TMPPM 2010 > Volume 1, General Information > Section 6: Claims Filing > Claims Filing Instructions > Claim Form Requirements > Attachments to Claims Attachments to Claims

To expedite claims processing, providers must supply all information on the claim form itself and limit attachments to those required by TMHP or necessary to supply information to properly adjudicate the claim. The following claim form attachments are required when appropriate:

All claims for services associated with an elective sterilization must have a valid Sterilization Consent Form attached or on file at TMHP.

Nonemergency ambulance transfers must have documentation of medical necessity including out-of-locality transfers.

Providers filing for coinsurance, deductible, or both on Medicare claims to TMHP must attach the paper MRAN received from Medicare or a Medicare intermediary, the computer generated MRANs from the CMS-approved software applications MREP for professional services or PC-Print for institutional services, or the TMHP Standardized MRAN form. Providers that submit paper crossover claims must submit only one of the approved MRAN formats. Paper crossover claims submitted with multiple MRAN forms (e.g., TMHP Standardized MRAN Forms and any other MRAN) with conflicting information will not be processed and will be returned to the provider. This requirement does not apply to claims transferred automatically to TMHP from the Medicare intermediary.

Medically necessary abortions performed (on the basis of a physician's professional judgement, the life of the mother is endangered if the fetus were carried to term), or abortions provided for pregnancy related to rape or incest must have a signed and dated physician certification statement. Elective abortions are not benefits of Texas Medicaid.

Hysterectomies must have a Hysterectomy Acknowledgment Statement attached or on file at TMHP.

Refer to: Form MD.4, "Hysterectomy Acknowledgment Form" in Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

Texas Medicaid & Healthcare Partnership
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