Automated Inquiry System (AIS)

vii

TMHP Electronic Data Interchange (EDI)

3-1

CMS-1500 Claim Filing Instructions

5-22

CMS-1450 Claim Filing Instructions

5-30

TMHP Electronic Claims Submission

5-13

Communication Guide

A-1

Donor Human Milk Form Example

B-36

Psychiatric Hospital Inpatient Admission Form

B-76

Psychiatric Inpatient (Extended) Request Form

B-77

THSteps-CCP ECI Request for Initial/Renewal Outpatient Therapy

B-107

THSteps-CCP Prior Authorization Request (2 pages)

B-105

Wheelchair/Seating Evaluation Form (THSteps-CCP) (6 pages)

B-117

CORF (THSteps-CCP Only) Claim Form Example

D-10

Durable Medical Equipment (THSteps-CCP Only) Claim Form Example

D-12

ECI (THSteps-CCP Only) Claim Form Example

D-12

Licensed Dietitian (THSteps-CCP Only) Claim Form Example

D-20

Occupational Therapists (THSteps-CCP Only) Claim Form Example

D-24

Orthotic and Prosthetic Suppliers (THSteps-CCP Only) Claim Form Example

D-25

Pharmacy (THSteps-CCP Only) Claim Form Example

D-25

Physical Therapist (THSteps-CCP Only) Claim Form Example

D-26

Private Duty Nurses (THSteps-CCP Only) Claim Form Example

D-27

Psychiatric Hospital/Facility (THSteps-CCP Only) Claim Form Example

D-27

Rehabilitation Hospital (THSteps-CCP Only) Claim Form Example

D-29

Speech-Language Pathologists (THSteps-CCP Only) Claim Form Example

D-33

Acronym Dictionary

F-1