5-11
5.1.8 HHSC Payment Deadline 5-11
5.1.8.1 Filing Deadline Calendar for 2008 5-13
5.1.8.2 Filing Deadline Calendar for 2009 5-14
5.2 TMHP Electronic Claims Submission 5-15
5.2.1 Electronic Claims 5-15
5.2.2 Electronic Claim Acceptance 5-15
5.2.3 Electronic Rejections 5-15
5.2.3.1 Newborn Claim Hints 5-16
5.2.4 Resubmission of TMHP EDI Rejections 5-16
5.2.5 TMHP EDI Batch Numbers, Julian Dates 5-16
5.2.6 TMHP Paper Claims Submission 5-16
5.2.7 Modifier Requirements for TOS Assignment 5-16
5.2.7.1 Assistant Surgery 5-16
5.2.7.2 Anesthesia 5-17
5.2.7.3 Interpretations 5-17
5.2.7.4 Technical Components 5-17
5.2.8 Preferred Provider Organization (PPO) 5-17
5.3 Coding 5-17
5.3.1 Diagnosis Coding 5-17
5.3.1.1 Place of Service (POS) Coding 5-18
5.3.2 Type of Service (TOS) 5-19
5.3.2.1 TOS Table 5-19
5.3.3 Procedure Coding 5-19
5.3.3.3 Rate Hearings 5-20
5.3.4 National Drug Code (NDC) 5-20
5.3.5 Modifiers 5-21
5.3.6 Benefit Code 5-24
5.4 Claims Filing Instructions 5-24
5.4.1 Claim Form Requirements 5-24
5.4.1.1 Provider Signature on Claims 5-24
5.4.1.2 Group Providers 5-25
5.4.1.3 Prior Authorization Numbers on Claims 5-25
5.4.1.4 Newborn Clients Without Medicaid Numbers 5-25
5.4.1.5 Multipage Claim Forms 5-25
5.4.1.6 Attachments to Claims 5-26
5.4.1.7 Clients with a Designated or Primary Care Provider 5-26
5.5 CMS-1500 Claim Filing Instructions 5-26
5.5.1 CMS-1500 Electronic Billing 5-27
5.5.2 CMS-1500 Claim Form (Paper) Billing 5-27
5.5.3 CMS-1500 Blank Claim Form 5-28
5.5.4 CMS-1500 Instruction Table 5-29
5.6 UB-04 CMS-1450 Claim Filing Instructions 5-33
5.6.1 UB-04 CMS-1450 Electronic Billing 5-33
5.6.2 UB-04 CMS-1450 Claim Form (Paper) Billing 5-33
5.6.3 UB-04 CMS-1450 Blank Claim Form 5-34
5.6.4 UB-04 CMS-1450 Instruction Table 5-35
5.6.5 Occurrence Codes 5-40
5.6.6 Patient Status Codes 5-42
5.6.7 Filing Tips for Outpatient Claims 5-42
5.7 2006 American Dental Association (ADA) Dental Claim Filing Instructions 5-43
5.7.1 2006 ADA Dental Claim Electronic Billing 5-43
5.7.2 ADA Dental Claim Form (Paper) Billing 5-43
5.7.3 2006 ADA Dental Claim Form 5-43
5.7.4 2006 ADA Dental Claim Form Instruction Table 5-43
5.8 Family Planning 2017 Claim Form 5-47
5.8.1 Family Planning 2017 Claim Form Instructions 5-48
5.9 Vision Claim Form 5-54
5.10 Remittance and Status (R&S) Report 5-56
5.10.1 R&S Report Delivery Options 5-56
5.10.2 Banner Pages 5-56
5.10.3 R&S Report Field Explanation 5-56
5.10.4 R&S Report Section Explanation 5-58
5.10.4.1 Claims - Paid or Denied 5-58
5.10.4.2 Adjustments to Claims 5-58
5.10.4.3 Financial Transactions 5-58
5.10.4.4 Claims Payment Summary 5-60
5.10.4.5 The Following Claims are Being Processed 5-60
5.10.4.6 Explanation of Benefit Codes Messages 5-60
5.10.4.7 Explanation of Pending Status Codes Appendix 5-60
5.10.5 R&S Report Examples 5-60
5.10.6 Banner Page R&S Report 5-61
5.10.6.1 Paid or Denied Claims (Hospital) R&S Report 5-62
5.10.6.2 Paid or Denied Claims (Physician) R&S Report 5-63
5.10.6.3 Adjustments R&S Report 5-64
5.10.6.4 Claims in Process R&S Report 5-65
5.10.6.5 System Payouts R&S Report 5-66
5.10.6.6 Manual Payouts R&S Report 5-67
5.10.6.7 Accounts Receivables R&S Report 5-68
5.10.6.8 Void and Stop Pay R&S Report 5-69
5.10.6.9 Refunds for Medicaid R&S Report 5-70
5.10.6.10 Refunds for Managed Care R&S Report 5-71
5.10.6.11 IRS Levy R&S Report 5-72
5.10.6.12 Backup Withholding Penalty Information R&S Report 5-73
5.10.6.13 Reissues R&S Report 5-74
5.10.6.14 Sub-Owner Recoupments R&S Report 5-75
5.10.6.15 Summary R&S Report 5-76
5.10.6.16 Appendix R&S Report 5-77
5.10.7 Provider Inquiries-Status of Claims 5-78
5.11 Other Insurance Claims Filing 5-78
5.11.1 Other Insurance Credits 5-78
5.11.1.1 Deductibles 5-79
5.11.1.2 HMO Copayments 5-79
5.11.1.3 Verbal Denial 5-79
5.11.1.4 110-Day Rule 5-79
5.11.1.5 Filing Deadlines 5-80
5.11.2 Claims Forward to Other Insurance Carriers 5-80
5.12 Medicare Claims 5-80
5.12.1 Medicare/Medicaid Filing Deadlines 5-81
5.13 Filing Medicare Primary Paper Claims 5-81
5.13.1 Crossover Claim Type 30 TMHP Standardized MRAN Form 5-82
5.13.2 Crossover Claim Type 30 Instructions 5-83
5.13.3 Crossover Claim Types 31 and 50 5-85
5.13.4 Crossover Claim Types 31 and 50 Instructions 5-86
5.13.5 Filing a Medicare-Denied Claim 5-87
5.13.6 Filing a Medicare-Adjusted Claim 5-87
5.14 Medically Needy Claims Filing 5-87
5.15 Claims for Hospice Clients 5-88
5.15.1 Medical Services Not Related to the Terminal Illness 5-88
5.15.2 Medical Services when Client is Discharged from Hospice 5-88
5.15.3 Lab and X-Ray 5-88
5.16 Children's Health Insurance Program (CHIP) Perinatal Claims 5-88
5.16.1 CHIP Perinatal Newborn Transfer Hospital Claims 5-88
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