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8.1.13.1 TMHP Paper Claims Submissions
Paper claims submissions require a Texas Provider Identifier (TPI) and National Provider Identifier (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 17a 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 valid prior authorization number must be on the claim in the appropriate block.
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 the primary care provider's TPI and NPI are missing and the treating provider is not the assigned primary care provider on the dates of service, the claim will be denied. If a PCCM client has selected a primary care provider, but the primary care provider change is pending, the pending primary care provider rendering services should call the PCCM provider helpline to obtain a referral prior to billing the claim.
Providers submitting claims for SSI voluntary clients must follow the client's individual HMO requirements for referrals, authorization, admission notification, and concurrent review. The HMO is responsible for notifying TMHP of the services that they have approved so those claims can be processed accordingly. Claims for SSI clients 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
PO Box 200555
Austin, TX 78720-0555
Claims delivered by UPS or other courier methods are to be addressed to the following:
Texas Medicaid & Healthcare Partnership
12357-B Riata Trace Parkway, Suite 150
Austin, TX 78727
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