TMPPM 2007 >5.9 Vision Claim Form

All vision services must be billed on a CMS-1500 claim form or the appropriate electronic formats. The eyeglass prescription must be in Block 24D (line 5 for the new prescription and line 6 for the old prescription). The Patient Certification Form must be retained in the patient's file - do not submit to TMHP. Vision care services are benefits of the Texas Medicaid Program only for clients age 21 years of age and older. Vision claims submitted on other forms are denied with EOB 01145, "Claim form not allowed for this program." Providers have 120 days from the date of the R&S report to resubmit claims to TMHP on the CMS-1500, with the R&S report where the claim appears as denied attached.

The following table shows the blocks required for vision claims on a CMS-1500 claim form.

Block No.

Description

Enter the patient's nine-digit client number from the Medicaid Identification Form (H3087).

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

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

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

9 and 9a-9d

Other insurance or government benefits

Was condition related to:

a)	Patient's employment

b)	Auto accident

c)	Other accident

Medicare HIC number

Patient's or authorized person's signature

13*

Insured or authorized person's signature

17 Name of referring physician or other source

17a Other ID# (TPI)

17b NPI (Optional)

Name, provider identifiers, and address of prescribing medical doctor or doctor of optometry

Diagnosis or nature of illness or injury

24A

DOS

24B

POS

24D

Describe procedures, medical services, or supplies furnished for each date given

24D, Line "5" for new prescription
24D, Line "6" for old prescription

Prescription/description of lenses and frames

24E

Diagnosis pointer

24F

Charges

26*

The account number for the patient that is used in the provider's office for its billing records.

27
Check "YES" or "NO"

Accept assignment

Total charges

Amount paid by other insurance

Signature of physician or supplier

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

Telephone number

Physician's or supplier's name, address, city, state, and ZIP code

No longer used

Referral from screening program (THSteps)

Providers must have patients sign the Patient Certification Form and retain in their records.

Refer to: "Vision Care Eyeglass Patient (Medicaid Client) Certification Form".

Do not submit to TMHP.

Selection of eyewear beyond program benefits/replacing lost or destroyed eyewear