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Section 6: Claims Filing
6.1 Claims Information 6-5
6.1.1 TMHP Processing Procedures 6-5
6.1.1.1 Fiscal Agent 6-5
6.1.1.2 Payment Error Rate Measurement (PERM) 6-6
6.1.2 Claims Filing Instructions 6-7
6.1.2.1 Maximum Number of Units allowed per Claim Detail 6-7
6.1.2.2 Tips on Expediting Paper Claims 6-8
6.1.3 Claims Filing Deadlines 6-8
6.1.3.1 Claims for Clients with Retroactive Eligibility 6-11
6.1.3.2 Exceptions to the 95-Day Filing Deadline 6-12
6.1.3.3 Appeal Time Limits 6-12
6.1.3.4 Claims with Incomplete Information and Zero Paid Claims 6-12
6.1.3.5 Claims Filing Reminders 6-12
6.1.4 HHSC Payment Deadline 6-13
6.1.4.1 Filing Deadline Calendar for 2011 6-14
6.1.4.2 Filing Deadline Calendar for 2012 6-15
6.2 TMHP Electronic Claims Submission 6-16
6.2.1 Benefit and Taxonomy Codes 6-16
6.2.2 Electronic Claim Acceptance 6-16
6.2.3 Electronic Rejections 6-16
6.2.3.1 Newborn Claim Hints 6-17
6.2.4 TMHP EDI Batch Numbers, Julian Dates 6-18
6.2.5 TMHP Paper Claims Submission 6-18
6.2.6 Modifier Requirements for TOS Assignment 6-18
6.2.6.1 Assistant Surgery 6-18
6.2.6.2 Anesthesia 6-18
6.2.6.3 Interpretations 6-18
6.2.6.4 Technical Components 6-18
6.2.7 Preferred Provider Organization (PPO) 6-19
6.3 Coding 6-19
6.3.1 Diagnosis Coding 6-19
6.3.1.1 Place of Service (POS) Coding 6-20
6.3.2 Type of Service (TOS) 6-21
6.3.2.1 TOS Table 6-21
6.3.3 Procedure Coding 6-22
6.3.3.3 Rate Hearings 6-23
6.3.4 National Drug Code (NDC) 6-24
6.3.5 Modifiers 6-25
6.3.6 Benefit Code 6-29
6.4 Claims Filing Instructions 6-30
6.4.1 Claim Form Requirements 6-30
6.4.1.1 Provider Signature on Claims 6-31
6.4.1.2 Group Providers 6-31
6.4.1.3 Prior Authorization Numbers on Claims 6-31
6.4.1.4 Newborn Clients Without Medicaid Numbers 6-31
6.4.1.5 Multipage Claim Forms 6-31
6.4.1.5.1 Professional Claims 6-31
6.4.1.5.2 Institutional Claims 6-32
6.4.1.5.3 Inpatient Hospital Claims 6-32
6.4.1.6 Attachments to Claims 6-33
6.4.1.7 Clients with a Designated or Primary Care Provider 6-33
6.5 CMS-1500 Paper Claim Filing Instructions 6-34
6.5.1 CMS-1500 Electronic Billing 6-35
6.5.2 CMS-1500 Claim Form (Paper) Billing 6-35
6.5.3 CMS-1500 Blank Paper Claim Form 6-36
6.5.4 CMS- 1500 Provider Definitions 6-37
6.5.5 CMS-1500 Instruction Table 6-38
6.6 UB-04 CMS-1450 Paper Claim Filing Instructions 6-42
6.6.1 UB-04 CMS-1450 Electronic Billing 6-42
6.6.2 UB-04 CMS-1450 Claim Form (Paper) Billing 6-43
6.6.3 UB-04 CMS-1450 Blank Paper Claim Form 6-44
6.6.4 UB-04 CMS-1450 Instruction Table 6-45
6.6.5 Occurrence Codes 6-50
6.6.6 Patient Status Codes 6-52
6.6.7 Filing Tips for Outpatient Claims 6-53
6.7 2006 American Dental Association (ADA) Dental Claim Filing Instructions 6-53
6.7.1 2006 ADA Dental Claim Electronic Billing 6-53
6.7.2 ADA Dental Claim Form (Paper) Billing 6-53
6.7.3 2006 ADA Dental Claim Form 6-54
6.7.4 2006 ADA Dental Claim Form Instruction Table 6-54
6.8 Family Planning Claim Filing Instructions 6-58
6.8.1 Family Planning Electronic Billing 6-58
6.9 Family Planning Claim Form (Paper Billing) 6-58
6.9.1 Family Planning 2017 Claim Form 6-59
6.9.2 Family Planning 2017 Claim Form Instructions 6-60
6.10 Vision Claim Form 6-67
6.11 Remittance and Status (R&S) Report 6-69
6.11.1 R&S Report Delivery Options 6-69
6.11.2 Banner Pages 6-69
6.11.3 R&S Report Field Explanation 6-70
6.11.4 R&S Report Section Explanation 6-72
6.11.4.1 Claims - Paid or Denied 6-72
6.11.4.2 Adjustments to Claims 6-72
6.11.4.3 Financial Transactions 6-73
6.11.4.3.1 Accounts Receivable 6-73
6.11.4.3.6 Voids and Stops 6-75
6.11.4.4 Claims Payment Summary 6-75
6.11.4.5 The Following Claims are Being Processed 6-76
6.11.4.6 Explanation of Benefit Codes Messages 6-76
6.11.4.7 Explanation of Pending Status Codes Appendix 6-76
6.11.5 R&S Report Examples 6-76
6.11.6 Banner Page R&S Report 6-77
6.11.6.1 Paid or Denied Claims (Hospital) R&S Report 6-78
6.11.6.2 Paid or Denied Claims (Physician) R&S Report 6-79
6.11.6.3 Adjustments R&S Report 6-80
6.11.6.4 Claims in Process R&S Report 6-81
6.11.6.5 System Payouts R&S Report 6-82
6.11.6.6 Manual Payouts R&S Report 6-83
6.11.6.7 Accounts Receivables R&S Report 6-84
6.11.6.8 Void and Stop Pay R&S Report 6-85
6.11.6.9 Refunds for Medicaid R&S Report 6-86
6.11.6.10 Refunds for Managed Care R&S Report 6-87
6.11.6.11 IRS Levy R&S Report 6-88
6.11.6.12 Backup Withholding Penalty Information R&S Report 6-89
6.11.6.13 Reissues R&S Report 6-90
6.11.6.14 Sub-Owner Recoupments R&S Report 6-91
6.11.6.15 Summary R&S Report 6-92
6.11.6.16 Appendix R&S Report 6-93
6.11.7 Provider Inquiries-Status of Claims 6-94
6.12 Other Insurance Claims Filing 6-95
6.12.1 Unbundled Services That Are Prior Authorized and Manually Priced
Procedure Codes 6-95
6.12.2 Other Insurance Credits 6-96
6.12.2.1 Deductibles 6-96
6.12.2.2 HMO Copayments 6-96
6.12.2.3 Verbal Denial 6-97
6.12.2.4 110-Day Rule 6-97
6.12.2.5 Filing Deadlines 6-98
6.12.3 Claims Forwarded to Other Insurance Carriers 6-98
6.13 Medicare Claims 6-99
6.13.1 Medicare Advantage Plans (MAPs) Claims 6-100
6.13.1.1 Copayments: 6-100
6.13.1.2 Coinsurance and Deductible Claims for Contracted MAPs 6-100
6.13.1.3 Coinsurance and Deductible Reimbursement for Noncontracted MAPs 6-100
6.13.2 Medicare/Medicaid Filing Deadlines 6-100
6.14 Filing Medicare Primary Paper Claims 6-100
6.14.1 Crossover Claim Type 30 TMHP Standardized MRAN Form 6-102
6.14.2 Crossover Claim Type 30 Instructions 6-103
6.14.3 Crossover Claim Types 31 and 50 6-105
6.14.4 Crossover Claim Types 31 and 50 Instructions 6-106
6.14.5 Filing a Medicare-Denied Claim 6-107
6.14.6 Filing a Medicare-Adjusted Claim 6-107
6.15 Medically Needy Claims Filing 6-107
6.16 Claims for Medicaid Hospice Clients Not Related to the Terminal Illness 6-108
6.16.1 Medical Services When Client is Discharged From Hospice 6-108
6.16.2 Claims Address for Medicaid Hospice Clients Not Related to the Terminal Illness 6-108
6.16.3 Lab and X-Ray 6-109
6.17 Children's Health Insurance Program (CHIP) Perinatal Claims 6-109
6.17.1 CHIP Perinatal Newborn Transfer Hospital Claims 6-109
6.18 Forms 6-109
6.1 Sample Letter XUB Computer Billing Service Inc 6-110
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