TMPPM 2010 > Volume 1, General Information > Section 6: Claims Filing

   
 

Section 6: Claims Filing

6.1 Claims Information 6-5

6.1.1 TMHP Processing Procedures 6-5

6.1.1.1 Fiscal Agent 6-5

6.1.1.2 Payment Error Rate Measurement (PERM) 6-6

6.1.2 Claims Filing Instructions 6-7

6.1.2.1 Tips on Expediting Paper Claims 6-7

6.1.3 Claims Filing Deadlines 6-8

6.1.3.1 Claims for Clients with Retroactive Eligibility 6-11

6.1.3.2 Exceptions to the 95-Day Filing Deadline 6-12

6.1.3.3 Appeal Time Limits 6-13

6.1.3.4 Claims with Incomplete Information and Zero Paid Claims 6-13

6.1.3.5 Claims Filing Reminders 6-14

6.1.4 HHSC Payment Deadline 6-14

6.1.4.1 Filing Deadline Calendar for 2010 6-16

6.1.4.2 Filing Deadline Calendar for 2011 6-17

6.2 TMHP Electronic Claims Submission 6-18

6.2.1 Benefit and Taxonomy Codes 6-18

6.2.2 Electronic Claim Acceptance 6-18

6.2.3 Electronic Rejections 6-18

6.2.3.1 Newborn Claim Hints 6-19

6.2.4 Resubmission of TMHP EDI Rejections 6-20

6.2.5 TMHP EDI Batch Numbers, Julian Dates 6-20

6.2.6 TMHP Paper Claims Submission 6-20

6.2.7 Modifier Requirements for TOS Assignment 6-20

6.2.7.1 Assistant Surgery 6-20

6.2.7.2 Anesthesia 6-20

6.2.7.3 Interpretations 6-20

6.2.7.4 Technical Components 6-21

6.2.8 Preferred Provider Organization (PPO) 6-21

6.3 Coding 6-21

6.3.1 Diagnosis Coding 6-21

6.3.1.1 Place of Service (POS) Coding 6-23

6.3.2 Type of Service (TOS) 6-24

6.3.2.1 TOS Table 6-24

6.3.3 Procedure Coding 6-25

6.3.3.1 Level I 6-26

6.3.3.2 Level II 6-26

6.3.3.3 Rate Hearings 6-27

6.3.4 National Drug Code (NDC) 6-27

6.3.5 Modifiers 6-29

6.3.6 Benefit Code 6-34

6.4 Claims Filing Instructions 6-35

6.4.1 Claim Form Requirements 6-35

6.4.1.1 Provider Signature on Claims 6-35

6.4.1.2 Group Providers 6-35

6.4.1.3 Prior Authorization Numbers on Claims 6-35

6.4.1.4 Newborn Clients Without Medicaid Numbers 6-36

6.4.1.5 Multipage Claim Forms 6-36

6.4.1.5.1 Professional Claims 6-36

6.4.1.5.2 Institutional Claims 6-36

6.4.1.6 Attachments to Claims 6-37

6.4.1.7 Clients with a Designated or Primary Care Provider 6-37

6.5 CMS-1500 Claim Filing Instructions 6-37

6.5.1 CMS-1500 Electronic Billing 6-39

6.5.2 CMS-1500 Claim Form (Paper) Billing 6-39

6.5.3 CMS-1500 Blank Claim Form 6-40

6.5.4 CMS-1500 Instruction Table 6-41

6.6 UB-04 CMS-1450 Claim Filing Instructions 6-46

6.6.1 UB-04 CMS-1450 Electronic Billing 6-47

6.6.2 UB-04 CMS-1450 Claim Form (Paper) Billing 6-47

6.6.3 UB-04 CMS-1450 Blank Claim Form 6-48

6.6.4 UB-04 CMS-1450 Instruction Table 6-49

6.6.5 Occurrence Codes 6-55

6.6.6 Patient Status Codes 6-57

6.6.7 Filing Tips for Outpatient Claims 6-58

6.7 2006 American Dental Association (ADA) Dental Claim Filing Instructions 6-59

6.7.1 2006 ADA Dental Claim Electronic Billing 6-59

6.7.2 ADA Dental Claim Form (Paper) Billing 6-59

6.7.3 2006 ADA Dental Claim Form 6-59

6.7.4 2006 ADA Dental Claim Form Instruction Table 6-59

6.8 Family Planning Claim Filing Instructions 6-64

6.8.1 Family Planning Electronic Billing 6-64

6.9 Family Planning Claim Form (Paper Billing) 6-64

6.9.1 Family Planning 2017 Claim Form 6-65

6.9.2 Family Planning 2017 Claim Form Instructions 6-66

6.10 Vision Claim Form 6-74

6.11 Remittance and Status (R&S) Report 6-76

6.11.1 R&S Report Delivery Options 6-76

6.11.2 Banner Pages 6-77

6.11.3 R&S Report Field Explanation 6-77

6.11.4 R&S Report Section Explanation 6-80

6.11.4.1 Claims - Paid or Denied 6-80

6.11.4.2 Adjustments to Claims 6-80

6.11.4.3 Financial Transactions 6-81

6.11.4.3.1 Accounts Receivable 6-81

6.11.4.3.2 IRS Levies 6-82

6.11.4.3.3 Refunds 6-82

6.11.4.3.4 Payouts 6-82

6.11.4.3.5 Reissues 6-83

6.11.4.3.6 Voids and Stops 6-83

6.11.4.4 Claims Payment Summary 6-83

6.11.4.5 The Following Claims are Being Processed 6-84

6.11.4.6 Explanation of Benefit Codes Messages 6-84

6.11.4.7 Explanation of Pending Status Codes Appendix 6-84

6.11.5 R&S Report Examples 6-84

6.11.6 Banner Page R&S Report 6-85

6.11.6.1 Paid or Denied Claims (Hospital) R&S Report 6-86

6.11.6.2 Paid or Denied Claims (Physician) R&S Report 6-87

6.11.6.3 Adjustments R&S Report 6-88

6.11.6.4 Claims in Process R&S Report 6-89

6.11.6.5 System Payouts R&S Report 6-90

6.11.6.6 Manual Payouts R&S Report 6-91

6.11.6.7 Accounts Receivables R&S Report 6-92

6.11.6.8 Void and Stop Pay R&S Report 6-93

6.11.6.9 Refunds for Medicaid R&S Report 6-94

6.11.6.10 Refunds for Managed Care R&S Report 6-95

6.11.6.11 IRS Levy R&S Report 6-96

6.11.6.12 Backup Withholding Penalty Information R&S Report 6-97

6.11.6.13 Reissues R&S Report 6-98

6.11.6.14 Sub-Owner Recoupments R&S Report 6-99

6.11.6.15 Summary R&S Report 6-100

6.11.6.16 Appendix R&S Report 6-101

6.11.7 Provider Inquiries-Status of Claims 6-102

6.12 Other Insurance Claims Filing 6-103

6.12.1 Other Insurance Credits 6-103

6.12.1.1 Deductibles 6-103

6.12.1.2 HMO Copayments 6-104

6.12.1.3 Verbal Denial 6-104

6.12.1.4 110-Day Rule 6-105

6.12.1.5 Filing Deadlines 6-105

6.12.2 Claims Forward to Other Insurance Carriers 6-106

6.13 Medicare Claims 6-107

6.13.1 Medicare Advantage Plans (MAPs) Claims 6-107

6.13.1.1 Copayments: 6-107

6.13.1.2 Coinsurance and Deductible Claims 6-107

6.13.2 Medicare/Medicaid Filing Deadlines 6-107

6.14 Filing Medicare Primary Paper Claims 6-108

6.14.1 Crossover Claim Type 30 TMHP Standardized MRAN Form 6-109

6.14.2 Crossover Claim Type 30 Instructions 6-110

6.14.3 Crossover Claim Types 31 and 50 6-113

6.14.4 Crossover Claim Types 31 and 50 Instructions 6-114

6.14.5 Filing a Medicare-Denied Claim 6-115

6.14.6 Filing a Medicare-Adjusted Claim 6-115

6.15 Medically Needy Claims Filing 6-116

6.16 Claims for Medicaid Hospice Clients Not Related to the Terminal Illness 6-116

6.16.1 Medical Services When Client is Discharged From Hospice 6-116

6.16.2 Claims Address for Medicaid Hospice Clients Not Related to the Terminal Illness 6-117

6.16.3 Lab and X-Ray 6-117

6.17 Children's Health Insurance Program (CHIP) Perinatal Claims 6-117

6.17.1 CHIP Perinatal Newborn Transfer Hospital Claims 6-117

6.18 Forms 6-118

6.1 Sample Letter XUB Computer Billing Service Inc 6-119


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