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December 2016 Texas Medicaid Provider Procedures Manual

Section 6: Claims Filing : 6.9 Family Planning Claim Form (Paper Billing) : 6.9.2 2017 Claim Form Instruction Table

6.9.2
The instructions describe what information must be entered in each of the block numbers of the 2017 Claim Form.
 
Required (Paper)
Family Planning Program: XIX (Check this box for Title XIX family planning services and for Healthy Texas Women (HTW) program services)
XIX, DFPP, PHC, EPHC (All)
Eligibility date (DFPP, PHC, or EPHC)
Enter the date (MM/DD/CCYY) this client was designated eligible for DFPP, PHC, or EPHC services.
DSHS Client no. (Medicaid PCN if XIX)
If previous DFPP, PHC, or EPHC claims or encounters have been submitted to TMHP, enter the client’s nine-digit DSHS client number, which begins with “F.”
If the client has Title XIX Medicaid, enter the client’s nine-digit client number from the Medicaid Identification form.
If this is a new client, without Medicaid, leave this block blank and TMHP will assign a DSHS client number for the client.
Patient’s name (last name, first name, middle initial)
Enter the client’s last name, first name, and middle initial as printed on the Medicaid Identification Form, if Title XIX, or as printed in the provider’s records, if DFPP, PHC, or EPHC.
Address (street, city, state)
Enter the client’s complete home address as described by the client (street, city, and state). This reflects the location where the client lives.
County of residence
Enter the county code that corresponds to the client’s address. Please use the HHSC county codes.
Enter numerically the month, day, and year (MM/DD/CCYY) the client was born.
Indicate if this is the client’s first visit to this provider (new patient) or if this client has been to this provider previously (established patient). If the provider’s records have been purged and the client appears to be new to the provider, check “New Patient.”
Patient’s Social Security number
Enter the client’s nine-digit Social Security number (SSN). If the client does not have a SSN, or refuses to provide the number, enter 000-00-0001.
Aggregate categories used here are consistent with reporting requirements of the Office of Management and Budget Statistical Direction.
Race is independent of ethnicity and all clients should be self-categorized as White, Black or African American, American Indian or Native Alaskan, Asian, Native Hawaiian or other Pacific Islander, or Unknown or Not Reported. An “Hispanic” client must also have a race category selected.
Indicate whether the client is of Hispanic descent by entering the appropriate code number in the box.
Ethnicity is independent of race and all clients should be counted as either Hispanic or non-Hispanic. The Office of Management and Budget defines Hispanic as “a person of Mexican, Puerto Rican, Cuban, Central, or South American culture or origin, regardless of race.”
Indicate the client’s marital status by entering the appropriate marital code number in the box.
Use the gross monthly income calculated and reported on the INDIVIDUAL Eligibility Form (EF05-14215), the HOUSEHOLD Eligibility Form (EF05-14214), or the HOUSEHOLD Eligibility Worksheet (EF05-13227).
Title XIX: Enter the gross monthly income reported by the client. Be sure to include all sources of income
If income is received in a lump sum, or if it is for a period of time greater than a month (e.g., for seasonal employment), divide the total income by the number of months included in the payment period.
If income is paid weekly, multiply weekly income by 4.33. If paid every two weeks, multiply amount by 2.165. If paid twice a month, multiply by 2.
DFPP, PHC, or EPHC: Use the family size reported on the eligibility assessment tool.
Title XIX providers: Enter the number of family members supported by the income listed in Box 15. Must be at least “one.”
Enter the number of living children this client has. This also must be completed for male clients.
Primary birth control method before initial visit
Primary birth control method at end of this visit
If no method used at end of this visit, give reason (required only if #20=r)
If the primary birth control method at the end of the visit was “no method” (r), you must complete this box with an appropriate code letter from this block (a through g).
Is there other insurance available?
Other insurance name and address
Insured’s policy/group no.
Other insurance paid amount
Enter the amount paid by the other insurance company. If payment was denied, enter “Denied” in this block.
Date of notification
Enter the date of the other insurance payment or denial in this block. This must be in the format of MM/DD/CCYY.
Name of referring provider
If a non-family planning service is being billed, and the service requires a referring provider, enter the provider’s name.
XIX (if available)
If a non-family planning service is being billed and the service requires a referring provider identifier, enter the referring provider’s NPI.
Level of practitioner
Primary care or generalist physicians and specialists are correctly classified as “Physicians.”
Certified nurse-midwives, nurse practitioners, clinical nurse specialists, and physician assistants providing encounters are correctly categorized as “Midlevel.”
Encounters provided by a registered nurse or a licensed vocational nurse would be categorized as “Nurse.”
Encounters provided by staff not included in the preceding classifications would be correctly categorized as “Other.”
If a client has encounters with staff members of different categories during one visit, select the highest category of staff with whom the client interacted.
Diagnosis code (Relate Items A-L to service line 32E)
Enter the applicable ICD indicator to identify which version of ICD codes is being reported.
Enter the patient’s diagnosis and/or condition codes. List no more than 12 diagnosis codes.
Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity.
Date of occurrence
Use this section when billing for complications related to sterilizations, contraceptive implants, or intrauterine devices (IUDs). This block should contain the date (MM/DD/CCYY) of the original sterilization, implant, or IUD procedure associated with the complications currently being billed.
All, if billing complications
Enter the dates of service (DOS) for each procedure provided in a MM/DD/CCYY format. If more than one DOS is for a single procedure, each date must be given (such as 3/16, 17, 18/2010).
Medicaid does not accept multiple (to-from) dates on a single-line detail. Bill only one date per line.
The 11-digit NDC number on the package or vial from which the medication was administered. Do not enter hyphens or spaces within this number (e.g., 00409231231).
Example:
Enter the appropriate POS code for each service from the POS table in the Texas Medicaid Provider Procedures Manual. If the client is registered at a hospital, the POS must indicate inpatient or outpatient status at the time of service.
Reserved for local use
Procedures, services, or supplies CPT/HCPCS modifier
Enter the appropriate CPT or HCPCS procedure codes for all procedures/services billed.
In the shaded area, enter the NDC quantity of units administered (up to 12 digits, including the decimal point.). A decimal point must be used for fractions of a unit.
Enter the diagnosis line item reference (A-L) for each service or procedure as it relates to each ICD diagnosis code identified in Block 29.
When multiple services are performed, the primary reference number for each service should be listed first, other applicable services should follow.
Diagnosis codes must be entered in Form Field 29 only. Do not enter diagnosis codes in Form Field 32E.
Units or days (quantity)
If multiple services are performed on the same day, enter the number of services performed (such as the quantity billed).
In the shaded area, enter the NDC unit of measurement code. There are 5 allowed values: F2, GR, ML, UN or ME.
Indicate the charges for each service listed (quantity multiplied by reimbursement rate). Charges must not be higher than fees charged to private-pay clients.
Performing provider number (XIX only)-TPI
Members of a group practice (except pathology and renal dialysis groups) must identify the nine-digit TPI of the provider within the group who performed the service.
Note: To avoid unnecessary denials, DFPP, PHC, and EPHC providers should include the performing provider’s TPI on the claim. Although not required for DFPP, PHC, and EPHC claims, if a claim or encounter that was submitted through DFPP, PHC, or EPHC is later determined eligible to be paid under Title XIX, the claim will be denied if the performing provider information is missing.
Performing provider number (XIX only)-NPI
Optional: Members of a group practice (except pathology and renal dialysis groups) must identify NPI of the provider within the group who performed the service.
Note: To avoid unnecessary denials, DFPP, PHC, and EPHC providers should include the performing provider’s NPI on the claim. Although not required for DFPP, PHC, and EPHC claims, if a claim or encounter that was submitted through DFPP, PHC, or EPHC is later determined eligible to be paid under Title XIX, the claim will be denied if the performing provider information is missing.
Federal tax ID number/EIN (optional)
Enter the federal TIN (Employer Identification Number [EIN]) that is associated with the provider identifier enrolled with TMHP.
Note: To avoid unnecessary denials, PHC and EPHC providers should include the federal tax ID on the claim. Although not required for PHC and EPHC claims, if a claim or encounter that was submitted through PHC or EPHC is later determined eligible to be paid under Title XIX, the claim will be denied if the tax ID information is missing.
Patient’s account number (optional)
Enter the client’s account number that is used in the provider’s office for its payment records.
Patient copay assessed (DFPP, PHC, or EPHC)
If the client was assessed a copayment (DFPP, PHC, or EPHC), enter the dollar amount assessed.
If no copay was assessed, enter $0.00. Copay cannot be assessed for Title XIX clients.
Copayment must not exceed $30.00 for DFPP patients or $40.00 for PHC or EPHC patients.
Enter the total of separate charges for each page of the claim. Enter the total of all pages on last claim if filing a multipage claim.
Signature of physician or supplier
The physician/supplier or an authorized representative must sign and date the claim. Billing services may print “Signature on file” in place of the provider’s signature if the billing service obtains and retains on file a letter signed and dated by the provider authorizing this practice.
When providers enroll to be an electronic biller, the “Signature on file” requirement is satisfied during the enrollment process.
Name and address of facility where services were rendered (if other than home or office)
If the services were provided in a place other than the client’s home or the provider’s facility, enter name, address, and ZIP Code, of the facility (such as the hospital or birthing center) where the service was provided.
Independently practicing health-care professionals must enter the name and number of the school district/cooperative where the child is enrolled (SHARS).
For laboratory specimens sent to an outside laboratory for additional testing, the complete name and address of the outside laboratory should be entered. The laboratory should bill Texas Medicaid for the services performed.
Enter the NPI of the provider where services were rendered (if other than home or office).
Physician’s, supplier’s billing name, address, ZIP Code, and telephone number

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.