7.1.11 Claims Filing InformationTMHP processes claims for the following clients/programs:
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• A claim must be submitted to TMHP for processing for a patient who was classified as SSI on the date of admission to a hospital. However, if the patient was an HMO client as of the date of admission to the hospital and was admitted as TANF or TANF-related (i.e., not SSI-certified), but changed to SSI during the same hospital stay, the claim must be submitted to the client's HMO for payment of the entire hospital stay. Electronic claims submissions require a National Provider Identifier (NPI) only. If a claim is submitted electronically with a Texas Provider Identifier (TPI), the claim will be denied. If an electronic claim is submitted without an NPI, the claim will be denied. Paper claims submissions require a TPI and NPI for the performing and billing provider. The performing provider's TPI is required in block 24j in the shaded area, and NPI in block 24j in the unshaded area of the CMS-1500 claims form. The billing provider's TPI is required in block 33B in the shaded area, and the NPI in block 33A in the unshaded area. An NPI is required in all other NPI provider identifier blocks. If the NPI and TPI are not in the proper blocks on the claim form and if the NPI is missing from any of the other NPI required blocks, the claim will be denied. Paper claims submissions for the referring provider require the complete name of the referring provider in block 17 and an NPI in block 17b. The referring provider for a managed care client must be the client's primary care provider. If there is not a referral from the primary care provider, a prior authorization number must be on the claim. If the provider of services is not the client's assigned primary care provider, the primary care provider's name and NPI number must be entered in the Referring Provider field of the approved electronic format. If this information is missing and the treating provider is not the assigned primary care provider on the dates of service, the claim will be denied. Providers submitting claims for SSI voluntary clients must follow the client's individual plan requirements for referrals, authorization, admission notification, and concurrent review. The plan is responsible for notifying TMHP of the services that they have approved so those claims can be processed accordingly. Claims for SSI clients who are voluntarily enrolled in PCCM or an HMO will be paid at Texas Medicaid fee-for-service rates. All Texas Medicaid fee-for-service processing guidelines are followed in processing these claims including the 95-day filing deadline. Send claims through regular mail to the following address:
Texas Medicaid & Healthcare Partnership Claims delivered by UPS or other courier methods are to be addressed to the following:
Texas Medicaid & Healthcare Partnership TMHP Electronic Claims Submission Electronic claims submission is available to providers filing claims for ICM clients, PCCM clients, and all SSI voluntary clients in STAR HMOs. Electronic claims submission is available to providers filing claims for STAR+PLUS inpatient hospital clients. Providers must use their provider identifier when billing. For assistance with enrolling to file electronic claims, contact the TMHP Electronic Data Interchange (EDI) Help Desk at 1-888-863-3638, or a provider representative. Contact individual plans for information on electronic claims submissions to STAR HMOs (refer to chart, STAR Program SAs). Refer to: "TMHP Electronic Data Interchange (EDI)" for more information about electronic claims submission. |
All PCCM claims (whether Temporary Assistance for Needy Families [TANF], TANF-related, or SSI)
