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December 2016 Texas Medicaid Provider Procedures Manual

Clinics and Other Outpatient Facility Services Handbook : 6 Renal Dialysis Facility : 6.4 Claims Filing and Reimbursement

6.4
6.4.1
Renal dialysis facility services must be submitted to TMHP in an approved electronic claims format or on a UB-04 CMS‑1450 paper claim form. Providers may purchase UB-04 CMS‑1450 paper claim forms from the vendor of their choice. TMHP does not supply them.
When completing a UB-04 CMS-1450 paper claim form, all required information must be included on the claim, as information is not keyed from attachments. Superbills, or itemized statements, are not accepted as claim supplements.
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 instructions on completing paper claims. Blocks that are not referenced are not required for processing by TMHP and may be left blank.
Reminder:
The original onset date must be included on the claim form to prevent claim denial. The original onset date must be the same date entered on Form CMS‑2728 sent to the Social Security office.

Texas Medicaid & Healthcare Partnership
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