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2012 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 4. Texas Health Steps (THSteps) Dental : 4.5 Claims Filing and Reimbursement : 4.5.4 Claims Information

4.5.4
Dental services must be submitted to TMHP in an approved electronic format or on the ADA Dental Claim Form. Providers may purchase ADA Dental claim forms from the vendor of their choice. TMHP does not supply the forms. A sample of the ADA Dental Claim form can be found on the ADA website at www.ada.org/7119.aspx.
When completing an ADA Dental claim form, all required information must be included on the claim, as TMHP does not key information from attachments. Superbills, or itemized statements, are not accepted as claim supplements.
All THSteps and ICF-MR claims must be received by TMHP within 95 days from each DOS and submitted to the following address:
Texas Medicaid & Healthcare Partnership
PO Box 200555
Austin, TX 78720-0555
Claims for emergency, orthodontic, or routine dental services must each be filed on separate forms. A claim submitted for either emergency or orthodontic services must be identified as such in Block 35 (Remarks) of the claim form.
A THSteps and ICF-MR dental provider cannot submit claims to Texas Medicaid under his individual performing provider identifier for the services provided by one or more associate dentists practicing in his office as employees or independent contractors with specific employer-employee or contractual relationships. All dentists providing services to Medicaid clients must enroll as THSteps dental providers regardless of employer relationships. The individual provider submitting claims may be reimbursed into a single accounting office to maintain these described relationships.
Claims submitted by newly-enrolled providers must be received within 95 days of the date the new provider identifier is issued, and within 365 days of the DOS.
Providers should submit claims to Texas Medicaid for their usual and customary fees.
Claims for dental services provided to children in foster care must be filed with Delta Dental, the dental claims processor for Superior HealthPlan.
Refer to:
Claims must not be submitted to Texas Medicaid for appointments missed by clients. A client with Medicaid cannot be billed for failure to keep an appointment. Only claims for actual services rendered are considered for payment.
Refer to:
Section 3: TMHP Electronic Data Interchange (EDI) (Vol. 1, General Information) for information on electronic claims submissions.
Section 6: Claims Filing (Vol. 1, General Information).
Subsection 1.5.9, “Billing Clients” in Section 1, “Provider Enrollment and Responsibilities” (Vol. 1, General Information).

Texas Medicaid & Healthcare Partnership
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