6.4.2.8

Attachments to Claims

To expedite claims processing, providers must supply all information on the claim form itself and limit attachments to those required by TMHP or necessary to supply information to properly adjudicate the claim. The following claim form attachments are required when appropriate:

•	All claims for services associated with an elective sterilization must have a valid Sterilization Consent Form attached or on file at TMHP.

•	Nonemergency ambulance transfers must have documentation of medical necessity including out‑of‑locality transfers.

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For fee-for-service clients, providers filing to TMHP for Medicaid payment of Medicare coinsurance and deductible according to current payment guidelines must attach the paper MRAN received from Medicare or a Medicare intermediary or the computer generated MRANs from the CMS-approved software applications MREP for professional services or PC-Print for institutional services. Providers that submit paper crossover claims must submit only one of the approved MRAN formats.

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For MAP clients, providers filing to TMHP for Medicaid payment of Medicare coinsurance and deductible according to current payment guidelines must submit with the paper claim the TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Template with the MAP EOB. If the template and MAP EOB contain conflicting information, the claim will not be processed and will be returned to the provider.

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Medically necessary abortions performed (on the basis of a physician’s professional judgement, the life of the mother is endangered if the fetus were carried to term), or abortions provided for pregnancy related to rape or incest must have a signed and dated physician certification statement. Elective abortions are not benefits of Texas Medicaid.

•	Hysterectomies must have a Hysterectomy Acknowledgment Statement attached or on file at TMHP.

Refer to:

Texas Medicaid - Title XIX Acknowledgment of Hysterectomy Information on the TMHP website at www.tmhp.com.