Table of Contents Previous Next

December 2016 Texas Medicaid Provider Procedures Manual

Inpatient and Outpatient Hospital Services Handbook : 6 Military Hospitals : 6.4 Claims Filing and Reimbursement

If TOB 110 is used to submit a claim, all charges must be noncovered and the claim will finalize with EOB 217, “Payment reduced through hospital action.”
It is appropriate to submit information only claims using TOB 110.
Military hospitals may submit total charges in one line with appropriate accommodation revenue codes. Emergency 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 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.
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 claim attachments. Superbills, or itemized statements, are not accepted as claims supplements.
Refer to:
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. Blocks that are not referenced are not required for processing by TMHP and may be left blank.
Military Hospital (Emergency Inpatient) on the TMHP website at for a claim form example.

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