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6.5.1 THSteps Medical Checkups
6.5.1.1 Claims Information
THSteps providers do not have to bill private insurance for a medical checkup; they can bill TMHP directly even if they know that the client has private insurance. For THSteps medical checkups, TMHP is responsible for determining whether a third-party resource (TPR) exists and for seeking payment from the TPR.
Providers should bill their usual and customary fee except for vaccines obtained from TVFC. Providers may not charge Medicaid or clients for the vaccine received from TVFC. Providers may charge a usual and customary fee not to exceed $14.85 for vaccine administration when providing immunizations to a client eligible for TVFC. Providers are reimbursed the lesser of the billed amount or the maximum allowable fee.
THSteps medical checkups may be billed electronically or on a CMS-1500 claim form. Providers may purchase CMS-1500 claim forms from the vendor of their choice. TMHP does not supply the forms. Providers may request information about electronic billing or the claim form by contacting the TMHP THSteps Contact Center at 1-800-757-5691.
All procedures, including the informational-only procedures, must have a billed amount associated with each procedure listed on the claim. Informational-only procedure codes must be billed in the amount of at least $.01.
Providers must record the following on the CMS-1500 claim form to receive reimbursement for a medical checkup:
• The provider identifier and benefit code
•The appropriate THSteps medical checkup procedure code (all ages) with diagnosis code V202
•The condition indicator codes, which must be placed in 24C (ST, S2, or NU only)
•The provider type modifiers
•The exception-to-periodicity modifier, when applicable
•A TB skin test procedure code if a test was administered (1 through 20 years of age)
•The immunization administration and vaccine procedure codes if any were administered (all ages)
•The place of service must be 72 for RHCs
•The EP modifier must be used for FQHCs
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