TMPPM 2008 > Texas Medicaid Services > Texas Health Steps (THSteps) > THSteps Medical and Dental Administrative Information

43.1.9.3 Billing

THSteps providers do not have to bill private insurance for a medical check up; they can bill TMHP directly even if the provider knows that the client has private insurance. For THSteps medical check ups, TMHP is responsible for determining if a third party resource (TPR) exists and for seeking payment from the TPR.

Providers should bill their usual and customary fee. Providers are reimbursed the lesser of the billed amount or the maximum allowable fee.

THSteps medical check ups may be billed electronically or on a CMS-1500 claim form. Providers may purchase CMS-1500 claim forms from the vendor of their choice. TMHP does not supply the forms.

Providers may request information about electronic billing or the claim form by contacting the TMHP THSteps Contact Center at 1-800-757-5691.

All procedures, including the informational-only procedures, must have a billed amount associated with each procedure listed on the claim. Informational-only procedure codes must be billed in the amount of at least $.01.

Providers must record the following on the CMS-1500 claim form to receive reimbursement for a medical check up:

•Appropriate THSteps medical check up procedure code (all ages).

•TB skin test procedure code, if administered (1 to 20 years of age).

•Immunization administration and vaccine procedure code(s) if administered (all ages).

•Condition indicator codes are placed in 24C. (ST, S2, or NU only).

•Provider type modifiers.

•EP modifier, if appropriate.

Submit claims to the following address:

Texas Medicaid & Healthcare Partnership
PO Box 200555
Austin, TX 78720-0555

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

"Claims Filing" for general information about claims filing.

"CMS-1500 Claim Filing Instructions" for billing instructions.