TMPPM 2008 > Texas Medicaid Services > Hospital (Medical/Surgical Acute Care Facility) > Outpatient

25.3.5 Claims Information

Identification of outpatient charges must be in Block 43, if submitting by narrative description or in Block 44, if submitting by HCPCS code. The Texas Medicaid Program recommends the use of specific procedure codes for claim submission. Do not use the revenue code description in Block 43. The HCPCS narrative description must be identified on the claim. For example, when submitting charges for physical therapy, do not use the description associated with revenue code 420. To receive reimbursement for physical therapy services, providers must identify the specific modality used (for example, gait training).

Charges on claims must be itemized on the face of the UB-04 CMS-1450 claim form instead of submitting attachments or charge tickets. Additional claims information can be found within individual topic areas within this section.

Charges on claims must be itemized on the face of the UB-04 CMS-1450 claim form instead of submitting attachments or charge details. TMHP uses information attached to the claim for clarification purposes only. The UB-04 CMS-1450 claim form is designed to list 28 details. For claims with more than 28 details, submit additional UB-04 CMS 1450 claim forms. Surgery codes are included in the 28 details. If a claim contains more than 28 details, continue the claim on additional UB-04 CMS-1450 claim forms. Total each claim form as a stand-alone claim. If you do not total each page, your claim may be denied for being over the limitation, and must be resubmitted with 28 or less details.

Claims for outpatient hospital services must be submitted to TMHP in an approved electronic format or on the UB-04 CMS-1450 claim form. Providers may purchase UB-04 CMS-1400 claim forms from the vendor of their choice. TMHP does not supply the forms.

When completing a UB-04 CMS-1450 claim form, all required information must be included on the claim, as information is not keyed from attachments. Superbills, or itemized statements, are not accepted as claim supplements.

Refer to: "TMHP Electronic Data Interchange (EDI)" for information on electronic claims submissions.

"Claims Filing" for general information about claims filing.

"UB-04 CMS-1450 Claim Filing Instructions" . Blocks that are not referenced are not required for processing by TMHP and may be left blank.