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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2 Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.17 Inpatient Rehabilitation Facility (Freestanding) (CCP) : 2.17.4 Claims Information

Providers must submit inpatient rehabilitation services to TMHP in an approved electronic claims format or on a UB‑04 CMS‑1450 paper claim form. Providers must purchase the UB‑04 CMS‑1450 paper claim forms from the vendor of their choice. TMHP does not supply the forms.
For OT, PT, and ST services, freestanding inpatient rehabilitation facilities and acute care hospitals can use revenue codes 128, 420, 424, 430, 434, 440, and 444.
TMHP must receive claims for payment consideration according to filing deadlines for inpatient claims. Claims for services that have been prior authorized must reflect the PAN in Block 63 of the UB‑04 CMS‑1450 paper claim form or its electronic 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 6.6, “UB-04 CMS-1450 Paper Claim Filing Instructions” in Section 6, “Claims Filing” (Vol. 1, General Information) for paper claims completion instructions.
Inpatient Rehabilitation Facility (Freestanding) (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.