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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2 Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.9 Medical Nutrition Counseling Services (CCP) : 2.9.4 Claims Information

Providers must submit services provided by licensed dietitians in an approved electronic claims format or on a CMS‑1500 paper claim form from the vendor of their choice. TMHP does not supply the forms.
Claims for services that have been prior authorized must reflect the PAN in Block 23 of the CMS‑1500 paper claim form or its equivalent.
Refer to:
Section 3: TMHP Electronic Data Interchange (EDI) (Vol. 1, General Information) for information on electronic claims submissions.
Section 6: Claims Filing (Vol. 1, General Information) for general information about claims filing.
Subsection 6.5, “CMS‑1500 Paper Claim Filing Instructions” in Section 6, Claims Filing (Vol. 1, General Information) for instructions on completing paper claims.
Medical Nutrition Counseling (CCP Only) on the TMHP website at for a claim form example.

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