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December 2016 Texas Medicaid Provider Procedures Manual

Section 6: Claims Filing : 6.11 Remittance and Status (R&S) Report : 6.11.3 R&S Report Field Explanation

6.11.3
Patient name. Lists the client’s last name and first name, as indicated on the eligibility file.
Claim number. The 24‑digit Medicaid ICN for a specific claim. The format for the TMHP claim number is expanded to PPP/CCC/MMM/CCYY/JJJ/BBBBB/SSS.
 
Program Type
 
Managed Care (for carve-out services administered by TMHP and PCCM claims with dates of service before March 1, 2012)
Claim Type
 
Media Source (MMM)
 
Medicaid #. The client’s Medicaid number.
Patient Account #. If a patient account number is used on the provider’s claim, it appears here.
Medical Record #. If a medical record number is used on the provider’s claim, it appears here.
Medicare #. If the claim is a result of an automatic crossover from Medicare, the last ten digits of the Medicare claim number appears directly under the TMHP claim number.
Diagnosis. Primary diagnosis listed on the provider’s claim.
Service Dates. Format MMDDYYYY (month, day, year) in “From” and “To” dates of service.
TOS/Proc. Indicates by code the specific service provided to the client. The one-digit TOS appears first followed by a HCPCS procedure code. A three-digit code represents a hospital accommodation or ancillary revenue code. For claims paid under prospective payment methodology, it is the code of the DRG.
Billed Quantity. Indicates the quantity billed per claim detail.
Billed Charge. Indicates the charge billed per claim detail.
Allowed Quantity. Indicates the quantity TMHP has allowed per claim detail.
Allowed Charge. Indicates the charges TMHP has allowed per claim detail. For inpatient hospital claims, the allowed amount for the DRG appears.
POS Column. The R&S Report includes the POS to the left of the Paid Amount. A one-digit numeric code identifying the POS is indicated in this column. Refer to subsection 6.3.1.1, “Place of Service (POS) Coding” in this section for the appropriate cross-reference among the two-digit numeric POS codes (Medicare), and one-digit numeric code on the R&S Report. Providers using electronic claims submission should continue using the same POS codes.
Paid Amt. The final amount allowed for payment per claim detail. The total paid amount for the claim appears on the claim total line.
EOB Codes and Explanation of Pending Status (EOPS) Codes. These codes explain the payment or denial of the provider’s claim. The EOB codes are printed next to or directly below the claim. The EOPS codes appear only in “The Following Claims Are Being Processed” section of the R&S Report. The codes explain the status of pending claims and are not an actual denial or final disposition. An explanation of all EOB and EOPS codes appearing on the R&S Report are printed in the Appendix at the end of the R&S Report. Up to five EOB codes are displayed.
Total TEFRA Billed and Allowed Charges. Indicates claim details that have been denied or reduced.
Benefit. Indicates the three digit benefit code associated with the claim.
Modifier. Modifiers have been developed to describe and qualify services provided. For THSteps dental services two modifiers are printed. The first modifier is the TID and the second is the SID.

Texas Medicaid & Healthcare Partnership
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