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5.4.1.5 Attachments to Claims
To expedite claims processing, providers must supply all information on the claim form itself and limit attachments to those required by TMHP or necessary to supply information to properly adjudicate the claim. The following claim form attachments are required when appropriate:
• All claims for services associated with an elective sterilization must have a valid Sterilization Consent Form attached or on file at TMHP.
•Nonemergency ambulance transfers must have documentation of medical necessity including out-of-locality transfers.
•Providers filing for coinsurance, deductible, or both on Medicare claims to TMHP must attach the TMHP Standardized MRAN form or the computer generated MRANs from the CMS-approved software applications Medicare Remit Easy Print (MREP) for professional services or PC-Print for institutional services. Providers that submit paper crossover claims must submit only one of the three approved MRAN formats-the new TMHP Standardized MRAN Forms, MREP, or PC-Print. Paper crossover claims submitted with multiple MRAN forms (e.g., TMHP Standardized MRAN Forms and any other MRAN) with conflicting information will not be processed and will be returned to the provider.This requirement does not apply to claims transferred automatically to TMHP from the Medicare intermediary.
•Medically necessary abortions performed (on the basis of a physician's professional judgement, the life of the mother is endangered if the fetus were carried to term), or abortions provided for pregnancy related to rape or incest must have a signed and dated physician certification statement. Elective abortions are not benefits of the Texas Medicaid Program.
•Hysterectomies must have a Hysterectomy Acknowledgment Statement attached or on file at TMHP.
Refer to: "Hysterectomy Services" .
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