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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 6: Claims Filing

Section 6: Claims Filing
6.1 Claims Information 6-5
6.1.1 TMHP Processing Procedures 6-5
6.1.1.1 Fiscal Agent 6-6
6.1.1.2 Payment Error Rate Measurement (PERM) 6-6
6.1.2 Claims Filing Instructions 6-7
6.1.2.1 Wrong Surgery Notification 6-8
6.1.2.2 Maximum Number of Units allowed per Claim Detail 6-9
6.1.2.3 Tips on Expediting Paper Claims 6-9
6.1.3 TMHP Paper Claims Submission 6-10
6.1.4 Claims Filing Deadlines 6-10
6.1.4.1 Claims for Clients with Retroactive Eligibility 6-13
6.1.4.2 Exceptions to the 95‑Day Filing Deadline 6-13
6.1.4.3 Appeal Time Limits 6-14
6.1.4.4 Claims with Incomplete Information and Zero Paid Claims 6-14
6.1.4.5 Claims Filing Reminders 6-14
6.1.5 HHSC Payment Deadline 6-15
6.1.5.1 Filing Deadline Calendar for 2012 6-16
6.1.5.2 Filing Deadline Calendar for 2013 6-17
6.2 TMHP Electronic Claims Submission 6-18
6.2.1 Benefit and Taxonomy Codes 6-18
6.2.2 Electronic Claim Acceptance 6-18
6.2.3 Electronic Rejections 6-18
6.2.3.1 Newborn Claim Hints 6-19
6.2.4 TMHP EDI Batch Numbers, Julian Dates 6-20
6.2.5 Modifier Requirements for TOS Assignment 6-20
6.2.5.1 Assistant Surgery 6-20
6.2.5.2 Anesthesia 6-20
6.2.5.3 Interpretations 6-20
6.2.5.4 Technical Components 6-20
6.2.6 Preferred Provider Organization (PPO) 6-21
6.3 Coding 6-21
6.3.1 Diagnosis Coding 6-21
6.3.1.1 Place of Service (POS) Coding 6-22
6.3.2 Type of Service (TOS) 6-23
6.3.2.1 TOS Table 6-23
6.3.3 Procedure Coding 6-24
6.3.3.1 Level I 6-24
6.3.3.2 Level II 6-25
6.3.3.3 Rate Hearings 6-25
6.3.4 National Drug Code (NDC) 6-26
6.3.5 Modifiers 6-27
6.3.6 Benefit Code 6-31
6.4 Claims Filing Instructions 6-32
6.4.1 National Correct Coding Initiative (NCCI) Guidelines 6-32
6.4.1.1 NCCI Processing Categories 6-33
6.4.1.2 CPT and HCPCS Claims Auditing Guidelines 6-34
6.4.2 Claim Form Requirements 6-36
6.4.2.1 Provider Signature on Claims 6-36
6.4.2.2 Group Providers 6-36
6.4.2.3 Prior Authorization Numbers on Claims 6-37
6.4.2.4 Newborn Clients Without Medicaid Numbers 6-37
6.4.2.5 Multipage Claim Forms 6-37
6.4.2.5.1 Professional Claims 6-37
6.4.2.5.2 Institutional Claims 6-37
6.4.2.5.3 Inpatient Hospital Claims 6-38
6.4.2.6 Attachments to Claims 6-39
6.4.2.7 Clients with a Designated or Primary Care Provider 6-39
6.5 CMS‑1500 Paper Claim Filing Instructions 6-39
6.5.1 CMS‑1500 Electronic Billing 6-40
6.5.2 CMS‑1500 Claim Form (Paper) Billing 6-41
6.5.3 CMS‑1500 Blank Paper Claim Form 6-42
6.5.4 CMS- 1500 Provider Definitions 6-43
6.5.5 CMS‑1500 Instruction Table 6-44
6.6 UB-04 CMS-1450 Paper Claim Filing Instructions 6-48
6.6.1 UB-04 CMS-1450 Electronic Billing 6-49
6.6.2 UB-04 CMS-1450 Claim Form (Paper) Billing 6-49
6.6.3 UB-04 CMS-1450 Blank Paper Claim Form 6-50
6.6.4 UB-04 CMS-1450 Instruction Table 6-51
6.6.5 Occurrence Codes 6-56
6.6.6 Patient Status Codes 6-58
6.6.7 Filing Tips for Outpatient Claims 6-59
6.7 2006 American Dental Association (ADA) Dental Claim Filing Instructions 6-59
6.7.1 2006 ADA Dental Claim Electronic Billing 6-59
6.7.2 ADA Dental Claim Form (Paper) Billing 6-59
6.7.3 2006 ADA Dental Claim Form 6-60
6.7.4 2006 ADA Dental Claim Form Instruction Table 6-60
6.8 Family Planning Claim Filing Instructions 6-64
6.8.1 Family Planning Electronic Billing 6-64
6.9 Family Planning Claim Form (Paper Billing) 6-64
6.9.1 Family Planning 2017 Claim Form 6-65
6.9.2 Family Planning 2017 Claim Form Instructions 6-66
6.10 Vision Claim Form 6-72
6.11 Remittance and Status (R&S) Report 6-74
6.11.1 R&S Report Delivery Options 6-74
6.11.2 Banner Pages 6-74
6.11.3 R&S Report Field Explanation 6-75
6.11.4 R&S Report Section Explanation 6-77
6.11.4.1 Claims – Paid or Denied 6-77
6.11.4.2 Adjustments to Claims 6-77
6.11.4.3 Financial Transactions 6-78
6.11.4.3.1 Accounts Receivable 6-78
6.11.4.3.2 IRS Levies 6-79
6.11.4.3.3 Refunds 6-79
6.11.4.3.4 Payouts 6-80
6.11.4.3.5 Reissues 6-80
6.11.4.3.6 Voids and Stops 6-80
6.11.4.4 Claims Payment Summary 6-80
6.11.4.5 The Following Claims are Being Processed 6-81
6.11.4.6 Explanation of Benefit Codes Messages 6-81
6.11.4.7 Explanation of Pending Status Codes Appendix 6-81
6.11.5 R&S Report Examples 6-81
6.11.6 Banner Page R&S Report 6-82
6.11.6.1 Paid or Denied Claims (Hospital) R&S Report 6-83
6.11.6.2 Paid or Denied Claims (Physician) R&S Report 6-84
6.11.6.3 Adjustments R&S Report 6-85
6.11.6.4 Claims in Process R&S Report 6-86
6.11.6.5 System Payouts R&S Report 6-87
6.11.6.6 Manual Payouts R&S Report 6-88
6.11.6.7 Accounts Receivables R&S Report 6-89
6.11.6.8 Void and Stop Pay R&S Report 6-90
6.11.6.9 Refunds for Medicaid R&S Report 6-91
6.11.6.10 Refunds for Managed Care R&S Report 6-92
6.11.6.11 IRS Levy R&S Report 6-93
6.11.6.12 Backup Withholding Penalty Information R&S Report 6-94
6.11.6.13 Reissues R&S Report 6-95
6.11.6.14 Sub-Owner Recoupments R&S Report 6-96
6.11.6.15 Summary R&S Report 6-97
6.11.6.16 Appendix R&S Report 6-98
6.11.7 Provider Inquiries—Status of Claims 6-99
6.12 Other Insurance Claims Filing 6-100
6.12.1 Unbundled Services That Are Prior Authorized and Manually Priced
Procedure Codes 6-100
6.12.2 Other Insurance Credits 6-101
6.12.2.1 Deductibles 6-101
6.12.2.2 Managed Care Organization (MCO) Copayments 6-101
6.12.2.3 Verbal Denial 6-102
6.12.2.4 110‑Day Rule 6-102
6.12.2.5 Filing Deadlines 6-103
6.12.3 Claims Forwarded to Other Insurance Carriers 6-103
6.13 Medicare Claims 6-104
6.13.1 Coinsurance and Deductible Payment Exceptions 6-104
6.13.2 Medicare Claims Filing 6-105
6.13.3 Medicare and Medicaid Assignment and Payments 6-105
6.13.4 Electronic Crossover Claims 6-105
6.13.4.1 Requirement for Group Billing Providers – Professional Claims 6-105
6.13.5 Paper Crossovers 6-105
6.13.5.1 TMHP Standardized Medicare and MAP Remittance Advice Notice Form 6-106
6.13.5.2 Crossover Claims Filing Deadlines 6-107
6.13.5.3 Filing a Medicare-Adjusted Claim 6-107
6.14 Filing Medicare Primary Paper Claims 6-107
6.14.1 Crossover Claim Type 30 TMHP Standardized MRAN Form 6-108
6.14.2 Crossover Claim Type 30 Instructions 6-109
6.14.3 Crossover Claim Type 31 6-111
6.14.4 Crossover Claim Type 31 Instructions 6-112
6.14.5 Crossover Claim Type 50 6-114
6.14.6 Crossover Claim Type 50 Instructions 6-115
6.15 Medically Needy Claims Filing 6-116
6.16 Claims Filing for Consumer-Directed Services (CDS) 6-116
6.17 Claims for Medicaid Hospice Clients Not Related to the Terminal Illness 6-117
6.17.1 Medical Services When Client is Discharged From Hospice 6-117
6.17.2 Claims Address for Medicaid Hospice Clients Not Related to the Terminal Illness 6-117
6.17.3 Lab and X-Ray 6-117
6.18 Claims for Texas Medicaid and CSHCN Services Program Eligible Clients 6-118
6.18.1 New Claim Submissions 6-118
6.18.2 CSHCN Services Program Claims Reprocessing for Retroactive Texas
Medicaid Eligibility 6-118
6.19 Claims for State Supported Living Center Residents (SSLC) 6-118
6.20 Children’s Health Insurance Program (CHIP) Perinatal Claims 6-118
6.20.1 CHIP Perinatal Newborn Transfer Hospital Claims 6-119
6.21 Forms 6-119
6.1 Sample Letter XUB Computer Billing Service Inc 6-120

Texas Medicaid & Healthcare Partnership
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