1a

Insured's ID No. (for program checked above, include all letters)

Enter the patient's nine-digit client number from the Medicaid Identification.

2

Patient's name

Enter the patient's last name, first name, and middle initial as printed on the Medicaid Identification Form (Form H3087).

3

Patient's date of birth
Patient's sex

Enter numerically the month, day, and year (MM/DD/YYYY) the client was born.
Indicate the patient's sex by checking the appropriate box.

5

Patient's address

Enter the patient's complete address as described (street, city, state, and ZIP Code).

9

Other insured's name

For special situations, use this space to provide additional information. Other uses include, but are not limited to the following:

•If the patient is deceased, enter the date of death. If the services were rendered on the date of death, indicate the time of death.

•If the service is a sterilization, identify the date and time of surgery.

•If the patient has chronic renal disease, enter the date of onset of dialysis treatments.

Ambulance Hospital-to-Hospital Transfers
Indicate the services required from the second facility and unavailable at the first facility.

10

Was condition related to:
A) Patient's employment
B) Auto accident
C) Other accident

Indicate by checking the appropriate box. If applicable, enter all available information for other health insurance coverage in Block 11.

11a-b

Other health insurance coverage

If another insurance resource has made payment, write "(Name) Insurance Company paid $(Amount) on (Date)."

If another insurance resource has been billed and denied the claim, write "(Name) Insurance Company denied claim on (Date)." Attach a copy of the denial letter or form to the Medicaid claim.

If the patient has health, accident, or other insurance policies or is covered by private or government benefit system which may pay in full or in part for the services billed on this form, enter all pertinent information available (in Box 9 a-d). If the patient is enrolled in Medicare, enter the patient's Health Insurance Claim (HIC) number from the Medicare Identification Card. The notation of "Denied" indicates the TPR denied the claim.

11c

Insurance plan or program name

Enter the benefit code, if applicable, for the billing or performing provider.

12

Patient or authorized person's signature

Providers are encouraged to obtain the patient's signature on claim forms; however, TMHP will process the claim without the signature of the patient. The patient's signature authorizes the release of the claim's medical information.

14

Date of injury or date of last menstrual period

If the services provided are accident or maternity-related, indicate the date of injury of the accident or the date of the last menstrual period.

17

Name of referring physician or other source

Enter the complete name of the referring provider in the following situations:

•Electronic billers must enter the provider identifier, six-digit Medicare number, or UPIN.

•Clinical pathology consultations to hospital inpatients or outpatients must identify the attending physician.

•Nonemergency services provided to limited clients on referral from the designated physician must identify the designated physician's nine-digit provider identifier.

•Consultation services must identify the referring physician.

•Services provided to a client in a nursing facility (skilled nursing facility [SNF], intermediate care facility [ICF], or extended care facility [ECF]) must identify the attending physician.

•Laboratory and radiology services must identify the ordering physician.

•Speech-language therapy must identify the ordering physician.

•Physical therapy must identify the ordering physician.

•Occupational therapy must identify the ordering physician.

•In-home TPN/hyperalimentation services must identify the ordering physician.

•THSteps-CCP services must identify the referring provider.

•Do not use Medicare number for limited clients. For limited clients, use a nine-digit provider identifier in 17a. Electronic billers should use the Medicare six-digit code number or provider identifier.

•The referring provider must be the primary care provider if the client is in a STAR or STAR+PLUS health plan. If there is not a referral from the primary care provider, a prior authorization number (PAN) must be on the claim.

•Claims received without this information will be returned to the provider.

Physician Claims (Referring Physician)

A referring physician is required for consultation, laboratory, radiology, and radiation therapy procedures. The complete name and address or the provider identifier of the referring physician must be in Block 17 of the claim form.

Freestanding ASC Claims
The performing surgeon/referring physician name/number must be identified.

17a

Other ID#

Enter the Other ID number, such as a Texas Medicaid nine-digit provider identifier (TPI), or Universal Provider Identification Number (UPIN), of the referring provider, ordering provider, or other source.

17b

NPI

Optional
Enter the NPI of the referring provider, ordering provider, or other source.

19

Reserved for local use

Multiple Transfers
Indicate that the claim is part of a multiple transfer and provide the other client's complete name and Medicaid number. Provide information about the accident including the date of occurrence, how it happened, whether it was self-inflicted or employment-related.

20

Was laboratory work performed outside your office?

Check the appropriate box. The information is not required to process claims, but it may be requested for retrospective review. If "YES," enter the name and address or provider identifier of the facility that performed the service in Block 32. Medicaid regulations require a provider bill only for those laboratory services that he or she actually performed. Any services performed outside of the provider's office must be billed by the performing laboratory or radiology center.

21

Diagnosis or nature of illness or injury

Enter the ICD-9-CM diagnosis code to the highest level of specificity available complete to five digits for each diagnosis observed.

A pathologist is not required to supply a diagnosis except for: estrogen receptor assays, HLTVIII, plasmapheresis, and anatomical pathology specimens. Radiology groups are required to provide a diagnosis for inflammatory process localization using radioactive tracer (Gallium 67), graphic stress telethermometry, computed tomography (CT) scans, echography, arteriography, venography, and magnetic resonance imaging (MRI).

The statement of medical necessity for abortions and the rationale for the decision must be included if it is not attached to the claim.

Ambulance
Ambulance providers must provide a concise description for each diagnosis observed or enter the ICD-9-CM diagnosis code to the highest level of specificity available complete to five-digits for each diagnosis observed.

Chiropractors
Chiropractors must indicate the exact level of subluxation (use of diagnosis codes 7390, 7391, 7392, 7393, 7394, 7395, 7398, 83900, 83901, 83902, 83903, 83904, 83905, 83906, 83907, 83908, 83920, 83921, and 83949 may be indicated in lieu of a written description) and the date of the X-ray that demonstrates the degree of subluxation.

THSteps medical check ups
For paper and electronic billers, the diagnosis code is V202.

23

Prior authorization no. (PAN)

Enter the PAN issued by TMHP, if applicable.

24

Various

24a through 24J-General Notes:

•Each line contains two sections-a shaded and an unshaded portion. Unless otherwise specified, all required information in Blocks 24A through 24J should be entered in the unshaded portion.

•The CMS-1500 claim form is designed to list only six-line items in Block 24. If more than six-line items are billed for the entire claim, a provider must attach additional forms with no more than 28-line items for the entire claim.

•Type of service (TOS) codes are no longer required for claims submissions.

24A

Date of service (DOS)

Enter the DOS for each procedure provided in a MM/DD/YYYY format. If more than one DOS is for a single procedure, each date must be given (such as "03/16, 17, 18/2005").

Electronic Billers
Medicaid does not accept multiple (to-from) dates on a single line detail. Bill only one date per line. "To" dates of service are not used on electronic claims.

24B

Place of service (POS)

Select the appropriate POS code for each service from the POS table under Place of Service (POS) Coding of this manual, "Place of Service (POS) Coding" . If the patient is registered at a hospital, the POS must indicate inpatient or outpatient status at the time of service.

Ambulance
The POS for all ambulance transfers is the destination.

THSteps medical check ups
For paper billers, the POS will always be "1" or "O." For electronic billers, the POS will always be "11."

24C

EMG (THSteps medical check up condition indicator)

Enter the appropriate condition indicator for THSteps medical check ups.

24D

Fully describe procedures, medical services, or supplies furnished for each date given

Enter the appropriate procedure codes for all procedures/services billed. If a procedure code is not available, enter a concise description.

Give complete information for:

•Injections. Provide a breakdown of each injection and separate the charge for an injection from the office visit charge. Indicate the name of the drug, strength, and dosage; and the necessity for the injection by using one of the modifiers.

•Sutures. Indicate number of sutures, length, and location of laceration.

•Laboratory. Indicate the specific type of laboratory procedure.

•X-ray. Indicate the number of views and type.

•When unusual or extenuating circumstances occur, give a brief medical report.

•THSteps medical check ups. Use a modifier to identify provider.

•Ambulance. The pick-up point and destination must be indicated on the claim form.

•Anesthesiologists and CRNAs. Enter the appropriate CPT anesthesia procedure code for all procedures billed. If the anesthesia is given for more than one procedure, identify all procedures performed and indicate which is considered the major procedure. A breakdown of charges is not necessary. Enter the time in minutes.

•Enter one of the following modifiers as appropriate:

•Anesthesiologists use "AA," "AD," or "QK."

•CRNAs use "QX" or "QZ."

•Use modifiers (e.g., acute, left, right) to describe services (refer to "Modifiers" of this manual).

•Eyewear. When billing for eyewear, the prescription must be entered; the new prescription must be placed on Line five and the old prescription on Line 6.

24E

Diagnosis pointer

Enter the line item reference (1, 2, 3, or 4) for each service or procedure as it relates to each ICD-9-CM diagnosis code identified in Block 21. If a procedure is related to more than one diagnosis, the primary diagnosis the procedure is related to must be the one identified. Do not enter more than one reference per procedure. This could result in denial of the service.

24F

Charges

Indicate the usual and customary charges for each service listed. Charges must not be higher than fees charged to private-pay patients.

24G

Days or units

If multiple services are performed on the same day, enter the number of services performed (such as the quantity billed.)

24J

Rendering provider ID# (performing)

Enter the provider identifier for the individual rendering services.

Enter the TPI in the shaded area of the block.

Optional
Enter the NPI in the unshaded area of the block.

Members of a group practice (except pathology and renal dialysis groups) must identify the provider identifier of the doctor/clinic within the group who performed the service. The number that identifies the doctor/clinic as a member of that group practice should not appear in Block 33 and must not be used to bill the Texas Medicaid Program. The space is also used to provide additional information, such as pertinent comments that may explain unusual procedure.

26

Patient's account number

Optional
Any alphanumeric characters (up to 15) in this block are referenced on the R&S report.

27

Accept assignment

Required
All providers of Texas Medicaid Program services must accept assignment to receive payment. Providers must check "yes." Electronic billers must submit a "Y."

28

Total charge

Enter the total of separate charges for each page of the claim. Enter the total of all pages on last claim if filing a multi-page claim.

29

Amount paid

Enter any amount paid by an insurance company or other sources known at the time of submission of the claim. Identify the source of each payment and date in Block 11. If the client makes a payment, the reason for the payment must be indicated in Block 11.

30

Balance due

If appropriate, subtract Block 29 from Block 28 and enter the balance.

31

Signature of physician or supplier

The physician/supplier or an authorized representative must sign and date the claim. Billing services may print "Signature on File" in place of the provider's signature if the billing service obtains and retains on file a letter signed and dated by the provider authorizing this practice.

Refer to: "Provider Signature on Claims" .

32

Name and address of facility where services rendered, if other than home or office

If services were provided in a place other than the patient's home or the provider's facility, enter name, address, and ZIP Code, and the provider identifier of the facility where the service was provided.

Ambulance
For ambulance transfers, if the destination is a hospital, enter the name and address, and the provider identifier of the facility.

Laboratory
For laboratory specimens sent to an outside laboratory for additional testing, the complete name and address or the provider identifier of the outside laboratory should be entered. The laboratory should bill the Texas Medicaid Program for the services performed.

32a

NPI

Optional
Enter the NPI of the service facility location.

32b

Other ID#

Enter the other ID number, such as a nine-digit TPI or UPIN, of the service facility location.

33

Physician or supplier's name, address, ZIP Code, and telephone number

Enter the Texas Medicaid Program provider name, street, city, state, ZIP Code, and telephone number of the billing provider.

33a

NPI

Optional
Enter the NPI of the billing provider.

33b

Other ID#

Enter the TPI number of the billing provider.