CSHCN 2008 > Hospital > Claims Information

18.5 Claims Information

The total number of details allowed for a UB-04 CMS-1450 claim form is 28. The TMHP claims processing system (C21) accepts a total of 61 details, and merges like revenue codes together to reduce the lines to 28 or less. If the C21 merge function is unable to reduce the lines to 28 or less, the claim will be denied, and the provider will need to reduce the number of details and resubmit the claim.

Note: Each surgical procedure code listed in Block 74 of the claim form is counted as one detail and is included in the 28-detail limitation.

Inpatient and outpatient hospital services must be submitted to TMHP in an approved electronic format or on a UB-04 CMS-1450 claim form. Providers may purchase UB-04 CMS-1450 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: Chapter 33, "TMHP Electronic Data Interchange (EDI)" on page 33-1, for information about electronic claims submissions.

Chapter 5, "Reimbursement and Claims Filing"on page 5-1, for general information about claims filing.

Chapter 5, "Instructions for Completing the UB-04 CMS-1450 Claim Form"on page 5-25, for instructions on completing paper claims. Blocks that are not referenced are not required for processing by TMHP and may be left blank.