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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 5 THSteps Medical : 5.5 Claims Filing and Reimbursement : 5.5.1 Claims Information

THSteps Medical providers are not required to bill other insurance before billing Medicaid. If a provider is aware of other insurance, the provider must choose whether or not to bill the other insurance. The provider has the following options:
If the provider chooses to bill Medicaid and not the client’s other insurance, the provider is indicating that he or she accepts the Medicaid payment as payment in full. Medicaid then has the right to recovery from the other insurance. The provider does not have the right to recovery and cannot seek reimbursement from the other insurance after Medicaid has made payment.
If the provider learns that a client has other insurance coverage after Medicaid has paid a claim, the provider must refund the payment to Medicaid before billing the other insurance.
Providers should bill their usual and customary fee except for vaccines obtained from TVFC. Providers may not charge Medicaid or clients for the vaccine received from TVFC. Providers may charge a usual and customary fee not to exceed $14.85 for vaccine administration when providing immunizations to a client eligible for TVFC. Providers are reimbursed the lesser of the billed amount or the maximum allowable fee.
THSteps medical checkups may be billed electronically or on a CMS‑1500 paper claim form. Providers may purchase CMS‑1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms. Providers may request information about electronic billing or the paper claim form by contacting the TMHP THSteps Contact Center at 1‑800‑757‑5691.
All procedures, including the informational-only procedures, must have a billed amount associated with each procedure listed on the claim. Informational-only procedure codes must be billed in the amount of at least $.01.
Providers must record the following on the CMS‑1500 claim form to receive reimbursement for a medical checkup, exception to periodicity checkup, or follow-up visit:
The appropriate THSteps medical checkup procedure code (all ages) with diagnosis code Z00121 or Z00129. All immunizations must be reported with diagnosis code Z23
Refer to:
Subsection 5.3.6, “THSteps Medical Checkups” in this handbook for a listing of modifiers.
Immunizations performed outside of a THSteps medical checkup must be billed without the benefit code EP1.

Texas Medicaid & Healthcare Partnership
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