TMPPM 2010 > Volume 1, General Information > Section 6: Claims Filing > TMHP Electronic Claims Submission > Electronic Rejections


6.2.3 Electronic Rejections

The most common reasons for electronic professional claim rejections are:

Client information does not match. Client information does not match the patient control number (PCN) on the TMHP eligibility file. The name, date of birth, sex, and nine-digit Medicaid identification number must be an exact match with the client's identification number on TMHP's eligibility record. If using TexMedConnect, send an interactive eligibility request to obtain an exact match with TMHP's record. If not using TexMedConnect, verify through the TMHP website or call AIS at 1-800-925-9126 to verify client information. A lack of complete client eligibility information causes a rejection and possibly delayed payment. To prevent delays when submitting claims electronically:

Always include the first and last name of the client on the claim in the appropriate fields.

Always enter the client's complete, valid nine-digit Medicaid number. Valid Medicaid numbers begin with 1, 2, 3, 4, or 5. CSHCN client numbers begin with a 9.

When submitting claims for newborns, use the guidelines in the following section.

Referring/Ordering Physician field blank or invalid. The referring physician's NPI must be present when billing for consultations, laboratory, or radiology. Consult the software vendor for this field's location on the electronic claims entry form.

Performing Physician ID field blank or invalid. When the billing provider identifier is a group practice, the performing provider identifier for the physician who performed the service must be entered. Consult the software vendor for this field's location on the electronic claim form.

Facility Provider field blank or invalid. When place of service (POS) is anywhere other than home or office, the facility's provider identifier must be present. If the provider identifier is not known, enter the name and address of the facility. Consult the software vendor for this field's location on the electronic claims entry form.

Invalid Type of Service or Invalid Type of Service/Procedure code combination. In certain cases some procedure codes will require a modifier to denote the procedure's type of service (TOS).

Note: The C21 claims processing system can accept only 40 characters (including spaces) in the Comments section of electronic submissions for ambulance and dental claims. If providers include more than 40 characters in that field, C21 will accept only the first 40 characters; the other characters will not be imported into C21. Providers must ensure that all of the information that is required for the claim to process appropriately is included in the first 40 characters.

Refer to: Subsection 6.2.7, "Modifier Requirements for TOS Assignment" in this section for TMHP EDI modifier information.

Texas Medicaid & Healthcare Partnership
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