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 Claim Form Examples for Medicaid Providers

The following forms are samples of completed claim forms needed by Texas Medicaid providers. The forms are grouped by handbook to make locating the correct form easier.


Ambulance Services Handbook

Ambulance Non-emergency Transport
Ambulance Emergency Transport from Residence to Hospital
Ambulance Emergency Transport from Scene of Accident to Hospital

Behavioral Health, Rehabilitation, and Case Management Services Handbook

Blind Children’s Vocational Discovery and Development Program
Case Management for Children and Pregnant Women
Licensed Clinical Social Worker (LCSW)
Licensed Marriage and Family Therapist (LMFT)
Licensed Professional Counselor (LPC)
Mental Health Case Management
Psychologist
Psychotherapy with Evaluation and Management (E/M)

Certified Respiratory Care Practitioner (CRCP) Services Handbook

Certified Respiratory Care Practitioner (CRCP)

Children's Services Handbook

Diagnosis and Treatment (Referral from THSteps Checkup)
Durable Medical Equipment (CCP Only)
Inpatient Rehabilitation Facility (Freestanding) (CCP Only)
Medical Checkup Follow-up Visit with Immunization Administration
Medical Checkup Follow-up Visit with TB Skin Test
Medical Nutrition Counseling (CCP Only)
Orthotic and Prosthetic Services (CCP Only)
Private Duty Nurses (CCP Only)
THSteps New Patient, Immunization Without Counseling no Referral and by an NP
THSteps Established Patient Exception to Periodicity and Referral, Immunizations with Counseling, and by a Physician
THSteps Established Patient and Referral, Tuberculin Skin Test (TST), and Physical Examination by a Physician
Acute Care Visit on the Same Day as a THSteps Preventive Visit Checkup
THSteps Preventive Visit Checkup with Immunization and Vaccine Administration

Clinics and Other Outpatient Facility Services Handbook

Birthing Center
2017 Claim Form
Family Planning Services for Hospitals, FQHCs
FQHC Encounter (T1015)
FQHC Follow-Up
Renal Dialysis Facility CAPD Training
Renal Dialysis Facility CAPD/CCPD
Renal Dialysis CMS-1500 Example
Rural Health Clinic Freestanding
Rural Health Clinic Freestanding (Immunization)
Rural Health Clinic Hospital-Based
Tuberculosis

Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook

Home Health Services DME/Medical Supplies

Gynecological and Reproductive Health and Family Planning Services Handbook

Family Planning Claim Form
Nurse Practitioner/Clinical Nurse Specialist (Family Planning)

Home Health Nursing and Private Duty Nursing Services Handbook

Home Health Services Skilled Nursing Visit
Home Health Services Skilled Nursing Visit and Physical Therapy


Inpatient and Outpatient Hospital Services Handbook

Ambulatory Surgical Center
Hospital-Based ASC
Hospital Inpatient
Military Hospital (Emergency Inpatient)

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook

Anesthesia
Certified Nurse-Midwife (CNM)
Certified Registered Nurse Anesthetist (CRNA)
Chiropractic Services
Dental (Doctor of Dentistry)
Dialysis Training
Genetics
Radiation Therapy
Surgery

Medical Transportation Program Handbook

Lodging Provider Paper Claim Form Example
Meals Provider Paper Claim Form Example

Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook

Physical Therapist

Radiology and Laboratory Services Handbook

Independent Laboratory
Office Visit with Lab and Radiology
Radiological/Physiological Laboratory and Portable X-Ray Supplier

Vision and Hearing Services Handbook

Hearing Aid Assessments
Vision Services


 Remittance and Status (R&S) Report Examples for Medicaid Providers



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