TMPPM 2010 > Volume 1, General Information > Section 6: Claims Filing > Remittance and Status (R&S) Report > R&S Report Field Explanation

   
 

6.11.3 R&S Report Field Explanation

Patient name. Lists the client's last name and first name, as indicated on the eligibility file.

Claim number. The 24-digit Medicaid ICN for a specific claim. The format for the TMHP claim number is expanded to PPP/CCC/MMM/CCYY/JJJ/BBBBB/SSS.

Acronym
Description

PPP

Program

CCC

Claim type

MMM

Media source (region)

CCYY

Year in which the claim was received

JJJ

Julian date on which the claim was received

BBBBB

TMHP internal batch number

SSS

TMHP internal claim sequence within the batch

Program Type

PPP
Program

001

Long Term Care

100

Medicaid

200

Managed Care

300

Family Planning (Titles V, X, and XX)

400

CSHCN

999

Default/summary for all media regions

Claim Type

Claim Type
Description

020

Physician/supplier (Medicaid only) (genetics agencies, THSteps [medical only], FQHC, optometrist, optician)

021

THSteps (dental)

023

Outpatient hospital, home health, RHC, FQHC

030

Physician crossovers

031

Hospital outpatient crossovers, home health crossovers, RHC crossovers

040

Inpatient hospital

050

Inpatient crossover

055

Family Planning Title V

056

Family Planning Title X

057

Family Planning Title XX

058

Family Planning Title XIX (Form 2017)

Media Source (MMM)

Region
Description

010

Paper

011

Paper adjustment

020

TDHconnect

021

TDHconnect adjustment

030

Electronic (including TexMedConnect)

031

Electronic adjustment (including TexMedConnect)

041

AIS adjustment

051

Mass adjustment

061

Crossover adjustment

071

Retroactive eligibility adjustment

080

State Action Request

081

State Action Request adjustment

090

Phone

091

Referral Identification Monitoring System (RIMS)

100

Fax

110

Mail

120

Encounter

121

Encounter Adjustment

Medicaid #. The client's Medicaid number.

Patient Account #. If a patient account number is used on the provider's claim, it appears here.

Medical Record #. If a medical record number is used on the provider's claim, it appears here.

Medicare #. If the claim is a result of an automatic crossover from Medicare, the last ten digits of the Medicare claim number appears directly under the TMHP claim number.

Diagnosis. Primary diagnosis listed on the provider's claim.

Service Dates. Format MMDDYYYY (month, day, year) in "From" and "To" dates of service.

TOS/Proc. Indicates by code the specific service provided to the client. The one-digit TOS appears first followed by a HCPCS procedure code. A three-digit code represents a hospital accommodation or ancillary revenue code. For claims paid under prospective payment methodology, it is the code of the DRG.

Billed Quantity. Indicates the quantity billed per claim detail.

Billed Charge. Indicates the charge billed per claim detail.

Allowed Quantity. Indicates the quantity TMHP has allowed per claim detail.

Allowed Charge. Indicates the charges TMHP has allowed per claim detail. For inpatient hospital claims, the allowed amount for the DRG appears.

POS Column. The R&S Report includes the POS to the left of the Paid Amount. A one-digit numeric code identifying the POS is indicated in this column. Refer to Subsection 6.3.1.1, "Place of Service (POS) Coding" in this section for the appropriate cross-reference among the two-digit numeric POS codes (Medicare), alpha POS codes, and one-digit numeric code on the R&S Report. Providers using electronic claims submission should continue using the same POS codes.

Paid Amt. The final amount allowed for payment per claim detail. The total paid amount for the claim appears on the claim total line.

EOB Codes and Explanation of Pending Status (EOPS) Codes. These codes explain the payment or denial of the provider's claim. The EOB codes are printed next to or directly below the claim. The EOPS codes appear only in "The Following Claims Are Being Processed" section of the R&S Report. The codes explain the status of pending claims and are not an actual denial or final disposition. An explanation of all EOB and EOPS codes appearing on the R&S Report are printed in the Appendix at the end of the R&S Report. Up to five EOB codes are displayed.

Benefit. Indicates the three digit benefit code associated with the claim.

Modifier. Modifiers have been developed to describe and qualify services provided. For THSteps dental services two modifiers are printed. The first modifier is the TID and the second is the SID.

Refer to: Subsection 6.2.7, "Modifier Requirements for TOS Assignment" in this section for a list of the most commonly used modifiers.


Texas Medicaid & Healthcare Partnership
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