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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 6: Claims Filing : 6.13 Medicare Claims : 6.13.5 Paper Crossovers : TMHP Standardized Medicare and MAP Remittance Advice Notice Form
Providers that receive any of the following Medicare RAs or RNs from Medicare or a Medicare intermediary are not required to submit the MRAN/MAP template to TMHP:
Providers that cannot retrieve the Medicare RA/RN from MREP or PC-Print, or who don't receive a paper Medicare RA/RN from Medicare or a Medicare intermediary, must submit the TMHP MRAN/MAP template.
Providers that submit paper crossover claims must submit only one of the following approved Medicare RA/RN formats along with a completed claim form:
Paper crossover claims that contain multiple Medicare RA/RN forms with conflicting information are returned to the provider or denied.
The following guidelines apply for the submission of the MRAN/MAP templates:
For the TMHP Crossover Professional Claim Type 30 form, the performing provider NPI and TPI must be submitted on each detail line item. A detail line item will be denied if the performing provider NPI or TPI is omitted, if the performing provider NPI is not associated with the TPI according to the performing provider’s enrollment information, or if the performing provider is not a member of the group billing provider.
The MRAN/MAP template must be submitted with a completed claim form, must be legible, and must identify only one client per page. Providers must not submit handwritten MRAN/MAP templates.
Claims that do not meet these standards will not be processed and will be returned to the provider.
By submitting the MRAN/MAP templates to TMHP, the provider attests that the information included in the form matches the Medicare RA or RN that was received from Medicare or the MAP. If the information on the crossover claim type form does not exactly match the information on the RA or RN, the claim may be denied.
Refer to:
Subsection 6.21, “Forms” in this section, for the MRAN/MAP templates and instructions.
Subsection 2.6, “Medicare Crossover Claim Reimbursement”in Section 2, “Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information).

Texas Medicaid & Healthcare Partnership
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