CSHCN 2008 > Reimbursement and Claims Filing

Reimbursement and Claims Filing

5.1 Reimbursement 5-3

5.1.1 Electronic Funds Transfer (EFT) 5-3

5.1.1.1 Advantages of EFT 5-3

5.1.1.2 Enrollment Procedures 5-3

5.1.2 Texas Medicaid Reimbursement Methodology (TMRM) 5-4

5.1.3 Manual Pricing 5-4

5.1.4 Maximum Allowable Fee Schedule 5-4

5.1.5 Physician Services in Hospital Outpatient Setting 5-4

5.2 TMHP Claims Information 5-5

5.2.1 Claims Processed by TMHP 5-5

5.2.2 Claims Processed by the Department of State Health Services (DSHS)-CSHCN
Services Program 5-5

5.2.3 TMHP Processing Procedures 5-6

5.2.4 Claims Filing Deadlines and Exceptions 5-6

5.2.5 Exception to Claim Filing Deadline 5-7

5.3 Third-Party Resource (TPR) 5-8

5.3.1 Health Maintenance Organization (HMO) 5-9

5.3.2 CSHCN Services Program Eligibility Form 5-9

5.3.3 Claims Filing Involving a TPR 5-9

5.3.4 Verbal Denials by a TPR 5-10

5.3.5 Filing Deadlines Involving a TPR 5-10

5.3.6 Blue Cross Blue Shield (BCBS) Nonparticipating Physicians 5-11

5.3.7 Refunds to TMHP Resulting From Other Insurance 5-11

5.3.8 Accident-Related Claims 5-12

5.3.8.1 Accident Resources and Refunds Involving Claims for Accidents 5-12

5.4 Multipage Claim Forms 5-12

5.5 Correction and Resubmission (Appeal) Time Limits 5-13

5.5.1 Claims with Incomplete Information 5-13

5.5.2 Other Insurance Appeals 5-13

5.5.3 Authorization and Filing Deadline Calendar for 2007 5-14

5.5.4 Authorization and Filing Deadline Calendar for 2008 5-15

5.6 Coding 5-16

5.6.1 Diagnosis Coding 5-16

5.6.2 Procedure Coding 5-16

5.6.2.1 Healthcare Common Procedure Coding System (HCPCS) 5-16

5.6.2.2 Level I 5-16

5.6.2.3 Level II 5-16

5.6.2.4 Modifiers 5-17

5.6.2.5 Place of Service (POS) Coding 5-17

5.6.2.6 Benefit Code 5-17

5.7 Claims Filing Instructions 5-18

5.7.1 Provider Types and Selection of Claim Forms 5-18

5.7.1.1 CMS-1500 5-18

5.7.1.2 CMS-1500 Claim Form Instructions 5-19

5.7.1.3 CMS-1500 Example 5-24

5.7.1.4 UB-04 CMS-1450 5-25

5.7.1.5 Instructions for Completing the UB-04 CMS-1450 Claim Form 5-25

5.7.1.6 Occurrence Codes 5-34

5.7.1.7 UB-04 CMS-1450 Example 5-36

5.7.1.8 Dental Claim Filing 5-37

5.7.1.9 Instructions for Completing the ADA Dental Claim Form 5-37

5.7.1.10 Electronic Claims Submission 5-39

5.7.1.11 Dates on Claims 5-40

5.7.1.12 Span Dates 5-40

5.7.1.13 Hospital Billing 5-40

5.8 TMHP-CSHCN Services Program Contact Center 5-40