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2012 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 5. THSteps Medical : 5.5 Claims Filing and Reimbursement : 5.5.1 Claims Information

5.5.1
THSteps providers do not have to bill private insurance for a medical checkup; they can bill TMHP directly even if they know that the client has private insurance. For THSteps medical checkups, TMHP is responsible for determining whether a third party resource (TPR) exists and for seeking payment from the TPR.
Providers should bill their usual and customary fee except for vaccines obtained from TVFC. Providers may not charge Medicaid or clients for the vaccine received from TVFC. Providers may charge a usual and customary fee not to exceed $14.85 for vaccine administration when providing immunizations to a client eligible for TVFC. Providers are reimbursed the lesser of the billed amount or the maximum allowable fee.
THSteps medical checkups may be billed electronically or on a CMS‑1500 paper claim form. Providers may purchase CMS‑1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms. Providers may request information about electronic billing or the paper claim form by contacting the TMHP THSteps Contact Center at 1‑800‑757‑5691.
All procedures, including the informational-only procedures, must have a billed amount associated with each procedure listed on the claim. Informational-only procedure codes must be billed in the amount of at least $.01.
Providers must record the following on the CMS‑1500 claim form to receive reimbursement for a medical checkup:
Immunizations performed outside of a THSteps medical checkup must be billed under the provider's provider identifier.

Texas Medicaid & Healthcare Partnership
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