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December 2016 Texas Medicaid Provider Procedures Manual

Inpatient and Outpatient Hospital Services Handbook : 3 Inpatient Hospital (Medical/Surgical Acute Care Inpatient Facility) : 3.7 Claims Filing and Reimbursement : 3.7.2 Inpatient Claims Information

3.7.2
Medicaid present on admission (POA) reporting is required for all inpatient hospital claims.
All hospital providers are required to submit a POA value for each diagnosis on the claim form, and no hospital is exempt from this POA requirement. Medicare crossover hospital claims must also comply with the Medicaid requirement to include the POA values.
POA is defined as present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient visit, including emergency department, observation, or outpatient surgery, are considered POA.
The following table shows the POA values:
 
POA Value
Payment will be made by Medicare when a hospital-acquired condition (HAC) is present
Note:
TMHP will not recalculate the DRG based on POA indicator values for Medicare crossover claims or MCOs.
Depending on the POA indicator value, the DRG may be recalculated, resulting in a lower payment to the hospital facility provider. If the number of days on an authorization is higher than the number of days allowed as a result of a POA DRG recalculation, the lesser of the number of days will be reimbursed.
Refer to:
“Section 6: Claims Filing” (Vol. 1, General Information).
A complete list of POA exempt diagnosis codes can be found on the CMS website at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1019OTN.pdf
Claims for inpatient hospital services must be submitted to TMHP in an approved electronic format or on the 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 the forms.
When completing a UB-04 CMS-1450 paper claim form, all required information must be included on the claim, as TMHP does not key any information from attachments. Superbills, or itemized statements, are not accepted as claim supplements.
In Block 44 of the UB-04 CMS-1450, enter the accommodation rate per day. Match the appropriate diagnoses listed in Blocks 67A through 67Q corresponding to each procedure. If a procedure corresponds to more than one diagnosis, enter the primary diagnosis. Each service and supply must be itemized on the claim.
Hospitals may submit information only claims to TMHP when one of the following situations exists. Hospitals must use TOB 110 to file these claims:
Inpatient 30‑day spell of illness benefit is exhausted.
Additional claims information can be found within individual topic areas in this section.
Refer to:
“Section 6: Claims Filing” (Vol. 1, General Information).
The Claim Form Examples page on the TMHP website at www.tmhp.com.

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