TMPPM 2009 > Appendices > Claim Form Examples

Claim Form Examples

Note: This section contains claim form examples only. These examples are not accurate depictions of claim form data required for claims adjudication. Refer to Section 5 "Claims Filing" for information about completing claim forms for submission to TMHP.

Claims prepared by computer billing services or office-based computers may have "Signature on File" printed in the signature block. Printing of the provider's name instead of "Signature on File" is not acceptable.

Refer to: "Provider Signature on Claims" for more details.

D.1 Ambulance 1 D-3

D.2 Ambulance 2 D-3

D.3 Ambulance 3 D-4

D.4 Ambulatory Surgical Center D-4

D.5 Anesthesia D-5

D.6 Birthing Center D-5

D.7 Blind Children's Vocational Discovery and Development Program (BCVDDP) D-6

D.8 Case Management for Early Childhood Intervention (ECI) D-6

D.9 Case Management for Children and Pregnant Women (CPW) D-7

D.10 Certified Nurse-Midwife (CNM) D-7

D.11 Certified Registered Nurse Anesthetist (CRNA) D-8

D.12 Certified Respiratory Care Practitioner (CRCP) D-8

D.13 Chemical Dependency Treatment Facility D-9

D.14 Chiropractic Services D-9

D.15 Comprehensive Outpatient Rehabilitation Facility (CORF) (THSteps-CCP Only) D-10

D.16 Dental (Doctor of Dentistry) D-10

D.17 Diagnosis and Treatment (Referral from THSteps Check Up) D-11

D.18 Dialysis Training D-11

D.19 Durable Medical Equipment (THSteps-CCP Only) D-12

D.20 Early Childhood Intervention (THSteps-CCP Only) D-12

D.21 Family Planning Claim Form D-13

D.22 Family Planning Services for Hospitals, FQHCs D-13

D.23 FQHC Encounter (T1015) D-14

D.24 FQHC Follow-Up D-14

D.25 Genetics D-15

D.26 Hearing Aid Assessments D-15

D.27 Home Health Services DME/Medical Supplies D-16

D.28 Home Health Services Skilled Nursing Visit D-16

D.29 Home Health Services Skilled Nursing Visit and Physical Therapy D-17

D.30 Hospital-Based ASC D-17

D.31 Hospital Inpatient D-18

D.32 Hospital Outpatient D-18

D.33 In-Home Total Parenteral Nutrition (TPN) Supplier D-19

D.34 Independent Laboratory D-19

D.35 Licensed Clinical Social Worker (LCSW) D-20

D.36 Licensed Dietitians (THSteps-CCP Only) D-20

D.37 Licensed Marriage and Family Therapist (LMFT) D-21

D.38 Licensed Professional Counselor (LPC) D-21

D.39 Maternity Service Clinic D-22

D.40 Mental Health Case Management D-22

D.41 Military Hospital (Emergency Inpatient) D-23

D.42 Nurse Practitioner/Clinical Nurse Specialist (Family Planning) D-23

D.43 Occupational Therapists (THSteps-CCP Only) D-24

D.44 Office Visit with Lab and Radiology D-24

D.45 Orthotic and Prosthetic Suppliers (THSteps-CCP Only) D-25

D.46 Pharmacy (THSteps-CCP Only) D-25

D.47 Physical Therapist D-26

D.48 Physical Therapists (THSteps-CCP Only) D-26

D.49 Private Duty Nurses (THSteps-CCP Only) D-27

D.50 Psychiatric Hospital/Facility (THSteps-CCP Only) D-27

D.51 Psychologist D-28

D.52 Radiation Therapy D-28

D.53 Radiological/Physiological Laboratory and Portable X-Ray Supplier D-29

D.54 Rehabilitation Hospital (THSteps-CCP Only) D-29

D.55 Renal Dialysis Facility CAPD Training D-30

D.56 Renal Dialysis Facility CAPD/CCPD D-30

D.57 Renal Dialysis CMS-1500 Example D-31

D.58 Rural Health Clinic Freestanding D-31

D.59 Rural Health Clinic Freestanding (Immunization) D-32

D.60 Rural Health Clinic Hospital-Based D-32

D.61 School Health and Related Services (SHARS) D-33

D.62 Speech-Language Pathologists (THSteps-CCP Only) D-33

D.63 Surgery D-34

D.64 THSteps Example of a New Patient, Immunization, Physical Examination
by a Nurse Practitioner, and FQHC Billing D-34

D.65 THSteps Example of an Established Patient and Referral, TB Skin Test,
and Physical Examination by a Physician D-35

D.66 Tuberculosis (TB) D-35

D.67 Vision D-36