TMPPM 2010 > Volume 1, General Information > Section 6: Claims Filing > Family Planning Claim Form (Paper Billing) > Family Planning 2017 Claim Form Instructions

   
 

6.9.1 Family Planning 2017 Claim Form

6.9.2 Family Planning 2017 Claim Form Instructions

Block No.
Description
Guidelines
Required

1

Family planning program

Check the box for the specific entitlement funds to which these family planning services are billed.
If the facility also receives Title X funds, the Level of Practitioner (28) must be indicated.

Note: Claims/Encounters will be cross-checked with Title XIX Medicaid eligibility before Title V, X, or XX processing.

V, XIX, XX

1a

Title X only

If it is a "Title X Only" encounter, the level of payment must be indicated.

If the facility also receives Title X funds, the level of practitioner (28) must be indicated.

X

2a

Billing provider TPI

Enter the billing provider's nine-digit TPI.

V, X, XIX, XX

2b

Billing provider NPI

Enter the billing provider's NPI.

V, X, XIX, XX

3

Provider name

Enter the provider's name as enrolled with TMHP.

V, X, XIX, XX

4

Eligibility date (V or XX)

Enter the date (MM/DD/CCYY) this client was originally designated eligible for Title V or XX services. If client has V or XX eligibility from a previous visit, enter that eligibility date.

For a Title XX client, this information comes from the 2025 claim form.

For a Title V client, this information comes from the Texas Eligibility Screening System (TESS).

V, XX

5

Family planning no. (Medicaid PCN if XIX)

If previous V, X, or XX claims or encounters have been submitted to TMHP, enter the client's nine-digit family planning number, which begins with "F."

If the client has Title XIX Medicaid, enter the client's nine-digit client number from the Medicaid Identification form.

If this is a new family planning client, without Medicaid, leave this block blank and TMHP will assign a family planning number for the client.

XIX

6

Patient's name (last name, first name, middle initial)

Enter the client's last name, first name, and middle initial as printed on the Medicaid Identification Form, if Title XIX, or as printed in the provider's records, if Title V, X, or XX.

V, X, XIX, XX

7

Address (street, city, state)

Enter the client's complete home address as described by the client (street, city, and state). This reflects the location where the client lives.

V, X, XIX, XX

7a

ZIP Code

Enter the client's ZIP Code.

V, X, XIX, XX

8

County of residence

Enter the county code that corresponds to the client's address. Please use the HHSC county codes.

V, X, XIX, XX

9

Date of birth

Enter numerically the month, day, and year (MM/DD/CCYY) the client was born.

V, X, XIX, XX

10

Sex

Indicate the client's gender by checking the appropriate box.

V, X, XIX, XX

11

Patient status

Indicate if this is the client's first visit to this family planning provider (new patient) or if this client has been to this family planning provider previously (established patient). If the provider's records have been purged and the client appears to be new to the provider, check "New Patient."

V, X, XIX, XX

12

Patient's Social Security number

Enter the client's nine-digit Social Security number (SSN). If the client does not have a SSN, or refuses to provide the number, enter 000-00-0001.

V, X, XIX, XX

13

Race (code #)

Indicate the client's race by entering the appropriate race code number in the box.

Aggregate categories used here are consistent with reporting requirements of the Office of Management and Budget Statistical Direction.

Race is independent of ethnicity and all clients should be self-categorized as White, Black or African American, American Indian or Native Alaskan, Asian, Native Hawaiian or other Pacific Islander, or Unknown or Not Reported. An "Hispanic" client must also have a race category selected.

V, X, XIX, XX

13a

Ethnicity

Indicate whether the client is of Hispanic descent by entering the appropriate code number in the box.

Ethnicity is independent of race and all clients should be counted as either Hispanic or non-Hispanic. The Office of Management and Budget defines Hispanic as "a person of Mexican, Puerto Rican, Cuban, Central, or South American culture or origin, regardless of race."

V, X, XIX, XX

14

Marital status

Indicate the client's marital status by entering the appropriate marital code number in the box.

V, X, XIX, XX

15

Family income (all)

Titles V, XX, XX: Use the gross monthly income calculated and reported on the eligibility assessment tool.

Title XIX providers: Enter the gross monthly income reported by the client. Be sure to include all sources of income. No documentation of income is required.

For clients who are married (including common-law marriages) or who are 20 years of age or older, enter the gross monthly income of all family members.

For unmarried clients age 19 years or younger, enter the gross monthly income of the client only, not the income of all family members.

To calculate gross monthly income for Title XIX:

If income is received in a lump sum, or if it is for a period of time greater than a month (e.g., for seasonal employment), divide the total income by the number of months included in the payment period.

If income is paid weekly, multiply weekly income by 4.33. If paid every two weeks, multiply amount by 2.165. If paid twice a month, multiply by 2.

Enter $1.00 for clients not wishing to reveal income information.

V, X, XIX, XX

15a

Family size

Titles V, X, XX: Use the family size reported on the eligibility assessment tool.

Title XIX providers: Enter the number of family members supported by the income listed in Box 15. Must be at least "one."

V, X, XIX, XX

16

Number times pregnant

Enter the number of times this client has been pregnant. If male, enter zero.

V, X, XIX, XX

17

Number live births

Enter the number of live births for this client. If male, enter zero.

V, X, XIX, XX

18

Number living children

Enter the number of living children this client has. This also must be completed for male clients.

V, X, XIX, XX

19

Primary birth control method before initial visit

Enter the appropriate code letter (a through r) in the box.

V, X, XIX, XX

20

Primary birth control method at end of this visit

Enter the appropriate code letter (a through r) in the box.

V, X, XIX, XX

21

If no method used at end of this visit, give reason (required only if #20=r)

If the primary birth control method at the end of the visit was "no method" (r), you must complete this box with an appropriate code letter from this block (a through g).

V, X, XIX, XX (only if #20=r)

22

Is there other insurance available?

Check the appropriate box.

 

23

Other insurance name and address

Enter the name and address of the health insurance carrier.

 

24a

Insured's policy/group no.

Enter the insurance policy number or group number.

 

24b

Benefit code

Benefit code, if applicable for the billing or performing provider.

 

25

Other insurance paid amount

Enter the amount paid by the other insurance company. If payment was denied, enter "Denied" in this block.

 

25a

Date of notification

Enter the date of the other insurance payment or denial in this block. This must be in the format of MM/DD/CCYY.

 

26

Name of referring provider

If a non-family planning service is being billed, and the service requires a referring provider, enter the provider's name.

XIX

27b

Referring NPI

If a non-family planning service is being billed and the service requires a referring provider identifier, enter the referring provider's NPI.

XIX

28

Level of practitioner

Enter the level of practitioner that performed the service. Primary care or generalist physicians and specialists are correctly classified as "Physicians." Certified nurse-midwives, nurse practitioners, clinical nurse specialists, and physician assistants providing family planning encounters are correctly categorized as "Midlevel." Family planning encounters provided by a registered nurse or a licensed vocational nurse would be categorized as "Nurse." Encounters provided by staff not included in the preceding classifications would be correctly categorized as "Other." If a client has encounters with staff members of different categories during one visit, select the highest category of staff with whom the client interacted.

Optional for agencies not receiving any Title X funding.

X

29

Diagnosis code (relate items 1, 2, 3, or 4 to item 32D by line # in 32E)

Enter the ICD-9-CM diagnosis code to the highest level of specificity available; complete to five digits for each diagnosis observed.

V, X, XIX, XX

30

Authorization number

Enter the authorization number for the client, if appropriate.

 

31

Date of occurrence

Use this section when billing for complications related to sterilizations, contraceptive implants, or intrauterine devices (IUDs). This block should contain the date (MM/DD/CCYY) of the original sterilization, implant, or IUD procedure associated with the complications currently being billed.

V, X, XIX, XX, if billing complications

32A

Dates of service

Enter the dates of service for each procedure provided in a MM/DD/CCYY format. If more than one DOS is for a single procedure, each date must be given (such as 3/16, 17, 18/2010).

Electronic Billers

Medicaid does not accept multiple (to-from) dates on a single-line detail. Bill only one date per line.

NDC

In the shaded area, enter the NDC qualifier of N4 and the 11-digit NDC number (number on packaged or container from which the medication was administered).

Do not enter hyphens or spaces within this number.

Example: N400409231231

Refer to: Subsection 6.3.4, "National Drug Code (NDC)" in this section.

V, X, XIX, XX

32B

Place of service

Enter the appropriate POS code for each service from the POS table under subsection 6.3.1.1, "Place of Service (POS) Coding" in this section. If the client is registered at a hospital, the POS must indicate inpatient or outpatient status at the time of service.

V, X, XIX, XX

32C

Reserved for local use

Leave this block blank.

Note: TOS codes are no longer required for claims submission.

 

32D

Procedures, services, or supplies CPT/HCPCS modifier

Enter the appropriate CPT or HCPCS procedure codes for all procedures/services billed using the family planning services listed in Section 3, "Medicaid Title XIX family planning services" in Gynecological and Reproductive Health, Obstetrics, and Family Planning Services Handbook (Vol. 2, Provider Handbooks).

NDC

Optional: In the shaded area, enter a 1- through 12-digit NDC quantity of unit.

A decimal point must be used for fractions of a unit.

Refer to: Subsection 6.3.4, "National Drug Code (NDC)" in this section.

V, X, XIX, XX

32E

Dx. ref. (29)

Enter the diagnosis line item reference (1, 2, 3, or 4) for each service or procedure as it relates to each ICD-9-CM diagnosis code identified in Block 29. If a procedure is related to more than one diagnosis, the primary diagnosis the procedure is related to must be the one identified. Do not enter more than one reference per procedure.

V, X, XIX, XX

32F

Units or days (quantity)

If multiple services are performed on the same day, enter the number of services performed (such as the quantity billed).

NDC

Optional: In the shaded area, enter the NDC unit of measurement code.

Refer to: Subsection 6.3.4, "National Drug Code (NDC)" in this section.

V, X, XIX, XX

No. of participants (teen counseling)

For Teen Group Counseling, enter the total number of participants included in the teen group counseling session. Required for Title XX, Teen Group Counseling claims.

No. of participants is required for Title XX teen group counseling

32G

$ Charges

Indicate the charges for each service listed (quantity times reimbursement rate). Charges must not be higher than fees charged to private-pay clients. Approved rate tables can be found in Section 3, "Medicaid Title XIX family planning services" in Gynecological and Reproductive Health, Obstetrics, and Family Planning Services Handbook (Vol. 2, Provider Handbooks).

V, X, XIX, XX

32H (a)

Performing provider number (XIX only)-TPI

Members of a group practice (except pathology and renal dialysis groups) must identify the nine-digit TPI of the doctor/clinic within the group who performed the service.

Note: It is recommended that providers complete this block for Titles V, X, and XX when the procedure code that is entered would normally require a performing provider identifier, if it were billed under Title XIX. If a claim or encounter that was submitted for V, X, or XX is later determined as eligible to be paid from Title XIX and the performing provider identifier is missing, the claim will be denied with a request for this information. To avoid unnecessary claim or encounter denial, complete this information for all claims and encounters.

XIX

32H (b)

Performing provider number (XIX only)-NPI

Optional: Members of a group practice (except pathology and renal dialysis groups) must identify NPI of the doctor/clinic within the group who performed the service.

Note: It is recommended that providers complete this block for Titles V, X, and XX when the procedure code that is entered would normally require a performing provider identifier, if it were billed under Title XIX. If a claim or encounter that was submitted for V, X, or XX is later determined as eligible to be paid from Title XIX and the performing provider identifier is missing, the claim will be denied with a request for this information. To avoid unnecessary claim or encounter denial, complete this information for all claims and encounters.

XIX

33

Federal tax ID number/EIN (optional)

Enter the federal TIN (Employer Identification Number [EIN]) that is associated with the provider identifier enrolled with TMHP.

 

34

Patient's account number (optional)

Enter the client's account number that is used in the provider's office for its payment records.

 

35

Patient copay assessed

If the client was assessed a copayment (V, X, or XX), enter the dollar amount assessed.

If no copay was assessed, enter $0.00. Copay cannot be assessed for Title XIX clients.

Copayment must not exceed 25 percent of total charges for Title V or XX patients.

V, X, XX

36

Total charges

Enter the total of separate charges for each page of the claim. Enter the total of all pages on last claim if filing a multipage claim.

V, X, XIX, XX

37

Signature of physician or supplier

The physician/supplier or an authorized representative must sign and date the claim. Billing services may print "Signature on file" in place of the provider's signature if the billing service obtains and retains on file a letter signed and dated by the provider authorizing this practice.

When providers enroll to be an electronic biller, the "Signature on file" requirement is satisfied during the enrollment process.

V, X, XIX, XX

38

Name and address of facility where services were rendered (if other than home or office)

If the services were provided in a place other than the client's home or the provider's facility, enter name, address, and ZIP Code, of the facility (such as the hospital or birthing center) where the service was provided.

Independently practicing health-care professionals must enter the name and number of the school district/cooperative where the child is enrolled (SHARS/ECI).

For laboratory specimens sent to an outside laboratory for additional testing, the complete name and address of the outside laboratory should be entered. The laboratory should bill Texas Medicaid for the services performed.

XIX

38a

NPI

Enter the NPI of the provider where services were rendered (if other than home or office).

XIX

39

Physician's, supplier's billing name, address, ZIP Code, and telephone number

Enter the billing provider name, street, city, state, ZIP Code, and telephone number.

 

Teen group counseling

Providers billing Teen Group Counseling must complete the following blocks:

1. Family Planning program-should be Title XX

2. (a-b) Provider numbers/provider identifiers

3. Provider name

5. Family planning No.-Enter 999999999
(electronic billers, enter 999999999 in the Medicaid No. block)

6. Patient's name-Enter "teen group counseling"

12. Patient's Social Security number-should be
999-99-9999

29. Diagnosis code-use V2509

32A. Dates of service

32B. Place of service

32D. Procedures, services, or supplies; CPT/HCPCS modifier

32E. Dx. ref. (29)

32F. No. of participants

32G. $ Charges

33. Federal Tax ID Number/EIN

36. Total charges

37. Signature of physician or supplier

XX-teen group counseling only


Texas Medicaid & Healthcare Partnership
CPT only copyright 2009 American Medical Association. All rights reserved.
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