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December 2016 Texas Medicaid Provider Procedures Manual

Section 6: Claims Filing : 6.12 Filing Medicare Primary Claims : 6.12.2 Paper Crossovers Claims : 6.12.2.2 TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Template

6.12.2.2
The TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Template must be submitted for paper MAP claims only. The template must be submitted with the claim form and the MAP EOB.
Note:
The following guidelines apply for the submission of the TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Templates:
For the TMHP Crossover Professional Claim Type 30 form, the performing provider NPI and TPI must be submitted on each detail line item. A detail line item is denied if the performing provider NPI or TPI is omitted, if the performing provider NPI is not associated with the TPI according to the performing provider’s enrollment information, or if the performing provider is not a member of the group billing provider.
The TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Template must be submitted with a completed claim form and MAP EOB, must be legible, and must identify only one client per page. Providers must not submit handwritten MAP templates.
Claims that do not meet these standards are not processed and are returned to the provider.
By submitting the TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Templates to TMHP, the provider attests that the information included in the template matches the EOB that was received from the MAP. If the information on the template does not exactly match the information on the RA or RN, the claim may be denied.
Refer to:
subsection 6.20, “Forms” in this section for the TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Templates and instructions.
Subsection 2.7, “Medicare Crossover Claim Reimbursement” in “Section 2: Texas Medicaid Fee‑for‑Service Reimbursement” (Vol. 1, General Information).

Texas Medicaid & Healthcare Partnership
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