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December 2016 Texas Medicaid Provider Procedures Manual

Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook : 2 Medicaid Title XIX Family Planning Services : 2.4 Claims Filing and Reimbursement

2.4
2.4.1
Providers may use the following claim forms to submit claims to TMHP:
 
All family planning services provided by physicians, PAs, NPs, CNSs, CNMs, and family planning agencies who also contract with HHSC
2017 claim form, CMS-1500 claim form, or approved electronic format of either form
UB-04 CMS-1450, 2017 claim form, or approved electronic format of either form
The following applies when filing claims:
Family planning services billed by RHCs must include modifier AJ, AM, SA, or U7. These services must be billed using the appropriate national place of service (72) for an RHC setting.
When completing a 2017, CMS-1500, or UB-04 CMS-1450 claim form, all required information must be included on the claim, as TMHP does not key any information from claim attachments. Superbills, or itemized statements, are not accepted as claim supplements.
Providers may copy 2017 Claim Form on the TMHP website at www.tmhp.com.
Providers may purchase CMS-1500 and UB-04 CMS-1450 claim forms from the vendor of their choice. TMHP does not supply the forms.
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 6.9, “Family Planning Claim Form (Paper Billing)” in “Section 6: Claims Filing” (Vol. 1, General Information).
Subsection 6.9.1, “2017 Claim Form” in “Section 6: Claims Filing” (Vol. 1, General Information).
Subsection 6.5.4, “CMS‑1500 Instruction Table” in “Section 6: Claims Filing” (Vol. 1, General Information).
Subsection 6.6.3, “UB-04 CMS-1450 Instruction Table” in Section 6, “Claims Filing” (Vol. 1, General Information).
Subsection 6.1.4, “Claims Filing Deadlines” in “Section 6: Claims Filing” (Vol. 1, General Information) for information about filing deadlines.
Section 7: Appeals (Vol. 1, General Information) for information about appealing claims.
Blocks that are not referenced are not required for processing by TMHP and may be left blank.
RHCs must use their National Provider Identifier (NPI), the appropriate benefit code as applicable, and the appropriate modifier and place of service as outlined in this section.

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