TMPPM 2008 > Appendices > Women's Health Program > WHP Claim Billing

O.5.2 Claims Information

Providers must bill for WHP services on the appropriate claim form based on their provider type.

FQHCs may use either the UB-04 CMS-1450 or the Family Planning 2017 claim form to bill family planning Medicaid services. However, if an FQHC also contracts with DSHS to provide Titles V, X, or XX family planning services, the Family Planning 2017 claim form/format must be used to submit all family planning claims, including Title XIX family planning claims.

Family planning agencies that also contract with DSHS for Title V, X, or XX must bill in an approved electronic format or on the Family Planning Claim Form 2017 with the indication of Title XIX. Medicaid family planning providers who do not also contract with DSHS for Title V, X, or XX, may use either the Family Planning 2017 claim form or the CMS-1500 claim form.

All other providers are encouraged to use the Family Planning Claim Form 2017. Providers may copy the Family Planning 2017 claim form provided in this manual on page 5-47 or download it from the TMHP website at www.tmhp.com.

Providers may purchase UB-04 CMS-1450 or CMS-1500 claim forms from the provider of their choice. TMHP does not supply the forms.

When completing a UB-04 CMS-1450 or CMS-1500 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)" (EDI)" for information on electronic claims submissions.

"Claims Filing" for general information about claims filing.

"UB-04 CMS-1450 Claim Filing Instructions" for instructions on completing UB-04 CMS-1450 paper claims.

"CMS-1500 Claim Filing Instructions" for instructions on completing CMS-1500 paper claims. Blocks that are not referenced are not required for processing by TMHP and may be left blank.

Providers can call the TMHP Contact Center at 1-800-925-9126 for provider inquiries regarding family planning services, such as reimbursement rates, procedures, or claims filing questions.