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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 6: Claims Filing : 6.4 Claims Filing Instructions : 6.4.2 Claim Form Requirements : 6.4.2.5 Multipage Claim Forms

6.4.2.5
Multipage Claim Forms
6.4.2.5.1
The approved electronic claims format is designed to list 50 line items. The total number of details allowed for a professional claim by the TMHP claims processing system (C21) is 28. If the services provided exceed 28 line items on an approved electronic claims format or 28 line items on paper claims, the provider must submit another claim for the additional line items.
The CMS‑1500 paper claim form is designed to list six line items in Block 24. If more than six line items are billed on a paper claim, a provider may attach additional forms (pages) totaling no more than 28 line items. The first page of a multipage claim must contain all the required billing information. On subsequent pages of the multipage claim, the provider should identify the client’s name, diagnosis, information required for services in Block 24, and the page number of the attachment (for example, page 2 of 3) in the top right-hand corner of the form and indicate “continued” in Block 28. The combined total charges for all pages should be listed on the last page in Block 28.
6.4.2.5.2
The total number of details allowed for an institutional claim by the TMHP claims processing system (C21) is 28. C21 merges like revenue codes together to reduce the lines to 28 or less. If the C21 merge function is unable to reduce the lines to 28 or less, the claim will be denied, and the provider will need to reduce the number of details and resubmit the claim.
An EDI approved electronic format of the UB-04 CMS-1450 is designed to list 61 lines. C21 merges like revenue codes together to reduce the lines to 28 or less.
Providers submitting electronic claims using TexMedConnect may not submit more than 28 lines. If the services exceed the 28 lines, the provider may submit another claim for the additional lines or merge codes.
The paper UB-04 CMS-1450 is designed to list 23 lines in Block 43. If services exceed the 23‑line limitation, the provider may attach additional pages. The first page of a multipage claim must contain all required billing information. On subsequent pages, the provider identifies the client’s name, diagnosis, all information required in Block 43, and the page number of the attachment (e.g., page 2 of 3) in the top right-hand corner of the form and indicate “continued” on Line 23 of Block 47. The combined total charges for all pages should be listed on the last page on Line 23 of Block 47.
Note:
When splitting a claim, all pages must contain the required information. Usually, there are logical breaks to a claim. For example, the provider may submit the surgery charges in one claim and the subsequent recovery days in the next claim.
TEFRA hospitals are required to submit all charges.
6.4.2.5.3
Medicaid present-on-admission (POA) reporting is required for all inpatient hospital claims that are paid under prospective payment basis methodology with the exception of the following facilities that Medicare exempts or are paid for by TEFRA methodology. These facilities include:
A POA value must be submitted for each diagnosis on the claim form. Claims submitted without POA are rejected unless the facility is exempt from POA reporting.
POA values are:
Diagnosis was present at the time of admission.
Payment will be made by Medicaid when a hospital acquired condition (HAC) is present.
Diagnosis was not present at the time of admission.
Documentation was insufficient.
Exempt from POA reporting.
Depending on the POA indicator value, the DRG may be recalculated, which could result in a lower payment to the hospital facility provider. If the number of days on an authorization is higher than the number of days allowed as a result of a POA DRG recalculation, the lesser of the number of days is reimbursed.

Texas Medicaid & Healthcare Partnership
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