TMPPM 2009 > Texas Medicaid Services > Family Planning Services > Family Planning Claim Billing

20.5.2 Claims Information

All family planning services (Titles V, X, XIX, and XX) provided by physicians, PAs, NPs, CNSs, and family planning agencies who also contract with DSHS for Title V, X, or XX must be submitted to TMHP in an approved electronic format or on the Family Planning 2017 claim form (revised January 2007). Providers may copy the Family Planning 2017 claim form provided in this manual on page 5-47 or download it from the TMHP website at www.tmhp.com.

Family planning services provided to an RHC client must be billed using modifiers AJ, AM, SA, or U7. These services must be billed using the appropriate national place of service (72) for an RHC setting.

Medicaid family planning providers who do not also contract with DSHS for Title V, X, or XX, may use either the Family Planning 2017 claim form or the CMS-1500 claim form.

Hospitals must use the UB-04 CMS-1450 claims form when billing family planning services. FQHCs may use either the UB-04 CMS-1450 or the Family Planning 2017 claim form to bill family planning Medicaid services; however, if an FQHC also contracts with DSHS to provide Titles V, X, or XX family planning services, the Family Planning 2017 claim form/format must be used to submit all family planning claims, including Title XIX family planning claims. Providers can call the TMHP Contact Center at 1-800-925-9126 to inquire about family planning services, such as reimbursement rates, procedures, or claims filing questions.

Providers may purchase CMS-1500 and UB-04 CMS-1450 claim forms from the vendor of their choice. TMHP does not supply the forms.

When completing a Family Planning 2017, CMS-1500, or UB-04 CMS-1450 claim form, all required information must be included on the claim, as TMHP does not key any information from claim attachments. Superbills, or itemized statements, are not accepted as claim supplements.

Refer to: "TMHP Electronic Data Interchange (EDI)" for information on electronic claims submissions.

"Claims Filing" for general information about claims filing.

"Family Planning 2017 Claim Form" .

"Family Planning 2017 Claim Form Instructions" for instructions for completing paper claims.

"CMS-1500 Claim Filing Instructions" , and "UB-04 CMS-1450 Claim Filing Instructions" . Blocks that are not referenced are not required for processing by TMHP and may be left blank.