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

   
 

6.10 Vision Claim Form

All vision services must be billed on a CMS-1500 claim form or the appropriate electronic formats. Vision claims submitted on other forms are denied with EOB 01145, "Claim form not allowed for this program."

For eyewear claims beyond program benefits, (e.g., replacing lost or destroyed eye wear), providers must have the patient sign the "Patient Certification Form" and retain in their records. Do not submit form to TMHP.

Refer to: "Vision Care Eyeglass Patient (Medicaid Client) Certification Form" in Vision and Hearing Services Handbook (Vol. 2, Provider Handbooks).

The following table shows the blocks required for vision claims on a CMS-1500 claim form.

Block No.
Description

1a

Enter the patient's nine-digit client number from the Medicaid Identification Form (H3087).

2

Enter the patient's last name, first name, and middle initial as printed on the Medicaid Identification Form (H3087).

3

Enter numerically the month, day, and year (MM/DD/YYYY) the client was born. Indicate the patient's sex by checking the appropriate box.

5

Enter the patient's complete address as described (street, city, state, and ZIP Code).

9 and 9a-9d

Other insurance or government benefits

10

Was condition related to:

a. Patient's employment

b. Auto accident

c. Other accident

11

Medicare HIC number

12

Patient's or authorized person's signature

13*

Insured or authorized person's signature

17 Name of referring physician or other source

17b NPI

Name, provider identifiers, and address of prescribing medical doctor or doctor of optometry

21

Diagnosis or nature of illness or injury

24A

DOS

24B

POS

24D

Describe procedures, medical services, or supplies furnished for each date given

24D, Line "5" for new prescription
24D, Line "6" for old prescription

Prescription/description of lenses and frames

24E

Diagnosis pointer

24F

Charges

26*

The account number for the patient that is used in the provider's office for its billing records.

27
Check "YES" or "NO"

Accept assignment

28

Total charges

29

Amount paid by other insurance

31

Signature of physician or supplier

32

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

33

Telephone number

33

Physician's or supplier's name, address, city, state, and ZIP code

No longer used

Referral from screening program (THSteps)


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