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December 2016 Texas Medicaid Provider Procedures Manual

Section 6: Claims Filing

Section 6: Claims Filing
Table of Contents
6.1 Claims Information 5
6.1.1 TMHP Processing Procedures 5
6.1.1.1 Fiscal Agent 6
6.1.1.2 Payment Error Rate Measurement (PERM) 6
6.1.2 Claims Filing Instructions 7
6.1.2.1 Wrong Surgery Notification 8
6.1.2.2 Maximum Number of Units allowed per Claim Detail 9
6.1.2.3 Tips on Expediting Paper Claims 9
6.1.3 TMHP Paper Claims Submission 10
6.1.4 Claims Filing Deadlines 10
6.1.4.1 Claims for Clients with Retroactive Eligibility 13
6.1.4.2 Claims for Newly Enrolled Providers 14
6.1.4.3 Exceptions to the 95‑Day Filing Deadline 14
6.1.4.4 Appeal Time Limits 14
6.1.4.5 Claims with Incomplete Information and Zero Paid Claims 15
6.1.4.6 Claims Filing Reminders 15
6.1.5 HHSC Payment Deadline 15
6.1.6 Filing Deadline Calendars 16
6.2 TMHP Electronic Claims Submission 16
6.2.1 Benefit and Taxonomy Codes 16
6.2.2 Electronic Claim Acceptance 16
6.2.3 Electronic Rejections 17
6.2.3.1 Newborn Claim Hints 17
6.2.4 * TMHP EDI Batch Numbers, Julian Dates 18
6.2.5 Modifier Requirements for TOS Assignment 18
6.2.5.1 Assistant Surgery 18
6.2.5.2 Anesthesia 18
6.2.5.3 Interpretations 18
6.2.5.4 Technical Components 18
6.3 Coding 19
6.3.1 Diagnosis Coding 19
6.3.1.1 Place of Service (POS) Coding 19
6.3.2 Type of Service (TOS) 20
6.3.2.1 TOS Table 20
6.3.3 Procedure Coding 21
6.3.3.1 HCPCS Updates 22
6.3.3.1.1 Annual HCPCS 22
6.3.3.1.2 Quarterly HCPCS 22
6.3.3.1.3 Rate Hearings for New HCPCS Codes 22
6.3.4 National Drug Code (NDC) 22
6.3.4.1 Paper Claim Submissions 23
6.3.4.2 NDC Requirements for Dual Eligible Clients 24
6.3.4.3 Drug Rebate Program 24
6.3.5 Modifiers 25
6.3.6 Benefit Code 30
6.4 Claims Filing Instructions 30
6.4.1 National Correct Coding Initiative (NCCI) Guidelines 31
6.4.1.1 NCCI Processing Categories 32
6.4.1.2 CPT and HCPCS Claims Auditing Guidelines 32
6.4.2 Claim Form Requirements 34
6.4.2.1 Provider Signature on Claims 34
6.4.2.2 Group Providers 35
6.4.2.3 Supervising Physician Provider Number Required on Some Claims 35
6.4.2.4 Ordering or Referring Provider NPI 35
6.4.2.5 Prior Authorization Numbers on Claims 36
6.4.2.6 Newborn Clients Without Medicaid Numbers 36
6.4.2.7 Multipage Claim Forms 36
6.4.2.7.1 Professional Claims 36
6.4.2.7.2 Institutional Claims 37
6.4.2.7.3 Inpatient Hospital Claims 37
6.4.2.8 Attachments to Claims 38
6.4.2.9 Clients with a Designated or Primary Care Provider 38
6.5 CMS‑1500 Paper Claim Filing Instructions 38
6.5.1 CMS‑1500 Electronic Billing 40
6.5.2 CMS‑1500 Claim Form (Paper) Billing 40
6.5.3 CMS- 1500 Provider Definitions 40
6.5.4 CMS‑1500 Instruction Table 41
6.6 UB-04 CMS-1450 Paper Claim Filing Instructions 46
6.6.1 UB-04 CMS-1450 Electronic Billing 46
6.6.2 UB-04 CMS-1450 Claim Form (Paper) Billing 47
6.6.3 UB-04 CMS-1450 Instruction Table 47
6.6.4 Filing Tips for Outpatient Claims 53
6.7 2012 American Dental Association (ADA) Dental Claim Filing Instructions 54
6.7.1 2012 ADA Dental Claim Electronic Billing 54
6.7.2 ADA Dental Claim Form (Paper) Billing 54
6.7.3 2012 ADA Dental Claim Form 54
6.7.4 2012 ADA Dental Claim Form Instruction Table 54
6.8 Family Planning Claim Filing Instructions 59
6.8.1 Family Planning Electronic Billing 59
6.9 Family Planning Claim Form (Paper Billing) 59
6.9.1 2017 Claim Form 60
6.9.2 2017 Claim Form Instruction Table 60
6.10 Vision Claim Form 66
6.11 Remittance and Status (R&S) Report 68
6.11.1 R&S Report Delivery Options 68
6.11.2 Banner Pages 68
6.11.3 R&S Report Field Explanation 69
6.11.4 R&S Report Section Explanation 71
6.11.4.1 Claims – Paid or Denied 71
6.11.4.2 Adjustments to Claims 71
6.11.4.3 Financial Transactions 72
6.11.4.3.1 Accounts Receivable 72
6.11.4.3.2 IRS Levies 73
6.11.4.3.3 Refunds 73
6.11.4.3.4 Payouts 74
6.11.4.3.5 Reissues 74
6.11.4.3.6 Voids and Stops 74
6.11.4.4 Claims Payment Summary 74
6.11.4.5 The Following Claims are Being Processed 75
6.11.4.6 Explanation of Benefit Codes Messages 75
6.11.4.7 Explanation of Pending Status Codes Appendix 75
6.11.5 R&S Report Examples 75
6.11.6 Provider Inquiries—Status of Claims 76
6.12 Filing Medicare Primary Claims 77
6.12.1 Electronic Crossover Claims 77
6.12.1.1 Type of Bills Values for Medicare Crossover Claims 78
6.12.1.2 Medicare Copayments 78
6.12.1.3 Requirement for Group Billing Providers – Professional Claims 78
6.12.2 Paper Crossovers Claims 78
6.12.2.1 Deductible or Coinsurance Amount Balancing 79
6.12.2.2 TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Template 80
6.12.2.3 Crossover Paper Claims Filing Deadlines 80
6.12.3 Filing Medicare-Adjusted Claims 80
6.13 Medically Needy Claims Filing 81
6.14 Claims Filing for Consumer-Directed Services (CDS) 81
6.15 Claims Filing for Home Health Agency Services 82
6.16 Claims for Medicaid Hospice Clients Not Related to the Terminal Illness 82
6.16.1 Medical Services When Client is Discharged From Hospice 83
6.16.2 Claims Address for Medicaid Hospice Clients Not Related to the Terminal Illness 83
6.16.3 Lab and X-Ray 83
6.17 Claims for Texas Medicaid and CSHCN Services Program Eligible Clients 83
6.17.1 New Claim Submissions 83
6.17.2 CSHCN Services Program Claims Reprocessing for Retroactive Texas Medicaid Eligibility 84
6.18 Claims for State Supported Living Center Residents (SSLC) 84
6.19 Children’s Health Insurance Program (CHIP) Perinatal Claims 84
6.19.1 CHIP Perinatal Newborn Transfer Hospital Claims 85
6.20 Forms 85
 
 

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