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December 2016 Texas Medicaid Provider Procedures Manual

Medical Transportation Program Handbook : 6 Claims Filing : 6.6 Paper Claims : 6.6.2 CMS-1500 Instruction Table

6.6.2
The table below describes what information must be entered in each of the block numbers of the CMS-1500 claim form. Providers obtain copies of the CMS-1500 paper claim form from a vendor of their choice; TMHP does not supply them.
Block numbers not referenced in the table may be left blank. They are not required for TMHP to process MTP claims.
 
Insured’s ID No. (for program checked above, include all letters)
Enter the patients last name, first name, and middle initial as printed on the MTP authorization form.
If the insured uses a last name suffix (e.g., Jr, Sr) enter it after the last name and before the first name.
The recommended POS code for MTP paper claims is 09. For electronic filing using TexMedConnect, the POS code is 99.
Fully describe procedures, medical services, or supplies furnished for each date given
“The recommended procedure code for TSAP claims is A0100 The recommended procedure code for CFS claims is A0170“
All providers of the Texas Medicaid must accept assignment to receive payment by checking Yes.
Billing services may print “Signature on File” in place of the provider’s signature if the billing service obtains and retains on file a letter signed by the provider authorizing this practice.

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