Section 6: Claims Filing

6.1​Claims Information

Providers that render services to Texas Medicaid fee-for-service and managed care clients must file the assigned claims. Texas Medicaid does not make payments to clients. Federal regulations prohibit providers from charging clients a fee for completing or filing Medicaid claim forms. Providers are not allowed to charge TMHP for filing claims. The cost of claims filing is part of the usual and customary rate for doing business. Providers cannot bill Texas Medicaid or Medicaid clients for missed appointments or failure to keep an appointment. Only claims for services rendered are considered for payment.

Medicaid providers are also required to complete and sign authorized medical transportation forms (e.g., Form H3017, Individual Transportation Participant [ITP] Service Record, or Form 3111, Verification of Travel to Healthcare Services by Mass Transit) or provide an equivalent (e.g., provider statement on official letterhead) to attest that services were provided to a client on a specific date. The client presents these forms to the provider.

Providers are not allowed to bill clients or Texas Medicaid for completing these forms.

All claims for Electronic Visit Verification (EVV) services, including fee-for-service and managed care claims, must be submitted electronically to TMHP using the appropriate electronic claims submission method. Paper claims for EVV services will not be accepted. The EVV aggregator will perform EVV claims matching and TMHP will forward the EVV claim with the EVV match code to the applicable payer for claims processing.

6.1.1​TMHP Processing Procedures

TMHP processes claims for services rendered to Texas Medicaid fee-for-service clients and carve-out services rendered to Medicaid managed care clients.

​Note:Claims for services rendered to a Medicaid managed care client must be submitted to the managed care organization (MCO) or dental plan that administers the client’s managed care benefits. Only claims for those services that are carved-out of managed care can be submitted to TMHP.

Claims for EVV services (Acute Care and Long Term Care Fee-For-Service and Long Term Support Services [LTSS] [managed care]) must be submitted to TMHP to perform the EVV claims matching process and forwarded to the applicable payer for adjudication.

​Refer to: The Medicaid Managed Care Handbook (Vol. 2, Provider Handbooks) for more information about carve-out services.

Medicaid claims are subject to the following procedures:

•​TMHP verifies all required information is present.

•​Claims filed under the same National Provider Identifier (NPI) and program and ready for disposition at the end of each week are paid to the provider with an explanation of each payment or denial. The explanation is called the Remittance and Status (R&S) Report, which may be received as a downloadable portable document format (PDF) version or on paper. A Health Insurance Portability and Accountability Act (HIPAA)-compliant 835 transaction file is also available for those providers who wish to import claim dispositions into a financial system.

An R&S Report is generated for providers that have weekly claim or financial activity with or without payment. The report identifies pending, paid, denied, and adjusted claims. If no claim activity or outstanding account receivables exist during the time period, an R&S Report is not generated for the week.

•​For services that are billed on a claim and have any benefit limitations for providers, the date of service determines which provider’s claims are paid, denied, or recouped. Claims that have been submitted and paid may be recouped if a new claim with an earlier date of service is submitted, depending on the benefit limitations for the services rendered.

Services that have been authorized for an extension of the benefit limitation will not be recouped. Providers can submit an appeal with medical documentation if the claim has been denied.

6.1.1.1​Fiscal Agent

TMHP acts as the state’s Medicaid fiscal agent. A fiscal agent arrangement is one of two methods allowed under federal law and is used by all other states that contract with outside entities for Medicaid claims payment. Under the fiscal agent arrangement, TMHP is responsible for paying claims, and the state is responsible for covering the cost of claims.

​Note:The fiscal agent arrangement does not affect Long Term Care (LTC) and Health and Human Services Commission (HHSC) Family Planning providers.

Provider Designations

The fiscal agent arrangement requires that providers be designated as either public or nonpublic. By definition, public providers are those that are owned or operated by a city, state, county, or other government agency or instrumentality, according to the Code of Federal Regulations. In addition, any provider or agency that performs intergovernmental transfers to the state would be considered a public provider. This includes those agencies that can certify and provide state matching funds, (i.e., other state agencies). New providers self-designate (public or private) on the provider enrollment application.

The fiscal agent:

•​Rejects all claims not payable under Texas Medicaid rules and regulations.

•​Suspends payments to providers according to procedures approved by HHSC.

•​Notifies providers of reduction in claim amount or rejection of claim and the reason for doing so.

•​Collects payments made in error, affects a current record credit to the department, and provides the department with required data relating to such error corrections.

•​Prepares checks or drafts to providers, except for cases in which the department agrees that a basis exists for further review, suspension, or other irregularity within a period not to exceed 30 days of receipt and determination of proper evidence establishing the validity of claims, invoices, and statements.

•​Makes provisions for payments to providers who have furnished eligible client benefits.

•​Withholds payment of claim when the eligible client has another source of payment.

•​Employs and assigns a physician, or physicians, and other professionals as necessary, to establish suitable standards for the audit of claims for services delivered and payment to eligible providers.

•​Requires eligible providers to submit information on claim forms.

6.1.1.2​Payment Error Rate Measurement (PERM)

The Improper Payments Information Act (IPIA) of 2002 directs federal agency heads, in accordance with the Office of Management and Budget (OMB) guidance, to annually review agency programs that are susceptible to significant erroneous payments and to report the improper payment estimates to the U.S. Congress.

Every three years the CMS will assess Texas Medicaid using the PERM process to measure improper payments in Texas Medicaid and the Children’s Health Insurance Program (CHIP).

CMS uses PERM to measure the accuracy of Medicaid and CHIP payments made by states for services rendered to clients. Under the PERM program, CMS will use three national contractors to measure improper payments in Medicaid and CHIP:

•​The statistical contractor will provide support to the program by identifying the claims to be reviewed and by calculating each state’s error rate.

•​The data documentation contractor will collect medical policies from the State and medical records from providers.

•​The review contractor will perform medical and data processing reviews of the selected claims in order to identify any improper payments.

Providers are required to provide medical record documentation to support the medical reviews that the federal review contractor will conduct for Texas Medicaid fee-for-service and CHIP claims.

​Note:The federal review contractor will also conduct reviews for Primary Care Case Management (PCCM) claims that were submitted to TMHP with dates of service on or before February 29, 2012.

Past studies have shown that the largest cause of error in medical reviews is lack of documentation or insufficient documentation. It is important that information be sent in a timely and complete manner, since a provider’s failure to timely submit complete records in support of the claims filed can result in a higher payment error rate for Texas, which in turn can negatively impact the amount of federal funding received by Texas for Medicaid and CHIP.

Providers must submit the requested medical records to the data documentation contractor and HHSC within 60 calendar days of the receipt of the written notice of request. If providers have not responded within 15 days, the data documentation contractor and possibly state officials will initiate reminder calls and letters to providers. The data documentation contractor and possibly state officials will also initiate reminder calls and letters to providers after 35 days. If providers have not responded in 60 days, the data documentation contractor will submit a letter to the provider and the state PERM director indicating a “no documentation error.” After the provider’s submittal of requested information, the data documentation contractor may request additional information to determine proper payment. In this instance, the provider is given 15 days to provide additional documentation.

If medical records are not received within 60 calendar days, the data documentation contractor will identify the claim as a PERM error and classify all dollars associated with the claim as an overpayment. Providers will be required to reimburse the overpayment in accordance with state and federal requirements.

A provider’s failure to maintain complete and correct documentation in support of claims filed or failure to provide such documentation upon request can result in the provider being sanctioned under Title 1, Texas Administrative Code (TAC) Part 15, Chapter 371. Sanction actions may include, but are not limited to, a finding of overpayment for the claims that are not sufficiently supported by the required documentation. Sanctions may include, but are not limited to, a finding of overpayment for the claims that are not sufficiently supported by the required documentation.

6.1.2​Claims Filing Instructions

This manual references paper claims when explaining filing instructions. HHSC and TMHP encourage providers to submit claims electronically. TMHP offers specifications for electronic claim formats. These specifications are available from the TMHP website and include a cross-reference of the paper claim filing requirements to the electronic format.

Providers can participate in the most efficient and effective method of submitting claims to TMHP by submitting claims through the TMHP Electronic Data Interchange (EDI) claims processing system using TexMedConnect or a third party vendor. The proceeding claim filing instructions in this manual apply to paper and electronic submitters. Although the examples of claims filing instructions refer to their inclusion on the paper claim form, claim data requirements apply to all claim submissions, regardless of the media. Claims must contain the provider’s complete name, physical address including the ZIP+4 code, NPI, taxonomy code, and benefit code (if applicable) to avoid unnecessary delays in processing and payment.

​Refer to: “Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information) for information on accessing the TMHP website.

6.1.2.1​Wrong Surgery Notification

Providers are required to notify TMHP when a wrong surgery or other invasive procedure is performed on a Texas Medicaid client. Notification is mandated by Senate Bill (SB) 203, Section 3, Regular Session, 81st Texas Legislature, which covers preventable adverse events (PAE) and reimbursement for services associated with PAE.

Professional, inpatient, and outpatient hospital claims that are submitted for the wrong surgery or invasive procedure will be denied. Any corresponding procedures that are rendered to the same client, on the same dates of service (for professional and outpatient hospital claims), or the same date of surgery (for inpatient hospital claims) will be denied. Claims that have already been reimbursed will be recouped.

The law requires providers that are submitting claims for services rendered to Texas Medicaid clients to indicate whether any of the following situations apply to the claim:

•​The incorrect operation or invasive procedure was performed on the correct client.

•​The operation or invasive procedure was performed on the incorrect client.

•​The incorrect operation or invasive procedure was performed on the incorrect body part.

Providers must notify Texas Medicaid of a wrong surgery or invasive procedure by submitting one of the following nonspecific injury, poisoning and other consequences of external causes diagnosis codes or modifiers with the procedure code for the rendered service:

Professional or outpatient hospital claims must include a valid diagnosis with up to seven-digit specificity, the procedure code that identifies the service rendered, and the PA, PB, or PC modifier that describes the type of “wrong surgery” performed.

Inpatient hospital claims must be submitted with type of bill (TOB) 110 as an inpatient hospital-nonpayment claim when a “wrong surgery” is reported. If other services or procedures that are unrelated to the “wrong surgery” are provided during the same stay as the “wrong surgery,” the inpatient hospital must submit a claim for the “wrong surgery” and a separate claim or claims for the unrelated services rendered during the same stay as the “wrong surgery.”

The “wrong surgery” claim must include TOB 110, the appropriate diagnosis code, the surgical procedure code for the surgical service rendered, and the date of surgery. The “wrong surgery” claim will be denied.

The unrelated services rendered during the same stay as the “wrong surgery” must include TOB 111, 112, 113, 114, or 115 on a claim separate from the “wrong surgery” claim. The unrelated services that are benefits of Texas Medicaid may be reimbursed by Texas Medicaid.

A claim that is denied for wrong surgery will have one of the following EOB codes:

6.1.2.2​Maximum Number of Units allowed per Claim Detail

The total number of units per claim detail can not exceed 9,999. Providers who submit a claim with more than 9,999 units must bill 9,999 units on the first detail of the claim and any additional units on separate details.

6.1.2.3​Tips on Expediting Paper Claims

Use the following guidelines to enhance the accuracy and timeliness of paper claims processing.

General requirements

•​Use original claim forms. Do not use copies of claim forms.

•​Detach claims at perforated lines before mailing.

•​Use 10 x 13 inch envelopes to mail claims. Do not fold claim forms, appeals, or correspondence.

•​Do not use labels, stickers, or stamps on the claim form.

•​Do not send duplicate copies of information.

•​Use 8 ½ x 11 inch paper. Do not use paper smaller or larger than 8 ½ x 11 inches.

•​Do not mail claims with correspondence for other departments.

Data Fields

•​Print claim data within defined boxes on the claim form.

•​Use black ink, but not a black marker. Do not use red ink or highlighters.

•​Use all capital letters.

•​Print using 10-pitch (12-point) Courier font. Do not use fonts smaller or larger than 12 points. Do not use proportional fonts, such as Arial or Times Roman.

•​Use a laser printer for best results. Do not use a dot matrix printer, if possible.

•​Do not use dashes or slashes in date fields.

Attachments

•​Use paper clips on claims or appeals if they include attachments. Do not use glue, tape, or staples.

•​Place the claim form on top when sending new claims, followed by any medical records or other attachments.

•​Number the pages when sending attachments or multiple claims for the same client (e.g., 1 of 2, 2 of 2).

•​Do not total the billed amount on each claim form when submitting multi-page claims for the same client.

•​Use the CMS-approved Medicare Remittance Advice Notice (MRAN) printed from Medicare Remit Easy Print (MREP) (professional services) or PC-Print (institutional services) when sending a Remittance Advice from Medicare or the paper MRAN received from Medicare or a Medicare intermediary. You may also download the TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Template from the TMHP website at www.tmhp.com.

•​Submit claim forms with MRANs and R&S Reports.

6.1.3​TMHP Paper Claims Submission

All paper claims must be submitted with an NPI and taxonomy code for the billing and performing provider. All other provider fields on the claim forms require an NPI only. If an NPI and taxonomy code are not included in the billing and performing provider fields, or if an NPI is not included on all other provider identifier fields, the claim will be denied. In addition to the NPI and taxonomy code for the billing provider, claim submissions will need to include the provider benefit code (if applicable) and complete physical address with ZIP + 4 code.

​Refer to: Subsection 6.4, “Claims Filing Instructions” in this section for more information.

6.1.4​Claims Filing Deadlines

For claims payment to be considered, providers must adhere to the time limits described in this section. Claims received after the following claims filing deadlines are not payable because Texas Medicaid does not provide coverage for late claims.

​Exception:Unless otherwise stated, claims must be received by TMHP within 95 days of each DOS. Appeals must be received by TMHP within 120 days of the disposition date on the R&S Report on which the claim appears. A 95-day or 120-day appeal filing deadline that falls on a weekend or a holiday is extended to the next business day following the weekend or holiday.

Only the following holidays extend the deadlines in 2023 and 2024:

The following are time limits for submitting claims:

•​Inpatient claims that are filed by the hospital must be received by TMHP within 95 days of the discharge date or last DOS on the claim.

•​Hospitals that are reimbursed according to diagnosis-related group (DRG) payment methodology may submit an interim claim because the client has been in the facility 30 consecutive days or longer. A total stay claim is needed after discharge to ensure accurate calculation for potential outlier payments for clients who are 20 years of age and younger.

•​Hospitals that are reimbursed according to Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 methodology may submit interim claims before discharge and must submit an interim claim if the client remains in the hospital past the hospital’s fiscal year end.

•​When medical services are rendered to a Medicaid client in Texas, TMHP must receive claims within 95 days of the DOS on the claim.

•​Re-enrolling providers who are assigned their previous enrollment information must submit claims so that they are received by TMHP within 95 days of the date of service.

•​Providers that are enrolling in Texas Medicaid for the first time or are making a change that requires the issuance of a new taxonomy and benefit code can submit claims within 95 days from the date their taxonomy and benefit code is issued as long as claims are submitted within 365 days of the date of service.

•​Providers who are revalidating an existing enrollment can continue to file claims while they are completing the revalidation process. TMHP must receive claims within 95 days of the date of service.

•​TMHP must receive claims from out-of-state providers within 365 days from the DOS. The DOS is the date the service is provided or performed.

•​TMHP must receive claims on behalf of an individual who has applied for Medicaid coverage but has not been assigned a Medicaid number on the DOS within 95 days from the date the eligibility was added to the TMHP eligibility file (add date) and within 365 days of the date of service or from the discharge date for inpatient claims.

•​Providers should verify eligibility and add date by contacting TMHP (Automated Inquiry System [AIS], TMHP EDI’s electronic eligibility verification, or TMHP Contact Center) when the number is received. Not all applicants become eligible clients. Providers that submit claims electronically within the 365-day federal filing deadline for services rendered to individuals who do not currently have a Texas Medicaid identification number will receive an electronic rejection. Providers can use the TMHP rejection report as proof of meeting the 365-day federal filing deadline and submit an administrative appeal.

​Important:Providers should keep documentation of all Texas Medicaid client eligibility verification. Documentation of client eligibility is required for the appeal process.

•​If a client becomes retroactively eligible or loses Medicaid eligibility and is later determined to be eligible, the 95-day filing deadline begins on the date that the eligibility start date was added to TMHP files (the add date). However, the 365-day federal filing deadline must still be met.

•​When a service is a benefit of Medicare and Medicaid, and the client is covered by both programs, the claim must be filed with Medicare first. TMHP must receive Medicaid claims within 95 days of the date of Medicare disposition.

Providers must submit a paper MRAN received from Medicare or a Medicare intermediary, the computer-generated MRANs from the CMS-approved software application MREP for professional services or PC-Print for institutional services, or the TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Template with a completed claim form to TMHP.

•​When a client is eligible for Medicare Part B only, the inpatient hospital claim for services covered as Medicaid only is sent directly to TMHP and is subject to the 95-day filing deadline (from date of discharge).

​Note:It is strongly recommended that providers who submit paper claims keep a copy of the documentation they send. It is also recommended that paper claims be sent by certified mail with a return receipt requested. This documentation, along with a detailed listing of the claims enclosed, provides proof that the claims were received by TMHP, which is particularly important if it is necessary to prove that the 95-day claims filing deadline has been met. TMHP will accept certification receipts as proof of the 95-day or 120-filing deadline. If a certified receipt is provided as proof, the certified receipt number must be indicated on the detailed listing along with the Medicaid number, billed amount, DOS, and a signed claim copy. The provider needs to keep such proof of multiple claims submissions if the provider’s enrollment with TMHP is pending.

•​If the provider is attempting to obtain prior authorization for services performed or will be performed, TMHP must receive the claim according to the usual 95-day filing deadline.

•​The provider bills TMHP directly within 95 days from the DOS. However, if a non-third party resource (TPR) is billed first, TMHP must receive the claim within 95 days of the claim disposition by the other entity.

​Note:The provider submits a copy of the disposition with the claim. A non-TPR is secondary to Texas Medicaid and may only pay benefits after Texas Medicaid.

​Refer to: Subsection 4.12, “Third Party Liability (TPL)” in Section 4, “Client Eligibility” (Vol. 1, General Information) for examples of non-TPRs.

•​When a service is billed to another insurance resource, the filing deadline is 95 days from the date of disposition by the other resource.

•​When a service is billed to a third party and no response has been received, Medicaid providers must allow 110 days to elapse before submitting a claim to TMHP. However, the 365-day federal filing deadline requirement must still be met.

•​A Compass21 (C21) process allows an HHSC Family Planning claim to be paid by Title XIX (Medicaid) if the client is eligible for Title XIX when those services are provided and billed under the HHSC Family Planning Program. In this instance, the Medicaid 95-day filing deadline is in effect and must be met or the claim will be denied.

•​For claims re-submitted to TMHP with additional detail changes (i.e., quantity billed), the additional details are subject to the 95-day filing deadline.

​Note:In accordance with federal regulations, all claims must be initially filed with TMHP within 365 days of the DOS, regardless of provider enrollment status or retroactive eligibility.

​Refer to: Subsection 6.1.2, “Claims Filing Instructions” in this section.

Subsection 1.1, “Provider Enrollment” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) for information on the provider enrollment process.

Subsection 7.1, “Appeal Methods” in “Section 7: Appeals” (Vol. 1, General Information) for information on the process for submitting appeals.

Subsection 6.1.4.3, “Exceptions to the 95-Day Filing Deadline” in this section.

Subsection A.12.3, “Automated Inquiry System (AIS)” in “Appendix A: State, Federal, and TMHP Contact Information” (Vol. 1, General Information) to learn how to retrieve client eligibility information by telephone.

​Refer to: “Section 8: Third Party Liability (TPL)” (Vol. 1, General Information).

Subsection 4.1.10, “Eligibility Verification” in “Section 4: Client Eligibility” (Vol. 1, General Information).

Subsection 6.11.6, “Provider Inquiries—Status of Claims” in this section.

6.1.4.1​Claims for Clients with Retroactive Eligibility

Claims for clients who receive retroactive eligibility must be submitted within 95 days of the date that the client’s eligibility was added to the TMHP eligibility file (add date) and within 365 days of the DOS.

Title 42 of the Code of Federal Regulations (42 CFR), at 447.45 (d) (1), states “The Medicaid agency must require providers to submit all claims no later than 12 months from the date of service.” The 12-month filing deadline applies to all claims. Claims not submitted within 365 days (12 months) from the date of service cannot be considered for payment.

Retroactive eligibility does not constitute an exception to the federal filing deadline. Even if the patient’s Medicaid eligibility determination is delayed, the provider must still submit the claim within 365 days of the date of service. A claim that is not submitted within 365 days of the date of service will not be considered for payment.

If a client is not yet eligible for Medicaid, providers must submit the claim using either 999999999 or 000000000 as the recipient identification number. Although TMHP will deny the claim, providers should retain the denial or electronic rejection report for proof of timely filing, especially if the eligibility determination occurs more than 365 days after the date of service. Claims denied for recipient ineligibility may be resubmitted when the patient becomes eligible for the retroactive date(s) of service. Texas Medicaid may then consider the claim for payment because the initial claim was submitted within the 365-day federal filing deadline and the denial was not the result of an error by the provider.

If the 365-day federal filing deadline requirement has passed, providers must submit the following to TMHP within 95 days from the add date:

•​A completed claim form.

•​One of the following dated within 365 days from the date of service:

•​A page from an R&S Report documenting a denial of the claim.

•​An electronic rejection report of the claim that includes the Medicaid recipient’s name and date of service.

Providers that have submitted their claims electronically can provide proof of timely filing by submitting a copy of an electronic claims report that includes the following information:

•​Client name or Medicaid identification number (PCN)

•​DOS

•​Total charges

•​Batch identification number (Batch ID) (in correct format)

​Note:Only reports that were accepted or rejected by TMHP will be honored. The claim filed (client name or PCN, DOS and total charges) should match the information on the batch report.

6.1.4.2​Claims for Newly Enrolled Providers

Claims submitted by newly enrolled providers must be received within 95 days of the date that enrollment is complete and within 365 days of the date of service. Providers with a pending application should submit any claims that are nearing the 365-day deadline from the date of service. Claims will be rejected by TMHP until enrollment is complete. Providers can use the TMHP rejection report as proof of meeting the 365-day deadline and submit an appeal.

​Note:Claims can be submitted for dates of service on or after the provider’s effective date of enrollment. Providers can find the effective date for their enrollment in their Welcome Letter in PEMS.

​Refer to: Subsection 1.1.9.7, “Copy of License, Temporary License, or Certification” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information).

All claims for services rendered to Texas Medicaid clients who do not have Medicare benefits are subject to a filing deadline from the date of service of:

•​95 days for in-state providers.

•​365 days for out-of-state providers.

TMHP cannot issue a prior authorization before Medicaid enrollment is complete. Upon notice of Medicaid enrollment, the provider must contact the appropriate TMHP Authorization Department before providing services that require a prior authorization number to Medicaid clients. Regular prior authorization procedures are followed after the TMHP Prior Authorization Department has been contacted.

Retroactive authorizations will not be issued unless the regular authorization procedures for the requested services allow for authorizations to be obtained after services are provided. For these services, providers have 95 days from the add date of the client’s retroactive eligibility in TMHP’s system to obtain authorization for services that have already been performed. Providers should refer to the specific manual section for details on authorization requirements, claims filing, and timeframe guidelines for authorization request submissions.

Providers who have not completed enrollment and have general claim submission questions may refer to this section for assistance with claim submission. If additional general information is needed, providers may call the TMHP Contact Center at 800-925-9126 to obtain information. Due to HIPAA privacy guidelines, specific client and claim information cannot be provided.

Providers who have completed enrollment and have questions about submitting claims may call the same number and select the option to speak with a TMHP Contact Center representative.

6.1.4.3​Exceptions to the 95-Day Filing Deadline

TMHP is not responsible for appeals about exceptions to the 95-day filing deadline. These appeals must be submitted to the HHSC Claims Administrator Operations Management. TAC allows HHSC to consider exceptions to the 95-day filing deadline under special circumstances.

6.1.4.4​Appeal Time Limits

All appeals of denied claims and requests for adjustments on paid claims must be received by TMHP within 120 days from the date of disposition, the date of the R&S Report on which that claim appears. If the 120-day appeal deadline falls on a weekend or holiday, the deadline will be extended to the next business day.

​Refer to: Subsection 6.1.2, “Claims Filing Instructions” in this section.

Hospitals appealing final technical denials, admission denials, DRG changes, continued-stay denials, or cost/day outlier denials refer to “Section 7: Appeals” (Vol. 1, General Information) for complete appeal information.

6.1.4.5​Claims with Incomplete Information and Zero Paid Claims

Claims listed on the R&S Report with $0 allowed and $0 paid may be resubmitted as electronic appeals. Previously, these claims were only accepted as paper claims and were not accepted as electronic appeals. Appeals may be submitted through a third party biller or through TexMedConnect.

Zero-paid claims that are still within the 95-day filing deadline should be submitted as new day claims, which are processed faster than appeals. Electronic appeal for these claims must be submitted within the 120-day appeal deadline. Electronic claims can be resubmitted past the 95-day deadline as new day claims if the following fields have not changed:

•​NPIs

•​Client Medicaid number

•​Dates of service

•​Total billed amount

Claims that are past the 95-day filing deadline and require changes to the fields listed above must be appealed on paper, with a copy of the R&S report. All other appeal guidelines remain unchanged.

​Important:Initial zero-paid claims and appeal submissions must meet the 95-day deadline and 120-day appeal deadline outlined in subsection 6.1.4, “Claims Filing Deadlines” in this section.

6.1.4.6​Claims Filing Reminders

After filing a claim to TMHP, providers should review the weekly R&S Report. If within 30 days the claim does not appear in the Claims In Process section, or if it does not appear as a paid, denied, or incomplete claim, the provider should resubmit it to TMHP within 95 days of the DOS.

The provider should allow TMHP 45 days to receive a Medicare-paid claim automatically transmitted for payment of deductible or coinsurance.

Electronic billers should notify TMHP about missing claims when:

•​An accepted claim does not appear on the R&S Report within ten workdays of the file submittal.

•​A claim or file does not appear on a TMHP Electronic Claims Submission Report within ten days of the file submission.

Certain claims, including those that were submitted for newborn services or that might be covered under Medicare, are suspended for review so that other state agencies can verify information. This review may take longer than 60 days.

These suspended claims will appear on the provider’s R&S Report under “The following claims are being processed” with a message indicating that the client’s eligibility is being investigated. Providers must wait until the claim is finalized and appears under “Paid or Denied” or “Adjustment to Claims” on the R&S Report before appealing the claim. If the claim does not appear on the R&S Report, providers must resubmit the claim to TMHP to ensure compliance with filing and appeal deadlines.

6.1.5​HHSC Payment Deadline

Payment deadline rules, as defined by HHSC, affect all providers with the exception of LTC and the HHSC Family Planning Program. The HHSC payment deadline rules for the fiscal agent arrangement ensure that state and federal financial requirements are met.

TMHP is required to finalize and pay claims within 24 months of:

•​Each date of service on a claim.

•​Discharge date for inpatient claims.

Texas Medicaid and Children with Special Health Care Needs (CSHCN) Service Program payments, excluding crossovers, cannot be made after 24 months. Claims and appeals that are submitted after the designated payment deadlines are denied.

​Note:Providers may appeal HHSC Office of Inspector General (OIG) initiated claims adjustments (recoupments) after the 24-month deadline but must do so within 120 days from the date of the recoupment. Refer to subsection 7.1.5, “Paper Appeals” in “Section 7: Appeals” (Vol. 1, General Information) for instructions. All appeals of OIG recoupments must be submitted by paper, no electronic or telephone appeals will be accepted.

6.1.6​Filing Deadline Calendars

The most current filing deadline calendars are available on the TMHP website at www.tmhp.com:

•​Filing Deadline Calendar for 2023

•​Filing Deadline Calendar for 2024

6.2​TMHP Electronic Claims Submission

TMHP uses the HIPAA-compliant American National Standards Institute (ANSI) ASC X12 5010 file format through secure socket layer (SSL) and virtual private networking (VPN) connections for maximum security.

Claims may be submitted electronically to TMHP through TexMedConnect on the TMHP website at www.tmhp.com or through billing agents who interface directly with the TMHP EDI Gateway.

Providers must retain all claim and file transmission records. They may be required to submit them for pending research on missing claims or appeals.

​Refer to: “Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information).

6.2.1​Benefit and Taxonomy Codes

Providers must submit the Benefit Code field (when applicable), Address field, and Taxonomy Code Field and all other required fields. These fields must be completed before submitting electronic claims.

Taxonomy codes do not affect pricing or the level of pricing, but rather are used to crosswalk the NPI to the billing provider. It is critical that the taxonomy code selected as the primary or secondary taxonomy code during a provider’s enrollment with TMHP is included on all electronic transactions.

Billing providers that are not associated with a group are required to submit a taxonomy code on all electronic claims. Claims submitted without a taxonomy code may be rejected.

Medicare does not require a taxonomy code for Part B claims. Therefore, some claims submitted to TMHP from Medicare for payment of deductible or coinsurance may not include the taxonomy code needed for accurate processing by TMHP.

6.2.2​Electronic Claim Acceptance

Providers should verify that their electronic claims were accepted by Texas Medicaid for payment consideration by referring to their Claim Response report, which is in the 27S batch response file (e.g., file name E085LDS1.27S). Providers should also check their Accepted and Rejected reports in the rej and acc batch response files (e.g., E085LDS1.REJ and E085LDS1.ACC) for additional information. Only claims that have been accepted on the Claim Response report (27S file) will be considered for payment and made available for claim status inquiry. Claims that are rejected must be corrected and resubmitted for payment consideration.

​Refer to: Subsection 3.2, “Electronic Billing” in “Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information), visit www.tmhp.com, or call the EDI Help Desk at 888-863-3638 for more information about electronic claims submissions.

6.2.3​Electronic Rejections

The most common reasons for electronic professional claim rejections are:

•​Client information does not match. Client information does not match the PCN on the TMHP eligibility file. The name, date of birth, sex, and nine-digit Medicaid identification number must be an exact match with the client’s identification number on TMHP’s eligibility record. If using TexMedConnect, send an interactive eligibility request to obtain an exact match with TMHP’s record. If not using TexMedConnect, verify through the TMHP website or call AIS at 800-925-9126 to verify client information. A lack of complete client eligibility information causes a rejection and possibly delayed payment. To prevent delays when submitting claims electronically:

•​Always include the first and last name of the client on the claim in the appropriate fields.

•​Always enter the client’s complete, valid nine-digit Medicaid number. Valid Medicaid numbers begin with 1, 2, 3, 4, 5, 6 or 7. CSHCN Services Program client numbers begin with a 9.

•​When submitting claims for newborns, use the guidelines in the following section.

•​Referring/Ordering Physician field blank or invalid. The referring physician’s NPI must be present when billing for consultations, laboratory, or radiology. Consult the software vendor for this field’s location on the electronic claims entry form.

•​Performing Physician ID field blank or invalid. When the billing NPI is a group practice, the performing NPI for the physician who performed the service must be entered. Consult the software vendor for this field’s location on the electronic claim form.

•​Facility Provider field blank or invalid. When place of service (POS) is anywhere other than home or office, the facility’s NPI must be present. If the NPI is not known, enter the name and address of the facility. Consult the software vendor for this field’s location on the electronic claims entry form.

•​Invalid Type of Service or Invalid Type of Service/Procedure code combination. In certain cases some procedure codes will require a modifier to denote the procedure’s type of service (TOS).

​Note:The C21 claims processing system can accept only 40 characters (including spaces) in the Comments section of electronic submissions for ambulance and dental claims. If providers include more than 40 characters in that field, C21 will accept only the first 40 characters; the other characters will not be imported into C21. Providers must ensure that all of the information that is required for the claim to process appropriately is included in the first 40 characters.

​Refer to: Subsection 6.2.5, “Modifier Requirements for TOS Assignment” in this section for TMHP EDI modifier information.

6.2.3.1​Newborn Claim Hints

The following are to be used for newborns:

•​If the mother’s name is “Jane Jones,” use “Boy Jane Jones” for a male child and “Girl Jane Jones” for a female child.

•​Enter “Boy Jane” or “Girl Jane” in first name field and “Jones” in last name field. Always use “boy” or “girl” first and then the mother’s full name. An exact match must be submitted for the claim to process.

•​Do not use “NBM” for newborn male or “NBF” for newborn female.

The following are the most common reasons for electronic hospital UB-04 CMS-1450 claim rejections:

•​Admit hour outside allowable range (such as 24 hours).

•​Billed amount blank.

•​Health coverage ID blank or invalid. This number must be the valid nine-digit Medicaid client number. Incorrect data includes: a number less than nine digits; PENDING; 999999999; and Unknown.

•​Referring physician information on outpatient claim is blank when laboratory/radiology services are ordered or a surgical procedure is performed. The referring physician’s NPI is required in Fields 78–79. Consult the software vendor for the location of this field on the electronic claims entry form.

6.2.4​TMHP EDI Batch Numbers, Julian Dates

All electronic transactions are assigned an eight-character Batch ID immediately upon receipt by the TMHP EDI Gateway. The batch ID format allows electronic submitters to determine the exact day and year that a batch was received. The batch ID format is JJJYSSSS, where each character is defined as follows:

•​JJJ – Julian date. The three J characters represent the Julian date that the file was received by the TMHP EDI Gateway. The first character (J) is displayed as a letter, where I = 0, J = 1, K = 2, and L = 3. The last two characters (JJ) are displayed as numbers. All three characters (JJJ) together represent the Julian date. For example, a Julian date of 143 would be J43.

•​Y – Year. The Y character represents the last digit of the calendar year when the TMHP EDI Gateway receives the file. For example, a “2” in this position indicates the year 2012.

•​SSSS = The unique 4-character sequence number assigned by EDI to the batch filed.

6.2.5​Modifier Requirements for TOS Assignment

Modifiers for TOS assignment are not required for Texas Health Steps (THSteps) Dental claims (claim type 021) and Inpatient Hospital claims (claim type 040). Additionally, procedures submitted by specific provider types such as genetics, eyeglass, and THSteps medical checkup are assigned the appropriate TOS based on the provider type or specific procedure code, and will not require modifiers.

Most procedure codes do not require a modifier for TOS assignment, but modifiers are required for some services submitted on professional claims (claim type 020) and outpatient hospital claims (claim type 023). Services that require a modifier for TOS assignment are listed in the following sections.

6.2.5.1​Assistant Surgery

For assistant surgical procedures, use one of the following modifiers: 80, 81, 82, and AS. Using these modifiers results in TOS 8 being assigned to the procedure.

6.2.5.2​Anesthesia

For anesthesia procedures, use one of the following modifiers: AA, AD, QK, QS, QX, QY, and QZ. Using these modifiers results in TOS 7 being assigned to the procedure.

6.2.5.3​Interpretations

For interpretations or professional components of laboratory, radiology, or radiation therapy procedures, use modifier 26. Using modifier 26 results in TOS I being assigned to the procedure.

​Note:Procedure codes that only have a TOS I are not required to use modifier 26.

6.2.5.4​Technical Components

For technical components of laboratory, radiology, or radiation therapy procedures, use modifier TC. Using this modifier results in TOS T being assigned to the procedure.

​Exception:Outpatient hospitals do not include the TC modifier when they provide technical components of lab and radiology services. These services automatically have TOS 4 or 5 assigned and are subject to the facility’s interim reimbursement rate or the clinical lab rate.

6.2.6​Electronic Visit Verification (EVV)

All claims for Electronic Visit Verification (EVV) services, including fee-for-service and managed care claims, must be submitted electronically to TMHP using the appropriate electronic claims submission method. Paper claims for EVV services will not be accepted. The EVV aggregator will perform EVV claims matching and TMHP will forward the EVV claim with the EVV match code to the applicable payer for claims processing.

6.3​Coding

Electronic billers must code all claims. TMHP encourages all providers to code their paper claims. Claims are processed fast and accurately if providers furnish appropriate information. By coding claims, providers ensure precise and concise representation of the services provided and are assured reimbursement based on the correct code. If providers code claims, a narrative description is not required and does not need to be included unless the code is a not an otherwise classified code.

​Important:Claims for anesthesia must have the CPT anesthesia procedure code narrative descriptions or CPT surgical codes; if these codes are not included, the claim will be denied.

The carrier for the Texas Medicare Program has coding manuals available for physicians and suppliers with codes not available in CPT. To order a CPT Coding Manual, write to the following address:

American Medical Association
Book and Pamphlet Fulfillment
PO Box 2964
Milwaukee, WI 53201

6.3.1​Diagnosis Coding

Texas Medicaid requires providers to provide International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes on their claims. The only diagnosis coding structure accepted by Texas Medicaid is the ICD-10-CM. Diagnosis codes must be to the highest level of specificity available. In most cases a written description of the diagnosis is not required.

All diagnosis codes that are submitted on a claim must be appropriate for the age of the client as identified in the ICD-10-CM description of the diagnosis code. Claims that are denied because one or more of the diagnosis codes submitted on the claim are not appropriate for the age of the client may be appealed with the correct diagnosis code or documentation of medical necessity to justify the use of the diagnosis code.

Diagnosis codes in the following categories are not valid as primary or referenced diagnosis:

•​Nonspecific injury, poisoning and other consequences of external causes

•​Diagnosis in the International Classification of Diseases for Oncology, 3rd Edition (ICD-O-3)

•​Factors influencing health status and contact with health services, unless otherwise directed in this manual.

•​External causes of morbidity

6.3.1.1​Place of Service (POS) Coding

The POS identifies where services are performed. Indicate the POS by using the appropriate code for each service identified on the claim.

​Important:Attention ambulance providers: POS 41 and 42 are accepted by Texas Medicaid for ambulance claims processing. The two-digit origin and destination codes are still required for claims processing.

Use the following codes for POS identification where services are performed:

​Note:Family planning and THSteps medical services performed in a rural health clinic (RHC) are billed using national POS code 72.

6.3.2​Type of Service (TOS)

The TOS identifies the specific field or specialty of services provided.

To determine the TOS payable for each procedure code, providers may refer to the online fee lookup (OFL) or the static fee schedules, both are available on the TMHP website at www.tmhp.com.

​Refer to: Subsection 6.2.5, “Modifier Requirements for TOS Assignment” in this section for TMHP EDI modifier information.

6.3.2.1​TOS Table

​Important: TOS codes are not used for claim submissions, but they do appear on R&S Reports.

6.3.3​Procedure Coding

Texas Medicaid uses the Healthcare Common Procedure Coding System (HCPCS). HCPCS provides health-care providers and third-party payers a common coding structure that uses codes designed around a five-character numeric or alphanumeric base. The procedure codes are updated annually and quarterly.

HCPCS consists of two levels of codes:

•​Level I—Current Procedural Terminology (CPT®) Professional Edition

•​Numeric, five digits

•​Makes up 80 percent of HCPCS

•​Maintained by AMA, which updates it annually

•​Updates by the AMA are coordinated with CMS before modifications are distributed to third-party payers

•​Anesthesia codes from CPT

•​Level II—HCPCS

•​Approved and released by CMS

•​Codes for both physician and non-physician services not contained in CPT (for example, ambulance, DME, prosthetics, and some medical codes)

•​Maintained and updated by the CMS Maintenance Task Force

•​Alphanumeric, a single alpha character (A through V) followed by four digits

•​The single alpha character represents one of the following:

6.3.3.1​HCPCS Updates

TMHP updates HCPCS codes on both an annual and quarterly basis. Major updates are made annually and minor updates are made quarterly.

Most of the procedure codes that do not replace a discontinued procedure code must go through the rate hearing process. HHSC conducts public rate hearings to provide an opportunity for the provider community to comment on the Medicaid proposed payment rate, as required by Chapter 32 of the Human Resources Code, §32.0282, and Title 1 of the Texas Administrative Code, §355.201.

6.3.3.1.1​Annual HCPCS

Annual HCPCS updates apply additions, changes, and deletions that include the program and coding changes related to the annual HCPCS, Current Dental Terminology (CDT), and CPT updates. These updates ensure that the coding structure is up-to-date by using the latest edition of the CPT and the nationally established HCPCS codes that are released by CMS.

6.3.3.1.2​Quarterly HCPCS

Quarterly HCPCS updates apply HCPCS additions, changes, and deletions that are released by CMS.

6.3.3.1.3​Rate Hearings for New HCPCS Codes

HHSC holds rate hearings for new HCPCS codes on a regular basis. Rate hearings are announced on the HHSC website at www.hhs.texas.gov/services/health/medicaid-chip/provider-information/texas-medicaid-chip-rate-analysis.

Claims for services that are provided before the rates are adopted through the rate hearing process are denied as pending a rate hearing (EOB 02008) until the applicable reimbursement rate is adopted. The client cannot be billed for these services.

Providers are responsible for meeting the initial 95-day filing deadline. Providers must submit the procedure codes that are most appropriate for the services provided, even if the procedure codes have not yet completed the rate hearing process and are denied by Texas Medicaid as pending a rate hearing.

Once the reimbursement rates are established in the rate hearing and applied, TMHP automatically reprocesses affected claims. Providers are not required to appeal the claims unless they are denied for other reasons after the claims reprocessing is complete.

​Refer to: Subsection 5.11, “Guidelines for Procedures Awaiting Rate Hearing” in “Section 5: Fee-for-Service Prior Authorizations” (Vol. 1, General Information) for more information about the authorization guidelines for procedure codes that are awaiting a rate hearing.

6.3.4​National Drug Code (NDC)

The NDC is an 11-digit number on the package or container from which the medication is administered. All Texas Medicaid fee-for-service and Family Planning providers must submit an NDC for professional or outpatient claims submitted with physician-administered prescription drug procedure.

N4 must be entered before the NDC on claims.

National Drug Unit of Measure: The submitted unit of measure should reflect the volume measurement administered. Refer to the NDC Package Measure column on the Texas NDC-to-HCPCS Crosswalk.

The valid units of measurement codes are:

•​F2—International unit

•​GR—Gram

•​ME—Milligram

•​ML—Milliliter

•​UN—Unit

​Note:Unit quantities are required.

6.3.4.1​Paper Claim Submissions

UB-04 CMS 1450

CMS-1500

2017 Claim Form

National Drug Unit

Claims will be edited for the value submitted in the NDC quantity field. In order to convert the HCPCS units submitted into the NDC quantity; use the Texas NDC-to-HCPCS Crosswalk to review the “HCPCS Description” and the “NDC Label” description to identify the quantity.

The Texas NDC-to-HCPCS Crosswalk identifies relationships between HCPCS codes and National Drug Codes (NDC). The Texas file is published at least quarterly. The Texas NDC-to-HCPCS Crosswalk can be found at www.txvendordrug.com/formulary/clinician-administered-drugs. Clinician-administered drugs that do not have an appropriate NDC to HCPCS combination for the procedure code that is submitted are not payable.

6.3.4.2​NDC Requirements for Dual Eligible Clients

The 11-digit NDC, NDC quantity, and NDC Unit of measure information is required on all professional and outpatient clinician-administered drug claims for dual-eligible clients. These drug claims are submitted to Medicare, which will cross over to Medicaid for consideration of coinsurance and deductible liabilities.

​Important:Claims which cross over without this required information may be denied due to missing, incomplete, or invalid NDC information. This information applies to all Medicaid providers who serve Medicare-Medicaid dual-eligible clients.

Providers may refer to subsection 6.3.4, “National Drug Code (NDC)” in this section for more information on NDC requirements. The Texas NDC-to-HCPCS Crosswalk identifies relationships between HCPCS codes.

6.3.4.3​Drug Rebate Program

Texas Medicaid will reimburse providers only for clinician-administered drugs and biologicals whose manufacturers participate in the Centers for Medicare & Medicaid Services (CMS) Drug Rebate Program and that show as active on the CMS list for the date of service the drug is administered.

CMS maintains a list of participating manufacturers and their rebate-eligible drug products, which is updated quarterly on the CMS website. TMHP will republish this list quarterly in a more accessible format.

When providers submit claims for clinician-administered drug procedure codes, they must include the National Drug Code (NDC) of the administered drug as indicated on the drug packaging. While 340B purchased claims are not eligible for drug rebates, NDCs are required to receive federal funding to pay the claim.

TMHP will deny claims for drug procedure codes under the following circumstances:

•​The NDC submitted with the drug procedure code is not on the CMS drug rebate list that was current on the date of service.

•​The NDC submitted with the drug procedure code has been terminated.

•​The drug procedure code is submitted with a missing or invalid NDC.

To avoid claim denials, providers must speak with the pharmacy or wholesaler with whom they work to ensure the product purchased is on the current CMS list of participating manufacturers and their drugs.

​Note:Texas Medicaid managed care organizations (MCOs) have their own policies and procedures regarding clinician-administered drugs. Providers must contact the client’s MCO for benefit and limitation information.

Providers can find a complete, downloadable list of procedure codes and the corresponding descriptions on the Vendor Drug Program website at www.txvendordrug.com.

Vitamins and minerals procedure codes will be listed on a separate tab of the supplemental file.

6.3.5​Modifiers

Modifiers describe and qualify the services provided by Texas Medicaid. A modifier is placed after the five-digit procedure code. Up to two modifiers may apply per service. Examples of frequently used modifiers are listed in the following table. Refer to the service-specific sections for additional modifier requirements.

The following modifiers may appear on R&S Reports (they are not entered by the provider):

•​PT. The DRG payment was calculated on a per diem basis for an inpatient stay because of patient transfer.

•​PS. The DRG payment was calculated on a per diem basis because the patient exhausted the 30-day inpatient benefit limitation during the stay.

•​PE. The DRG payment was calculated on a per diem basis because the patient was ineligible for Medicaid during part of the stay. Also used to adjudicate claims with adjustments to outlier payments.

6.3.6​Benefit Code

A benefit code is an additional data element used to identify state programs.

Providers that participate in the following programs must use the associated benefit code when submitting claims and authorizations:

6.4​Claims Filing Instructions

This section contains instructions for completion of Medicaid-required claim forms. When filing a claim, providers should review the instructions carefully and complete all requested information. A correctly completed claim form is processed faster.

This section provides a sample claim form and its corresponding instruction table for each acceptable Texas Medicaid claim form.

All providers, except those on prepayment review, should submit paper claims to TMHP to the following address:

Texas Medicaid & Healthcare Partnership
Claims
PO Box 200555
Austin, TX 78720-0555

Providers on prepayment review must submit all paper claims and supporting medical record documentation to the following address:

Texas Medicaid & Healthcare Partnership
Attention: Prepayment Review MC–A11 SURS
PO Box 203638
Austin, TX 78720-3638

6.4.1​National Correct Coding Initiative (NCCI) Guidelines

The Patient Protection and Affordable Care Act (PPACA) mandates that all claims that are submitted to TMHP be filed in accordance with the NCCI guidelines, including claims for services that have been prior authorized or authorized with medical necessity documentation.

The following NCCI MUE limitations have been deactivated as approved by CMS:

The CMS NCCI and MUE guidelines can be found on the CMS website at www.cms.gov.

The NCCI guidelines consist of HCPCS or CPT procedure code pairs that must not be reported together and MUEs that determine whether procedure codes are submitted in quantities that are unlikely to be correct.

The NCCI and MUE spreadsheets are published and updated by CMS and are available on the CMS Medicaid NCCI Coding web page under “NCCI and MUE Edits” as follows:

•​NCCI edit spreadsheets. The website contains the Medicaid NCCI edit spreadsheet for hospital services and the Medicaid NCCI edit spreadsheet for practitioner services. The spreadsheets list the procedure code pairs that will not be reimbursed separately if they are billed by the same provider with the same date of service. Column 1 procedure codes may be reimbursed and Column 2 procedure codes will be denied. The spreadsheets also contain a column that indicates whether or not a modifier is allowed for services that may be reimbursed separately.

•​MUE edit spreadsheets. The website contains the Medicaid MUE edit spreadsheets for hospital services, practitioner services, and supplier services. The spreadsheets list procedure codes and the number of units that may be reimbursed for each procedure code. Units that are submitted beyond these limitations will be denied.

​Note:Providers are required to comply with NCCI and MUE guidelines as well as the guidelines that are published in the Texas Medicaid Provider Procedures Manual, all currently published website articles, fee schedules, and all other application information published on the TMHP website at www.tmhp.com. In instances when Texas Medicaid medical policy is more restrictive than NCCI or MUE guidance, Texas Medicaid medical policy prevails.

HHSC continue to implement and enforce correct coding initiatives. Providers may see additional claim denials related to NCCI and MUE edits including those services that were prior authorized or authorized with medical necessity documentation.

If a rendered service does not comply with a guideline as defined by NCCI, medical necessity documentation may be submitted with the claim for the service to be considered for reimbursement; however, medical necessity documentation does not guarantee payment for the service.

​Important:Prior authorization and authorization based on documentation of medical necessity is a condition for reimbursement; it is not a guarantee of payment.

Claims that were submitted with dates of service from October 1, 2010, through June 30, 2013, will not be reprocessed in accordance with the NCCI guidelines; however, any claims with dates of service on or after October 1, 2010, that are appealed or reprocessed for reasons other than NCCI auditing will be subject to NCCI auditing guidelines.

6.4.1.1​NCCI Processing Categories

The following coding rule categories are applied to claims that are submitted with dates of service on or after October 1, 2010:

6.4.1.2​CPT and HCPCS Claims Auditing Guidelines

Claims with dates of service on or after October 1, 2010, must be filed in accordance with Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) guidelines as defined in the American Medical Association (AMA) and Centers for Medicare & Medicaid Services (CMS) coding manuals. Claims that are not filed in accordance with CPT and HCPCS guidelines may be denied, including claims for services that were prior authorized or authorized based on documentation of medical necessity.

If a rendered service does not comply with CPT or HCPCS guidelines, medical necessity documentation may be submitted with the claim for the service to be considered for reimbursement; however, medical necessity documentation does not guarantee payment for the service.

​Important:Prior authorization and authorization based on documentation of medical necessity is a condition for reimbursement; it is not a guarantee of payment.

The following coding rule categories apply to claims submissions:

6.4.2​Claim Form Requirements

6.4.2.1​Provider Signature on Claims

Every paper CMS-1500, American Dental Association (ADA) Dental Claim Form, and 2017 Claim Form must be submitted with the provider’s or an authorized representative’s handwritten signature (or signature stamp) in the appropriate block of the claim form. Signatory supervision of the authorized representative is required. Providers delegating signature authority to a member of the office staff or to a billing service remain responsible for the accuracy of all information on a claim submitted for payment. Initials are only acceptable for first and middle names. The last name must be spelled out. An acceptable example is J.A. Smith for John Adam Smith. An unacceptable example is J.A.S. for John Adam Smith. Typewritten names must be accompanied by a handwritten signature; in other words, a typewritten name with signed initials is not acceptable. The signature must be contained within the appropriate block of the claim form. Claims prepared by computer billing services or office-based computers may have “Signature on File” printed in the signature block, but it must be in the same font that is used in the rest of the form. For claims prepared by a billing service, the billing service must retain a letter on file from the provider authorizing the service.

Printing the provider’s name instead of “Signature on File” is unacceptable. Because space is limited in the signature block, providers should not type their names in the block. Claims not meeting these specifications appear in the “Paid or Denied Claims” sections of the R&S Reports.

​Refer to: Sample Letter XUB Computer Billing Service Inc on the TMHP website at www.tmhp.com.

6.4.2.2​Group Providers

Providers billing as a group must give the performing provider NPI on their claims as well as the group provider NPI. This requirement excludes THSteps medical providers.

6.4.2.3​Supervising Physician Provider Number Required on Some Claims

The supervising physician provider number is required on claims for services that are ordered or referred by one provider at the direction of or under the supervision of another provider, and the referral or order is based on the supervised provider’s evaluation of the client.

If a referral or order for services to a Texas Medicaid client is based on a client evaluation that was performed by the supervised provider, the billing provider’s claim must include the names and NPIs of both the ordering provider and the supervising provider. The billing provider must obtain all of the required information from the ordering or referring provider before submitting the claim to TMHP.

Providers who submit TexMedConnect electronic claims for professional, ambulance, or vision services can provide the claim information in the designated field for the supervising provider of the referring or ordering provider.

Providers can refer to TexMedConnect instructions on the TMHP website at www.tmhp.com for details about the “Referring/Other Supervising Provider” field for professional, ambulance, and vision electronic claims.

​Note:Pharmacy claims are currently excluded from this requirement.

6.4.2.4​Ordering or Referring Provider NPI

All Texas Medicaid claims for services that require a physician order or referral must include the ordering or referring provider’s NPI:

•​If the ordering or referring provider is enrolled in Texas Medicaid as a billing or performing provider, the billing or performing provider NPI must be used on the claim as the ordering or referring provider.

•​If the ordering or referring provider is not currently enrolled in Texas Medicaid as a billing or performing provider, the provider must enroll to receive an ordering or referring-only taxonomy and benefit code. After the ordering or referring provider is enrolled, the ordering or referring provider’s NPI must be used on the claim as the ordering or referring provider.

​Important:The billing provider is responsible for confirming that the ordering or referring provider is enrolled as an ordering or referring-only provider.

Claims that are submitted without the ordering or referring provider’s NPI and claims submitted with an NPI for a provider who is not enrolled in Texas Medicaid may be subject to retrospective review and denial for a missing or invalid NPI.

​Note:Providers who enroll in Texas Medicaid as ordering- and referring-only providers can use their NPI for orders and referrals for Texas Medicaid clients and CSHCN Services Program clients.

6.4.2.5​Attending Provider NPI Requirements

The attending provider is the individual who would normally be expected to certify and re-certify the medical necessity of the number of services rendered or who has primary responsibility for the patient’s medical care and treatment.

​Note:Outpatient claim providers may be instructed to submit the ordering provider name and NPI number in the attending provider field.

6.4.2.6​Prior Authorization Numbers on Claims

Claims filed to TMHP must contain only one prior authorization number per claim. Prior authorization numbers must be indicated on the appropriate electronic field or on the paper claim forms in the indicated block:

•​CMS-1500—Block 23

•​UB-04 CMS-1450—Block 63

•​ADA—Block 2

•​Family Planning—Block 30

6.4.2.7​Newborn Clients Without Medicaid Numbers

If a Medicaid eligible newborn has not been assigned a Medicaid number on the DOS, the provider must wait until a Medicaid client number is assigned to file the claim. The provider writes the number instead of “Pending.” The 95-day filing period begins on the “add date,” which is the date the eligibility is received and added to the TMHP eligibility file. Providers verify eligibility and add date through TexMedConnect or by calling AIS or the TMHP Contact Center at 800-925-9126 after the number is received.

Providers must check Medicaid eligibility regularly to file claims within the required 95-day filing deadline.

​Refer to: “Section 4: Client Eligibility” (Vol. 1, General Information).

6.4.2.8​Multipage Claim Forms

6.4.2.8.1​Professional Claims

The approved electronic claims format is designed to list 50 line items. The total number of details allowed for a professional claim by the TMHP claims processing system (C21) is 28. If the services provided exceed 28 line items on an approved electronic claims format or 28 line items on paper claims, the provider must submit another claim for the additional line items.

The CMS-1500 paper claim form is designed to list six line items in Block 24. If more than six line items are billed on a paper claim, a provider may attach additional forms (pages) totaling no more than 28 line items. The first page of a multipage claim must contain all the required billing information. On subsequent pages of the multipage claim, the provider should identify the client’s name, diagnosis, information required for services in Block 24, and the page number of the attachment (for example, page 2 of 3) in the top right-hand corner of the form and indicate “continued” in Block 28. The combined total charges for all pages should be listed on the last page in Block 28.

​Note:Providers who submit professional claims for inpatient services are required to include only the facility’s NPI on the CMS-1500 paper claim form or electronic equivalent.

6.4.2.8.2​Institutional Claims

The total number of details allowed for an institutional claim by the TMHP claims processing system (C21) is 28. C21 merges like revenue codes together for inpatient claims to reduce the lines to 28 or less. If the C21 merge function is unable to reduce the lines to 28 or less, the claim will be denied, and the provider will need to reduce the number of details and resubmit the claim.

An EDI approved electronic format of the UB-04 CMS-1450 is designed to list 71 lines. C21 merges like revenue codes together to reduce the lines to 28 or less.

Providers submitting electronic claims using TexMedConnect may not submit more than 28 lines. If the services exceed the 28 lines, the provider may submit another claim for the additional lines or merge codes.

The paper UB-04 CMS-1450 is designed to list 23 lines in Block 43. If services exceed the 23-line limitation, the provider may attach additional pages. The first page of a multipage claim must contain all required billing information. On subsequent pages, the provider identifies the client’s name, diagnosis, all information required in Block 43, and the page number of the attachment (e.g., page 2 of 3) in the top right-hand corner of the form and indicate “continued” on Line 23 of Block 47. The combined total charges for all pages should be listed on the last page on Line 23 of Block 47.

When splitting a claim, all pages must contain the required information. Usually, there are logical breaks to a claim. For example, the provider may submit the surgery charges in one claim and the subsequent recovery days in the next claim.

TEFRA hospitals are required to submit all charges.

6.4.2.8.3​Inpatient Hospital Claims

Medicaid present-on-admission (POA) reporting is required for all inpatient hospital claims that are paid under prospective payment basis methodology. No hospitals are exempt from this POA requirement.

Medicare crossover hospital claims must also comply with the Medicaid requirement to include the POA values. Claims submitted without the POA indicators are denied. POA values are:

​Note:Texas Medicaid follows Medicare guidelines for payments referenced in the above table.

Depending on the POA indicator value, the DRG may be recalculated, which could result 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 is reimbursed.

​Refer to: Federal Register, Vol. 76, No. 108 (for CMS).

6.4.2.9​Attachments to Claims

To expedite claims processing, providers must supply all information on the claim form itself and limit attachments to those required by TMHP or necessary to supply information to properly adjudicate the claim. The following claim form attachments are required when appropriate:

•​All claims for services associated with an elective sterilization must have a valid Sterilization Consent Form attached or on file at TMHP.

•​Nonemergency ambulance transfers must have documentation of medical necessity including out-of-locality transfers.

•​For fee-for-service clients, providers filing to TMHP for Medicaid payment of Medicare coinsurance and deductible according to current payment guidelines must attach the paper MRAN received from Medicare or a Medicare intermediary or the computer generated MRANs from the CMS-approved software applications MREP for professional services or PC-Print for institutional services. Providers that submit paper crossover claims must submit only one of the approved MRAN formats.

•​For MAP clients, providers filing to TMHP for Medicaid payment of Medicare coinsurance and deductible according to current payment guidelines must submit with the paper claim the TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Template with the MAP EOB. If the template and MAP EOB contain conflicting information, the claim will not be processed and will be returned to the provider.

•​Medically necessary abortions performed (on the basis of a physician’s professional judgement, the life of the mother is endangered if the fetus were carried to term), or abortions provided for pregnancy related to rape or incest must have a signed and dated physician certification statement. Elective abortions are not benefits of Texas Medicaid.

•​Hysterectomies must have a Hysterectomy Acknowledgment Statement attached or on file at TMHP.

​Refer to: Texas Medicaid - Title XIX Acknowledgment of Hysterectomy Information on the TMHP website at www.tmhp.com.

•​Claims for services that were paid by an MCO and then recouped must contain the recoupment EOB from the MCO for consideration of payment. The claims must meet the 95-day deadline from the recoupment disposition date.

​Note:Letter requests for refunds will not be accepted. A recoupment EOB with a disposition date is required.

6.4.2.10​Clients with a Designated or Primary Care Provider

Claims for clients with a primary care provider or designated provider (i.e., Texas Medicaid fee-for-service clients enrolled as Limited Program clients) must indicate the primary care provider or designated provider NPIs in the billing or performing provider fields.

When clients receive services from a different provider, such as a specialist, the primary care provider or designated provider’s information must be included in the referring provider fields on the claim.

6.5​CMS-1500 Paper Claim Filing Instructions

The following providers bill for services using the ANSI ASC X12 837P 5010 electronic specifications or the CMS-1500 paper claim form:

Providers obtain copies of the CMS-1500 paper claim form from a vendor of their choice; TMHP does not supply them.

6.5.1​CMS-1500 Electronic Billing

Electronic billers must submit CMS-1500 paper claim forms with TexMedConnect or approved vendor software that uses the ANSI ASC X12 837P 5010 format. Specifications are available to providers developing in-house systems, software developers, and vendors on the TMHP website at www.tmhp.com/topics/edi. Because each software developer is different, location of fields may vary. Contact the software developer or vendor for this information. Direct questions and development requirements to the TMHP EDI Help Desk at 888-863-3638.

​Refer to: Subsection 3.2, “Electronic Billing” in “Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information) for information about electronic billing.

6.5.2​CMS-1500 Claim Form (Paper) Billing

Claims must contain the billing provider’s complete name, physical address with ZIP +4 code, taxonomy, and benefit code (if applicable). Claims without this information cannot be processed. Each claim form must have the appropriate signatory evidence in the signature certification block.

​Refer to: The Professional Paper Claim Form (CMS-1500) page of the CMS website at www.cms.gov for more information about the CMS-1500 paper claim form. Providers can purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms. Providers can find examples of completed claim forms on the Claim Form Examples page of the TMHP website at www.tmhp.com.

​Important: When completing a CMS-1500 paper claim form, all required information must be included on the claim in the appropriate block. Information is not keyed from attachments. Superbills or itemized statements are not accepted as claim supplements.

6.5.3​CMS- 1500 Provider Definitions

The following definitions apply to the provider terms used on the CMS-1500 paper claim form:

Referring Provider

The referring provider is the individual who directed the patient for care to the provider that rendered the services being submitted on the claim form.

Examples include, but are not limited to the following:

•​A primary care provider referring to a specialist

•​An orthodontist referring to an oral and maxillofacial surgeon

•​A physician referring to a physical therapist

•​A provider referring to a home health agency

Ordering Provider

The ordering provider is the individual who requested the services or items listed in Block D of the CMS-1500 paper claim form.

Examples include, but are not limited to, a provider ordering diagnostic tests, medical equipment, or supplies.

Rendering Provider

The rendering provider is the individual who provided the care to the client. In the case where a substitute provider was used, that individual is considered the rendering provider.

An individual such as a lab technician or radiology technician who performs services in a support role is not considered a rendering provider.

Supervising Provider

The supervising provider is the individual who provided oversight of the rendering provider and the services listed on the CMS-1500 paper claim form.

An example would be the supervision of a resident physician.

Purchased Service Provider

A purchased service provider is an individual or entity that performs a service on a contractual or reassignment basis.

Examples of services include the following:

•​Processing a laboratory specimen

•​Grinding eyeglass lenses to the specifications of the referring provider

•​Performing diagnostic testing services (excluding clinical laboratory testing) subject to Medicare’s antimarkup rule

In the case where a substitute provider is used, that individual is not considered a purchased service provider.

6.5.4​CMS-1500 Instruction Table

The instructions describe what information must be entered in each of the block numbers of the CMS-1500 paper claim form. Block numbers not referenced in the table may be left blank. They are not required for claim processing by TMHP.

6.6​UB-04 CMS-1450 Paper Claim Filing Instructions

The following provider types may bill electronically or use the UB-04 CMS-1450 paper claim form when requesting payment:

If a service is rendered in the facility setting but the facility’s medical record does not clearly support the information submitted on the facility claim, the facility may request additional information from the physician before submitting the claim to ensure the facility medical record supports the filed claim.

​Note:In the case of an audit, facility providers will not be allowed to submit an addendum to the original medical records for finalized claims.

6.6.1​UB-04 CMS-1450 Electronic Billing

Electronic billers must submit UB-04 CMS-1450 claims with TexMedConnect or approved vendor software that uses the ANSI ASC X12 837I 5010 format. Specifications are available to providers developing in-house systems and software developers and vendors. Because each software package is different, field locations may vary. Contact the software developer or vendor for this information. Direct questions and development requirements to the TMHP EDI Help Desk at 888-863-3638.

​Refer to: Subsection 3.2, “Electronic Billing” in “Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information) for more information about electronic billing.

​Note:The maximum number of electronic claim details that will be accepted electronically is 71. Only 28 details will be processed.

6.6.2​UB-04 CMS-1450 Claim Form (Paper) Billing

Providers obtain the UB-04 CMS-1450 paper claim forms from a vendor of their choice.

​Note:To avoid claim denial, only the provider’s NPI should be placed in form locators 76-79 of the UB-04 CMS-1450 paper claim form or in the referring provider field on the electronic claim unless the client is a limited client.

Completed UB-04 CMS-1450 claims must contain the billing provider’s full name, physical address, including the ZIP+4 Code, NPI, taxonomy and benefit code (if applicable). Claims without this information in the appropriate fields cannot be processed.

​Refer to: The Institutional paper claim form (CMS-1450) CMS website at www.cms.gov for more information about the CMS-1450 paper claim form. Providers can purchase CMS-1450 paper claim forms from the vendor of their choice. TMHP does not supply the forms. Providers can find examples of completed claim forms on the Claim Form Examples page of the TMHP website at www.tmhp.com.

Subsection 6.6.3, “UB-04 CMS-1450 Instruction Table” in this section.

6.6.3​UB-04 CMS-1450 Instruction Table

The instructions describe what information must be entered in each of the block numbers of the UB-04 CMS-1450 paper claim form. Block numbers not referenced in the table may be left blank. They are not required for claim processing by TMHP.

6.6.4​Filing Tips for Outpatient Claims

The following are outpatient claim filing tips:

•​Use HCPCS codes in Block 44 when available and give a narrative description in Block 43 for all services and supplies provided.

​Important:Services and supplies that exceed the 28 items per claim limitation must be submitted on an additional UB-04 CMS-1450 paper claim form and will be assigned a different claim number by TMHP.

•​Combine central supplies and bill as one item. IV supplies may be combined and billed as one item. Include appropriate quantities and total charges for each combined procedure code used. Using combination procedure codes conserves space on the claim form.

•​The 28-item limitation per claim: a UB-04 CMS-1450 paper claim form submitted with 28 or fewer items is given an internal control number (ICN) by TMHP. Multipage claim forms are processed as one claim for that client if all pages contain 28 or fewer items.

•​Itemized Statements: Itemized statements are not used for assignment of procedure codes. HCPCS codes or narrative descriptions of procedures must be reflected on the face of the UB-04 CMS-1450 paper claim form. Attachments will only be used for clarification purposes.

​Refer to: Subsection 6.3.3, “Procedure Coding” in this section.

6.7​American Dental Association (ADA) Dental Claim Filing Instructions

Providers billing for dental services and Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID) dental services may bill electronically or use the ADA claim form.

​Note:TMHP is responsible for reimbursing all THSteps dental services provided by dentists.

6.7.1​ADA Dental Claim Electronic Billing

Electronic billers must submit THSteps dental claims using TexMedConnect or an approved vendor software that uses the ANSI ASC X12 837D 5010 format. Specifications are available to providers developing in-house systems and software developers and vendors. Because each software package is different, block locations may vary. Contact the software developer or vendor for this information. Direct questions and development requirements to the TMHP EDI Help Desk at 888-863-3638.

​Note:Dental providers who submit American National Standards Institute, Accredited Standards Committee X12 (ANSI ASC X12N) 837D transactions through the TMHP Electronic Data Interchange (EDI) are required to include the header date of service (HDOS) to comply with International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) claims processing guidelines.

​Refer to: “Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information) for more information about electronic filing.

6.7.2​ADA Dental Claim Form (Paper) Billing

All participating THSteps dental providers are required to submit a ADA Dental claim form for paper claim submissions to Texas Medicaid. These forms may be obtained by contacting the ADA at 800-947-4746.

Claims must contain the billing provider’s complete name, physical address, NPI, and taxonomy code. Claims without a provider name, physical address, NPI, and taxonomy code cannot be processed.

6.7.3​ADA Dental Claim Form

Samples of the ADA Dental Claim form can be found on the ADA website at www.ada.org.

6.7.4​ADA Dental Claim Form Instruction Table

The following table is an itemized description of the questions appearing on the form. Thoroughly complete the ADA Dental claim form according to the instructions in the table to facilitate prompt and accurate reimbursement and reduce follow-up inquiries.

6.8​Family Planning Claim Filing Instructions

The following providers bill for services using the ANSI ASC X12 837P 5010 electronic specifications or the CMS-1500 paper claim form:

6.8.1​Family Planning Electronic Billing

Electronic billers must submit family planning claims with TexMedConnect or approved vendor software that uses the ANSI ASC X12 837P 5010 format. Specifications are available to providers developing in-house systems, software developers, and vendors on the TMHP website at www.tmhp.com/topics/edi. Because each software developer is different, location of fields may vary. Contact the software developer or vendor for this information. Direct questions and development requirements to the TMHP EDI Help Desk at 888-863-3638.

​Refer to: Subsection 3.2, “Electronic Billing” in “Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information) for information about electronic billing.

6.9​Family Planning Claim Form (Paper Billing)

Claims must contain the billing providers complete name, physical address, NPI, and taxonomy code. Claims without a provider name, physical address, NPI, and taxonomy code cannot be processed.

6.9.1​2017 Claim Form

A copy of a blank 2017 Claim Form and copies of example completed claim forms are available on the Claim Form Examples page of the TMHP website at www.tmhp.com.

6.9.2​2017 Claim Form Instruction Table

The instructions describe what information must be entered in each of the block numbers of the 2017 Claim Form.

6.10​Vision Claim Form

All vision services must be billed on a CMS-1500 paper claim form or the appropriate electronic formats. Vision claims submitted on other forms are denied with EOB 01145, “Claim form not allowed for this program.”

For eyewear claims beyond program benefits, (e.g., replacing lost or destroyed eye wear), providers must have the patient sign the “Patient Certification Form” and retain in their records. Do not submit form to TMHP.

​Refer to: Medicaid Vision Eyewear Client Certification Form on the TMHP website at www.tmhp.com.

The following table shows the blocks required for vision claims on a CMS-1500 paper claim form.

6.11​Remittance and Status (R&S) Report

The R&S Report provides information on pending, paid, denied, and adjusted claims. TMHP provides weekly R&S Reports to give providers detailed information about the status of claims submitted to TMHP. The R&S Report also identifies accounts receivables established as a result of inappropriate payment. These receivables are recouped from claim submissions. All claims for the same NPI and program processed for payment are paid at the end of the week, either by a single check or with Electronic Funds Transfer (EFT). If no claim activity or outstanding account receivables exist during the cycle week, the provider does not receive an R&S Report. Providers are responsible for reconciling their records to the R&S to determine payments and denials received.

​Note:Providers receive a single R&S Report that details Texas Medicaid activities and provides individual program summaries. Combined provider payments are made based on the provider’s settings for Texas Medicaid fee-for-service.

Providers must retain copies of all R&S Reports for a minimum of five years. Providers must not use R&S Report originals for appeal purposes, but must submit copies of the R&S Reports with appeal documentation.

​Refer to: “Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information) for information on electronic claims submissions.

6.11.1​R&S Report Delivery Options

TMHP offers two options for the delivery of the R&S Report:

•​A PDF version that is available on the TMHP website through the secure provider portal.

•​An Electronic Remittance and Status (ER&S) Report that is available through EDI.

The PDF version of the R&S Report is available through TexMedConnect, and can be downloaded by registered users of the TMHP website at www.tmhp.com. The report is available each Monday morning, immediately following the weekly claims cycle. Payments associated with the R&S Report are released the next Friday following the weekly claims cycle. Newly-enrolled providers are initially set up to receive the PDF version of the R&S Report.

The EDI delivery method is also available. Using HIPAA-compliant EDI standards, the (ER&S 835 file) can be downloaded through the TMHP EDI Gateway using third party software. The ER&S Report is available on Thursday the week the provider payments are released.

​Note:In rare instances, payments and R&S delivery may be delayed due to a system outage or holiday.

In addition to the PDF R&S Report, an optional R&S Report delivery method is also available. Using HIPAA-compliant EDI standards, the ER&S Report can be downloaded through the TMHP EDI Gateway using TexMedConnect or third party software. The ER&S Report is also available each Monday after the completion of the claims processing cycle.

​Refer to: “Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information) for more information about EDI formats and enrollment for the ER&S Report.

6.11.2​Banner Pages

Banner pages serve two purposes:

•​They identify the provider’s name and address.

•​They are used to inform providers of new policies and procedures.

The title pages include the following information:

•​TMHP address for submitting paper appeals

•​Provider’s name, address, and telephone number

•​Unique R&S Report number specific to each report

•​Provider identifier (NPI, and atypical provider identifier [API])

•​Report sequence number (indicates the week number of the year)

•​Date of the week being reported on the R&S Report

•​Tax Identification Number

•​Page number (R&S Report begins with page 1)

•​AIS telephone number

•​Taxonomy code

6.11.3​R&S Report Field Explanation

•​Patient name. Lists the client’s last name and first name, as indicated on the eligibility file.

•​Claim number. The 24-digit Medicaid ICN for a specific claim. The format for the TMHP claim number is expanded to PPP/CCC/MMM/CCYY/JJJ/BBBBB/SSS.

Program Type

Claim Type

Media Source (MMM)

•​Medicaid #. The client’s Medicaid number.

•​Patient Account #. If a patient account number is used on the provider’s claim, it appears here.

•​Medical Record #. If a medical record number is used on the provider’s claim, it appears here.

•​Medicare #. If the claim is a result of an automatic crossover from Medicare, the last ten digits of the Medicare claim number appears directly under the TMHP claim number.

•​Diagnosis. Primary diagnosis listed on the provider’s claim.

•​Service Dates. Format MMDDYYYY (month, day, year) in “From” and “To” dates of service.

•​TOS/Proc. Indicates by code the specific service provided to the client. The one-digit TOS appears first followed by a HCPCS procedure code. A three-digit code represents a hospital accommodation or ancillary revenue code. For claims paid under prospective payment methodology, it is the code of the DRG.

•​Billed Quantity. Indicates the quantity billed per claim detail.

•​Billed Charge. Indicates the charge billed per claim detail.

•​Allowed Quantity. Indicates the quantity TMHP has allowed per claim detail.

•​Allowed Charge. Indicates the charges TMHP has allowed per claim detail. For inpatient hospital claims, the allowed amount for the DRG appears.

•​POS Column. The R&S Report includes the POS to the left of the Paid Amount. A one-digit numeric code identifying the POS is indicated in this column. Refer to subsection 6.3.1.1, “Place of Service (POS) Coding” in this section for the appropriate cross-reference among the two-digit numeric POS codes (Medicare), and one-digit numeric code on the R&S Report. Providers using electronic claims submission should continue using the same POS codes.

•​Paid Amt. The final amount allowed for payment per claim detail. The total paid amount for the claim appears on the claim total line.

•​EOB Codes and Explanation of Pending Status (EOPS) Codes. These codes explain the payment or denial of the provider’s claim. The EOB codes are printed next to or directly below the claim. The EOPS codes appear only in “The Following Claims Are Being Processed” section of the R&S Report. The codes explain the status of pending claims and are not an actual denial or final disposition. An explanation of all EOB and EOPS codes appearing on the R&S Report are printed in the Appendix at the end of the R&S Report. Up to five EOB codes are displayed.

•​Total TEFRA Billed and Allowed Charges. Indicates claim details that have been denied or reduced.

•​Benefit. Indicates the three digit benefit code associated with the claim.

•​Modifier. Modifiers have been developed to describe and qualify services provided. For THSteps dental services two modifiers are printed. The first modifier is the TID and the second is the SID.

6.11.4​R&S Report Section Explanation

6.11.4.1​Claims – Paid or Denied

The heading “Claims – Paid or Denied Claims” is centered on the top of each page in this section. Claims in this section finalized the week before the preparation of the R&S Report. The claims are sorted by claim status, claim type, and by order of client names. The reported status of each claim will not change unless further action is initiated by the provider, HHSC, or TMHP.

The following information is provided on a separate line for all inpatient hospital claims processed according to prospective payment methodology:

•​Age. Client’s age according to TMHP records

•​Sex. Client’s sex according to TMHP records: M = Male, F = Female, U = Unknown

•​Pat-Stat. Indicates the client’s status at the time of discharge or the last DOS on the claim (refer to instructions for UB-04 CMS-1450 paper claim form, Block 17)

•​Proc. ICD-10-PCS code indicates the primary surgical procedure used in determining the DRG

​Important: Only paper claims appear in this section of the R&S Report. Claims filed electronically without required information are rejected. Users are required to retrieve the response file to determine reasons for rejections.

TMHP cannot process incomplete claims. Incomplete claims may be submitted as original claims only if the resubmission is received by TMHP within the original filing deadline.

​Refer to: Subsection 6.1, “Claims Information” in this section for a description of different claim types.

6.11.4.2​Adjustments to Claims

Adjustments – Paid or Denied is centered at the top of each page in this section. Adjustments are sorted by claim type and then patient name and Medicaid number. Media types 011, 021, 031, 041, 051, 061, 071, and 081 appear in this section. An adjustment prints in the same format as a paid or denied claim.

The adjusted claim is listed first on the R&S Report. EOB 00123, “This is an adjustment to previous claim XXXXXXXXXXXXXXXXXXXXXXXX which appears on R&S Report dated XX/XX/XX” follows this claim. Immediately below is the claim as originally processed. An accounts receivable is created for the original claim total as noted by EOB 00601, “A receivable has been established in the amount of the original payment: $XXX,XXX,XXX.XX. Future payments will be reduced or withheld until such amount is paid in full.” prints below the claim indicating the amount to be recouped. This amount appears under the heading, “Financial Transactions Accounts Receivable.” EOB 06065, “Account Receivable is due to the adjusted claim listed. For details, refer to your R&S Report for the date listed within the original date field.”

Claims adjusted as a result of a rate change will be listed on the R&S Report with EOB 01154 “This adjustment is a result of a rate change.”

​Refer to: Subsection 6.2.5, “Modifier Requirements for TOS Assignment” in this section for a list of the most commonly used modifiers.

6.11.4.3​Financial Transactions

All claim refunds, reissues, voids/stops, recoupments, backup withholdings, levies, and payouts appear in this section of the R&S Report. The Financial Transactions section does not use the R&S Report form headings. Additional subheadings are printed to identify the financial transactions. The following descriptions are types of financial items.

6.11.4.3.1​Accounts Receivable

This label identifies money subtracted from the provider’s current payment owed to TMHP. Specific claim data are not given on the R&S Report unless the accounts receivable control number is provided which should be referenced when corresponding with TMHP. Accounts receivable appear on the R&S Report in the following format:

•​Control Number. A number to reference when corresponding with TMHP.

•​Recoupment Rate. The percentage of the provider’s payment that is withheld each week unless the provider elects to have a specific amount withheld each week.

•​Maximum Periodic Recoupment Amount. The amount to be withheld each week. This area is blank if the provider elects to have a percentage withheld each week.

•​Original Date. The date the financial transaction was processed originally.

•​Original Amount. The total amount owed TMHP.

•​Prior Date. The date the last transaction on the accounts receivable occurred.

•​Medical Record Number. A number assigned by the provider, if available. This area is blank for purged claims.

•​Prior Balance. The amount owed from a previous R&S Report.

•​Applied Amount. The amount subtracted from the current R&S Report.

•​Balance. Indicates the total outstanding accounts receivable (AR) balance that remains due to TMHP.

•​FYE. The fiscal year end (FYE) for cost reports.

•​EOB. The EOB code that corresponds to the reason code for the accounts receivable.

•​Patient Name. The name of the patient on the claim, if the accounts receivable are claim-specific.

•​Claim Number. The ICN of the original claim, if the accounts receivable are claim-specific.

•​Backup Withholding Penalty Information. A penalty assessed by the Internal Revenue Service (IRS) for noncompliance due to a B-Notice. Although the current payment amount is lowered by the amount of the backup withholding, the provider’s 1099 earnings are not lowered.

•​Control Number. TMHP control number to reference when corresponding with TMHP.

•​Original Date. The date the backup withholding was set up originally.

•​Withheld Amount. Amount withheld (31 percent) of the provider’s checkwrite.

6.11.4.3.2​IRS Levies

The payments withheld from a provider’s checkwrite as a result of a notice from the IRS of a levy against the provider appear in the “IRS Levy Information” section of the R&S Report. Payments are withheld until the levy is satisfied or released. Although the current payment amount is lowered by the amount of the levy payment, the provider’s 1099 earnings are not lowered. IRS levies are reported in the following format:

•​Control Number. TMHP control number to reference when corresponding with TMHP.

•​Maximum Recoupment Rate. The percentage of the provider’s payment that is withheld each week, unless the provider elects to have a specific amount withheld each week.

•​Maximum Recoupment Amount. The amount to be withheld periodically.

•​Original Date. The date the levy was set up originally.

•​Original Amount. The total amount owed to the IRS.

•​Prior Balance. The amount owed from a previous R&S Report.

•​Prior Date. The date the last transaction on the levy occurred.

•​Current Amount. The amount subtracted from the current R&S Report and paid to the IRS.

•​Remaining Balance. The amount still owed on the levy. (This amount becomes the “previous balance” on the next R&S Report.)

6.11.4.3.3​Refunds

Refunds are identified by EOB 00124, “Thank you for your refund; your 1099 liability has been credited.” This statement is verification that dollars refunded to TMHP for incorrect payments have been received and posted. The provider’s check number and the date of the check are printed on the R&S Report. Claim refunds appear on the R&S Report in the following format:

•​Claim Specific:

•​ICN. The claim number of the claim to which the refund was applied this cycle.

•​Patient Name. The first name, middle initial, and last name of the patient on the applicable claim.

•​Medicaid Number. The patient’s Medicaid or CSHCN Services Program number.

•​Date of Service. The format MMDDCCYY (month, day, and year) in “From” DOS.

•​Total Billed. The total amount billed for the claim being refunded.

•​Amount Applied This Cycle. The refund amount applied to the claim.

•​EOB. Corresponds to the reason code assigned.

•​Nonclaim Specific:

•​Control Number. A control number to reference when corresponding with TMHP.

•​FYE. The fiscal year for which this refund is applicable.

•​EOB. Corresponds to the reason code assigned.

6.11.4.3.4​Payouts

Payouts are dollars TMHP owes to the provider. TMHP processes two types of payouts: system payouts that increase the weekly check amount and manual payouts that result in a separate check being sent to the provider. Specific claim data are not given on the R&S Report for payouts. A control number is given, which should be referenced when corresponding with TMHP. System and manual payouts appear on the R&S Report in the following format:

•​Payout Control Number. A control number to reference when corresponding with TMHP.

•​Payout Amount. The amount of the payout.

•​FYE. The fiscal year for which the payout is applicable.

•​EOB. Corresponds to the reason code assigned.

•​Patient Name. Name of the patient (if available).

•​PCN. Medicaid number of the patient (if available).

•​DOS. Date of service (if available).

6.11.4.3.5​Reissues

The provider’s 1099 earnings are not affected by reissues. A messages states, “Your payment has been increased by the amount indicated below”:

•​Check Number. The number of the original check.

•​Check Amount. The amount of the original check.

•​R&S Number. The number of the original R&S Report.

•​R&S Date. The date of the original R&S Report.

6.11.4.3.6​Voids and Stops

The provider’s 1099 earnings are credited by the amount of the voided/stopped payment.

•​Check Number. The number of the voided/stopped payment.

•​Check Amount. The amount of the voided/stopped payment.

•​R&S Number. The number of the voided/stopped payment.

•​R&S Date. The date of the voided/stopped payment.

6.11.4.4​Claims Payment Summary

This section summarizes all payments, adjustments, and financial transactions listed on the R&S Report. The section has two categories: one for amounts “Affecting Payment This Cycle” and one for “Amount Affecting 1099 Earnings.”

If the provider is receiving a check on this particular R&S Report, the following information is given: “Payment summary for check XXXXXXXXX in the amount of XXX,XXX,XXX.XX.” If the payment is EFT: “Payment summary for direct deposit by EFT XXXXXXXXX in the amount of XXX,XXX,XXX.XX.” The check number also is printed on the check that accompanies the R&S Report.

Headings for the Payment Summary for “Affecting Payment This Cycle” and
“Amount Affecting 1099 Earnings”

•​Claims Paid. Indicates the number of claims processed for the week and the year-to-date total.

•​System Payouts. The total amount of system payouts made to the provider by TMHP.

•​Manual Payouts (Remitted by separate check or EFT). The total amount of manual payouts made to the provider by TMHP.

•​Amount Paid to IRS for Levies. The amount remitted to IRS and withheld from the provider’s payment due to an IRS levy.

•​Amount Paid to IRS for Backup Withholding. The amount paid to the IRS for backup withholding.

•​Accounts Receivable Recoupments. The total amount withheld from the provider’s payment due to accounts receivable.

•​Miscellaneous Levies. The amount withheld from the provider’s payment and remitted to HHSC for a SHARS Admin Fee levy.

•​Amounts Stopped/Voided. The total amount of the payment that was voided or stopped with no reissuance of payment.

•​System Reissues. The amount of the reissued payment.

•​Claim Related Refunds. The total amount of claim-related refunds applied during the weekly cycle.

•​Nonclaim Related Refunds. The total amount of nonclaim-related refunds applied during the weekly cycle.

•​Approved to Pay/Deny Amount. The total amount of claim payments that were approved to pay/deny within the week. (This column will not be used at this time.)

•​Pending Claims. The total amount billed for claims in process as of the cutoff date for the report.

6.11.4.5​The Following Claims are Being Processed

In the “Following Claims are Being Processed” section, the R&S Report may list up to five EOPS codes per claim. The claims listed in this section are in process and cannot be appealed for any reason until they appear in either the “Claims Paid or Denied,” or “Adjustments Paid and Denied” sections of the R&S Report. TMHP is listing the pending status of these claims for informational purposes only. The pending messages should not be interpreted as a final claim disposition. Weekly, all claims and appeals on claims TMHP has “in process” from the provider are listed on the R&S Report. The Following Claims are Being Processed claim prints in the same format as a paid or denied claim.

6.11.4.6​Explanation of Benefit Codes Messages

This section lists the descriptions of all EOBs that appeared on the R&S Report. EOBs appear in numerical order.

EDI ANSI X12 5010 835 files display the appropriate Claims Adjustment Reason Code (CARC), Claims Adjustment Group Code (CAGC), and Remittance Advice Remarks Code (RARC) explanation codes that are associated with EOB denials.

The 835 file includes the CARC, CAGC, and RARC explanation codes that are associated with the highest priority detail EOB to provide a clearer explanation for the denial.

6.11.4.7​Explanation of Pending Status Codes Appendix

This section lists the description of all EOPS codes that appeared on the R&S Report. EOPS appear in numerical order.

EOB and EOPS codes may appear on the same pending claim because some details may have already finalized while others may have questions and are pending.

6.11.5​R&S Report Examples

Examples of R&S Reports are available on the TMHP website at www.tmhp.com.

6.11.6​Provider Inquiries—Status of Claims

TMHP provides several effective mechanisms for researching the status of a claim. Weekly, TMHP provides the R&S Report reflecting all claims with a paid, denied, or pending status. Providers verify claim status using the provider’s log of pending claims.

Electronic billers allow ten business days for a claim to appear on their R&S Reports. If the claim does not appear on an R&S Report as paid, pending, or denied, a transmission failure, file rejection, or claims rejection may exist. Providers check records for transmission reports correspondence from the TMHP EDI Help Desk.

The provider allows at least 30 days for a Medicaid paper claim to appear on an R&S Report after the claim has been submitted to TMHP. If a claim has not been received by TMHP and must be submitted a second time, the second claim must also meet the 95-day filing deadline.

The provider allows TMHP 45 days to receive a Medicare-paid claim automatically transmitted for payment of coinsurance or deductible according to current payment guidelines. Claims that fail to cross over from Medicare may be filed to TMHP by submitting a paper MRAN received from Medicare or a Medicare intermediary, the computer generated MRANs from the CMS-approved software applications MREP for professional services or PC-Print for institutional services or, for MAP clients, TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Template with the completed claim form.

If the claim does not appear on an R&S Report as paid, pending, or denied, providers can use any of the following procedures to inquire about the status of the claim:

•​The provider can use the claim status inquiry function of TexMedConnect on the TMHP website at www.tmhp.com.

•​The provider can call AIS at 800-925-9126 to determine if the claim is pending, paid, denied, or if TMHP has no record of the claim.

•​If any of the three options above indicates that TMHP has no record of the claim, the provider can call the TMHP Contact Center at 800-925-9126 and speak to a TMHP contact center representative.

•​If the TMHP Contact Center has no record of a claim that was submitted within the original filing deadline, the provider can submit a copy of the original claim to TMHP for processing. Electronic billers may refile the claim electronically. For claims submitted by a hospital for inpatient services, the filing deadline is 95 days from the discharge date or the last DOS on the claim. For all other types of providers, the filing deadline is 95 days from each DOS on the claim.

•​If the 95-day filing deadline has passed and the claim is still within 120 days of the date of the rejection report or the R&S Report, the provider can submit a signed copy of the claim and all of the documentation that supports the original claim submission, including any electronic rejection reports, to:

Texas Medicaid & Healthcare Partnership
Inquiry Control Unit
12365-A Riata Trace Parkway, Suite 100
Austin, TX 78727

Providers must retain copies of all R&S Reports for a minimum of five years. Providers must not send original R&S Reports back with appeals. Providers must submit one copy of the R&S Report to TMHP per appeal.

​Refer to: Subsection A.12.3, “Automated Inquiry System (AIS)” in “Appendix A: State, Federal, and TMHP Contact Information” (Vol. 1, General Information).

6.12​Filing Medicare Primary Claims

When a service is a benefit of both Medicare and Medicaid, the claim must be filed to Medicare first.

Providers should not file a claim with Medicaid until Medicare has dispositioned the claim unless the service is a Medicaid-only service.

All Medicare providers and suppliers who offer services and supplies to Qualified Medicaid Beneficiaries (QMB) or Medicaid Qualified Medicare Beneficiaries (MQMB) must not bill dual eligible clients for Medicare cost-sharing. This includes deductible, coinsurance, and copayments for any Medicaid covered items and services.

Medicaid claims for Qualified Medicare Beneficiary (QMB) and Medicaid Qualified Medicare Beneficiary (MQMB) clients can be filed to Medicaid for consideration of coinsurance and deductible payment as follows:

•​Medicare primary claims filed to Medicare Administrative Contractors (MACs) may be transferred electronically to TMHP through a Benefit Coordination and Recovery Center (BCRC).

•​Providers can submit crossover claims directly to TMHP using a paper claim form only for the specific circumstances indicated in the following section.

​Note:These guidelines do not apply to services that are rendered to clients who are living in a nursing facility.

​Refer to: Subsection 2.7, “Medicare Crossover Claim Reimbursement” in “Section 2: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for information about reimbursement for QMBs and MQMBs.

Subsection 4.9, “Medicare and Medicaid Dual Eligibility” in “Section 4: Client Eligibility” (Vol. 1, General Information) for information about MQMBs and QMBs eligibility.

6.12.1​Electronic Crossover Claims

Medicare primary claims filed to MACs may be transferred electronically to TMHP through a BCRC for claims that are processed as assigned. Providers should contact their MAC for more information.

This electronic crossover process allows providers to receive disposition from both carriers while only filing the claim once. Providers must allow 60 days from the date of Medicare’s disposition for a claim to appear on the Medicaid R&S Report.

If all services on the claim are denied by Medicare, the claim is not automatically transferred to TMHP by the MAC through the BCRC. Providers must submit the denied crossover claims to TMHP on paper.

Claims that are submitted to Medicare must include the facility’s NPI. Medicare crossover claims must comply with the Medicaid requirement to include a facility NPI. If a Medicare crossover claim includes a service for which Medicaid requires a facility NPI but the claim does not include the facility’s NPI number, the claim will be denied by Texas Medicaid.

​Important:TMHP accepts only electronic crossover claims that are automatically transferred to TMHP by the MAC through the BCRC. TMHP accepts only paper crossover claims from providers and other entities. TMHP does not accept electronic crossover new day claims or appeals from providers and other entities. TMHP accepts only paper appeals.

6.12.1.1​Type of Bills Values for Medicare Crossover Claims

Type of bills (TOB) values in the 12x series may be billed to Medicare for Medicare Inpatient Part B services as appropriate, but TOB values in the 12x series are not valid for Medicaid claims.

​Reminder:Texas Medicaid only allows interim billing and late changes to be submitted on inpatient claims

6.12.1.2​Medicare Copayments

Claims for Medicare copayments can also be submitted to TMHP. TMHP processes and pays Medicare HMO and Medicare PPO copayments for dual-eligible clients according to Medicaid guidelines.

The following procedure codes may be reimbursed for Medicare copayments:

The following Medicaid codes have been created for copayments, which are considered an atypical service:

TMHP may reimburse the copayment in addition to a service the HMO or PPO has denied if the client is eligible for Texas Medicaid and the procedure is reimbursed under Medicaid guidelines. Providers are not allowed to hold the client liable for the copayment.

An office or emergency room (ER) visit (the ER physician is paid only when the ER is not staffed by the hospital) is reimbursed a maximum copayment of $10 per visit. The hospital ER visit is reimbursed at a maximum of $50 to the facility. TMHP pays up to four copayments per day, per client. ER visits are limited to one per day, per client, and are considered one of the four copayments allowed per day.

​Refer to: Subsection 2.7.5.2, “Nephrology (Hemodialysis, Renal Dialysis) and Renal Dialysis Facility Providers” in “Section 2: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for information about claims for nephrology (hemodialysis, renal dialysis) and renal dialysis facility providers for Medicare crossover Claims.

Subsection 2.7.5, “Exceptions” in “Section 2: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for information about exceptions for Medicare Part A, Part B, and Part C (noncontracted MAPs) reimbursement.

6.12.1.3​Requirement for Group Billing Providers – Professional Claims

The performing provider NPI must be included on the professional electronic claim if the billing provider is a group. Claims are processed using the performing provider NPI that is submitted on the Medicare claim.

​Important:The performing provider who is identified on the claim must be a member of the billing provider’s group. If the performing provider is not a member of the billing provider group, the detail line item will be denied.

A claim is denied if the performing provider NPI is missing, invalid, or is not a member of the billing provider’s group. Denied claims may be appealed on paper with the appropriate performing provider information.

6.12.2​Paper Crossovers Claims

TMHP accepts only paper crossover claims or appeals from providers and other entities.

The following paper crossover claims may be submitted to TMHP:

•​For QMB and MQMB clients, if a crossover claim is not transferred to TMHP electronically through the BCRC, the provider can submit a paper claim to TMHP for coinsurance and deductible reimbursement consideration.

•​For MQMB clients, if a claim is denied by Medicare because the services are not a benefit of Medicare or because Medicare benefits have been exhausted, the provider can submit a paper claim to TMHP for coinsurance and deductible reimbursement consideration, and reimbursement consideration for the Medicaid-only services that were denied by Medicare. The Medicare EOB that contains the relevant claim denial must be submitted to TMHP with the completed claim from within 95 days from the Medicare disposition date and 365 days from the date of service. The denied services are processed as Medicaid-only services.

Claims that are submitted to Medicare must include the facility’s NPI. Medicare crossover claims must comply with the Medicaid requirement to include a facility NPI. If a Medicare crossover claim includes a service for which Medicaid requires a facility NPI but the claim does not include the facility’s NPI number, the claim will be denied by Texas Medicaid.

​Important:Claims that are denied by Medicare for administrative reasons must be appealed to Medicare before they are submitted to Texas Medicaid.

The paper submission must include all of the following:

•​The Medicare Remittance Advice (RA) or Remittance Notice (RN), using the CMS-approved software MREP, for professional services, or PC-Print or a paper MRAN from Medicare.

•​The appropriate, completed paper CMS-1500 or UB-04 CMS-1450 paper claim form.

​Note:Although it is not required, it is strongly recommended that providers send claim forms with their Medicare appeals in case one is needed for further processing.

•​The appropriate TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Template for Medicare Advantage Plan only. The template must be submitted with the claims form and the MAP EOB.

Providers that receive Remittance Advice Notices from a Medicare intermediary may submit these in place of the MRAN to TMHP which must contain the following required information:

•​Client name

•​Medicare number

•​NPI

•​Dates of service

•​Procedure code (Professional and Outpatient claims)

•​Billed amount

•​Medicare allowed amount or non-covered amount

•​Deductible amount

•​Co-insurance amount

•​Medicare paid amount

•​Medicare ICN

•​Quantity billed

6.12.2.1​Deductible or Coinsurance Amount Balancing

The Texas Medicaid claims processing system validates that the total Medicare deductible and coinsurance amounts on the claim header match the sum of the detail Medicare deductible and coinsurance amounts.

For paper crossover claims, providers must submit the same information to Texas Medicaid that was received from Medicare.

Texas Medicaid will reimburse Medicare crossover claims up to the Texas Medicaid allowed amount for Medicaid-covered services. System enhancements have been identified to ensure appropriate age restrictions are enforced applicable to the services rendered.

Example:​For a Medicare service provided to an adult client, if that service is only payable to Medicaid for clients who are 20 years of age and younger, the age restriction will be applied and the Medicaid allowed amount will be zero. Since the Medicare payment exceeds the Medicaid allowed amount or encounter payment for the service, Texas Medicaid will not make a payment for coinsurance liabilities.

Because Medicare reimbursed more than Medicaid allowed, the client has no liability for any balance or Medicare coinsurance related to the rendered services.

6.12.2.2​TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Template

The TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Template must be submitted for paper MAP claims only. The template must be submitted with the claim form and the MAP EOB.

​Note:Providers must not submit the template for traditional Medicare crossover claims.

The following guidelines apply for the submission of the TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Templates:

•​The Medicare ICN must be included on the form. Claims are denied if the Medicare ICN is omitted.

•​For the TMHP Crossover Professional Claim Type 30 form, the performing provider NPI and taxonomy code must be submitted on each detail line item. A detail line item is denied if the performing provider NPI or taxonomy code is omitted, or if the performing provider is not a member of the group billing provider.

•​For the TMHP Crossover Outpatient Facility Claim Type 31 form, the detail line items are required. Claims are denied if the details are omitted.

•​The TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Template must be submitted with a completed claim form and MAP EOB, must be legible, and must identify only one client per page. Providers must not submit handwritten MAP templates.

Claims that do not meet these standards are not processed and are returned to the provider.

By submitting the TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Templates to TMHP, the provider attests that the information included in the template matches the EOB that was received from the MAP. If the information on the template does not exactly match the information on the RA or RN, the claim may be denied.

​Refer to: Subsection 6.20, “Forms” in this section for the TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Templates and instructions.

Subsection 2.7, “Medicare Crossover Claim Reimbursement” in “Section 2: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information).

6.12.2.3​Crossover Paper Claims Filing Deadlines

The paper crossover claim with all required, EOBs, templates, and forms must be received by TMHP within 95 days of the Medicare date of disposition and 365 days from the date of service in order to be considered for processing.

6.12.3​Filing Medicare-Adjusted Claims

TMHP accepts crossover appeals only on paper.

Providers may submit Medicare-adjusted claims by submitting the adjusted Medicare RA/RNs (paper or electronic) and the appropriate TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Template. The information on the Medicare RA/RN must exactly match the information submitted on the TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Template.

​Refer to: Subsection 3.7.1, “Medicaid Relationship to Medicare” in the Inpatient and Outpatient Hospital Services Handbook (Vol. 2, Provider Handbooks) for additional information on hospital Medicare claims filing requirements.

​Important:TMHP does not accept electronic crossover appeals.

6.13​Medically Needy Claims Filing

TMHP must receive claims for unpaid bills not applied toward spend down within 95 days from the date eligibility was added to the TMHP client eligibility file (add date). These bills must be on the appropriate claim form (for example, CMS-1500 or UB-04 CMS-1450). Providers are allowed to submit completed CMS claim forms directly to the Medically Needy Clearinghouse (MNC) or to applicants for the Medically Needy Program (MNP) to be used to meet spend down. The completed CMS claim forms used to meet spend down are held for ten calendar days by the MNC, then forwarded to TMHP claims processing. Claims for services provided after the spend down is met must be received within 95 days from the date eligibility is added. Inpatient hospital facility claims must be received within 95 days from the date of discharge or last DOS on the claim. This applies when eligibility is not retroactive.

The client’s payment responsibilities are as follows:

•​If the entire bill was used to meet spend down, the client is responsible for payment of the entire bill.

•​If a portion of one of the bills was used to meet the spend down, the client is responsible for paying the portion applied toward the spend down, unless it exceeds the Medicaid allowable amount.

•​The claim must show the total billed amount for the services provided. Charges for ineligible days or spend down amounts should not be deducted or noncovered on the claim.

•​A client’s payment toward spend down is not reflected on the claim submitted to TMHP.

•​A client is not required to pay the spend down amount before a claim is filed to Medicaid.

•​Payments made by the client for services not used in the spend down but were incurred during an eligible period must be reimbursed to the client before the provider files a claim to TMHP.

•​Services that require prior authorization and are provided before the client becomes eligible for Medicaid by meeting spend down are not reimbursable by Texas Medicaid.

•​If a bill or a completed CMS claim form was not used to meet spend down and the dates of service are within the client’s eligible period, submit the total bill to TMHP.

When eligibility has been established, a TP 55 with spend down client can receive the same care and services available to all other Medicaid clients. If eligibility is established through TP 30 with spend down, the client’s Medicaid eligibility is restricted to coverage for an emergency medical condition only. Emergency medical condition is defined under Emergency medical condition is defined under subsection 4.3.2.2, “Exceptions to Lock-in Status” in “Section 4: Client Eligibility” (Vol. 1, General Information).

6.14​Claims Filing for Consumer-Directed Services (CDS)

Clients who participate in the CDS option for both PCS and a waiver program, through HHSC are required to choose one Financial Management Services Agency (FMSA) to provide services through both programs. FMSAs are permitted to file only the financial management services (FMS) fee, also known as the monthly administrative fee, through one program. The FMSA should file the FMS claim through the program with the highest reimbursement rate. Currently, the waiver programs have a higher reimbursement rate for the FMS fee than the Texas Medicaid PCS benefit, so a FMSA should file claims for the monthly FMS fee through the waiver programs.

The U8 modifier, which is used when submitting claims for the monthly PCS administrative fee, must be prior authorized. The DSHS case managers have two options when sending a prior authorization request for PCS to TMHP:

•​If a client is only using the CDS option for Texas Medicaid PCS, a case manager will submit a prior authorization request to TMHP that approves the U8 modifier and either the U7 or UB modifier. In this case, the provider authorization notification letter will include the U8 modifier and the U7 or UB modifier.

•​If a client is using the CDS option for both Texas Medicaid PCS and a waiver program, a case manager will submit a prior authorization request to TMHP that approves either the U7 or UB modifier. The U8 modifier will not be prior authorized in this situation.

When a provider authorization notification letter is received by a FMSA, the provider should verify that the correct modifiers have been prior authorized for each PCS client. Providers who think that the approved modifiers are incorrect should contact the DSHS case manager and ask for the correct modifiers to be submitted to TMHP for prior authorization.

6.15​Claims Filing for Home Health Agency Services

Providers must use only type of bill (TOB) 321 in Form Locator (FL) 4 of the UB-04 CMS-1450. Other TOBs are invalid and will result in a claim denial. Home Health Services must be submitted to TMHP in an approved electronic format or on a CMS-1500 or a UB-04 CMS-1450 paper claim form. Submit home health DME and medical supplies to TMHP in an approved electronic format, or on a CMS-1500 or on a UB-04 CMS-1450 paper claim form. Providers may purchase CMS-1500 or UB-04 CMS-1450 paper claim forms from the vendor of their choice. TMHP does not supply them.

When completing a CMS-1500 or a UB-04 CMS-1450 paper claim form, all required information must be included on the claim, as TMHP does not key information from attachments.

​Refer to: “Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information) for information about electronic claims submissions.

Subsection 6.5, “CMS-1500 Paper Claim Filing Instructions” in this section for instructions on how to complete paper claims. Blocks that are not referenced are not required for processing by TMHP and may be left blank.

Subsection 6.6, “UB-04 CMS-1450 Paper Claim Filing Instructions” in this section.

Outpatient claims must have the appropriate revenue code and, if appropriate, the corresponding Healthcare Common Procedure Coding System (HCPCS) code or narrative description. The prior authorization number must appear on the CMS-1500 paper claim form in Block 23 and in Block 63 of the UB-04 CMS-1450 paper claim form. The certification dates or the revised request date on the POC must coincide with the DOS on the claim. Prior authorization does not waive the 95-day filing deadline requirement.

6.16​Claims for Medicaid Hospice Clients Not Related to the Terminal Illness

When the services are unrelated to the terminal illness, providers must submit a claim for Medicaid services to TMHP. The claim must include a statement and documentation from the hospice that the services billed are not related to the client’s terminal illness.

If TMHP denies the claim, the following information must be submitted with the providers appeal.

•​A copy of the R&S Report, with the client or claim number in question circled

•​Clinical records, which may be obtained from the hospice provider

•​Supporting documentation giving reasons the services billed are not related to the terminal illness

​Refer to: Subsection 4.3.3, “Hospice Program” in “Section 4: Client Eligibility” (Vol. 1, General Information) for more information related to Medicaid hospice client benefits and eligibility.

6.16.1​Medical Services When Client is Discharged From Hospice

Submit claims to TMHP for Medicaid services with a statement that the services billed were provided after the client was discharged from the Hospice Program. The provider must obtain a copy of Form 3071, Medicaid Hospice Cancellation, from the Hospice Program to support the discharge.

If TMHP denies the claim, the provider may appeal the decision with the following information:

•​A copy of the R&S Report, with the client or claim number in question circled

•​Supporting documentation stating that the client was not in hospice at the time

6.16.2​Claims Address for Medicaid Hospice Clients Not Related to the Terminal Illness

Mail paper claims to the following address:

Texas Medicaid & Healthcare Partnership
PO Box 200105
Austin, TX 78720-0105

Appeal claims by writing to the following address:

Texas Medicaid & Healthcare Partnership
PO Box 200645
Austin, TX 78720-0645

6.16.3​Lab and X-Ray

Submit claims for services unrelated to the terminal illness to TMHP. Submit claims for services related to the terminal illness to the hospice provider.

6.17​Claims for Texas Medicaid and CSHCN Services Program Eligible Clients

The CSHCN Services Program is the payer of last resort when clients have other insurance, including Texas Medicaid and private carriers. The CSHCN Services Program does not supplement a client’s Texas Medicaid benefits; however, services that are not a benefit of Texas Medicaid, such as hospice and medical foods, may be covered by the CSHCN Services Program.

6.17.1​New Claim Submissions

New claims that are submitted for clients who are eligible for both Texas Medicaid and CSHCN Services Program benefits during the same eligibility period will be processed through the appropriate program and may result in a separate claim for each program. The Medicaid claim number and disposition will be listed under the “Claims – Paid or Denied” section of the Medicaid/Managed Care R&S Report. If the claim includes services that are not benefits of Texas Medicaid but are benefits of the CSHCN Services Program, a claim will be created with a unique claim number that will be listed under the “Claims – Paid or Denied” section of the CSHCN Services Program R&S Report.

​Note:If all of the services that are submitted on the claim are Texas Medicaid benefits, a CSHCN Services Program claim will not be created. Only a Texas Medicaid claim will be created, and the claim number will appear on the provider’s Medicaid/Managed Care R&S Report.

6.17.2​CSHCN Services Program Claims Reprocessing for Retroactive Texas Medicaid Eligibility

Claims that have already been paid by the CSHCN Services Program for clients who received retroactive Texas Medicaid eligibility for dates of service covered on the paid claims will be reprocessed to pay under the appropriate program. The reprocessed CSHCN Services Program claim number will appear under the “Adjustments – Paid or Denied” section of the CSHCN Services Program R&S Report. An accounts receivable will be created for services covered by Texas Medicaid that will be reflected on the “Financial Transactions” page under the “Accounts Receivable” section of the CSHCN Services Program R&S Report. The claim will be reprocessed to Texas Medicaid and given a new claim number. The new Texas Medicaid claim number and disposition will appear under the “Claims – Paid or Denied” section of the Medicaid/Managed Care R&S Report.

TMHP will contact providers when it reprocesses claims for services that require a Texas Medicaid prior authorization. Providers will be informed that a Texas Medicaid prior authorization must be submitted within a specified time frame for the claim to be considered for processing through Texas Medicaid.

6.18​Claims for State Supported Living Center Residents (SSLC)

Medicaid providers who render off-campus acute care services to Medicaid-eligible State Supported Living Center (SSLC) residents must submit claims directly to Medicaid. This is applicable only to residents of the SSLCs operated by HHSC.

Claims and prior authorization requests for acute care services rendered to these individuals must be submitted to Medicaid. These requests must be submitted according to guidelines for acute care services as indicated in this manual.

​Refer to: “Section 5: Fee-for-Service Prior Authorizations” (Vol. 1, General Information) for more information on prior authorizations.

6.19​Children’s Health Insurance Program (CHIP) Perinatal Claims

Claims for services provided to CHIP Perinatal Program clients are submitted to and considered for reimbursement as follows:

•​For women with income at or below 198 percent FPL:

•​Hospital facility charges are paid through Emergency Medicaid and processed by TMHP.

•​Professional service charges are paid through the CHIP Perinatal Program and processed through CHIP.

​Note:Delivery-related professional services claims denied by the CHIP Perinatal health plan will be considered for reimbursement through Emergency Medicaid and will require the CHIP Perinatal health plan denial notice. These claims should be submitted through the existing Medicaid appeals process within 95 days from the date of the CHIP Perinatal Health plan denial notice. The provider must provide a copy of the complete explanation of benefits that includes the complete description of the reason for denial.

•​For newborns with a family income at or below 198 percent FPL:

•​Hospital facility charges are paid through Medicaid and processed by TMHP.

•​Professional service charges are paid through Medicaid and processed by TMHP.

Inpatient services (limited to labor with delivery) for unborn children and women with income at or below 202 of FPL will be covered under CHIP Perinatal, and these claims will be paid by the CHIP Perinatal health plan.

6.19.1​CHIP Perinatal Newborn Transfer Hospital Claims

TMHP processes CHIP Perinatal newborn transfer hospital claims even if the claim from the initial hospital stay has not been received.

The hospital transfer must have occurred within 24 hours of the discharge date from the initial delivery hospital stay. This change applies only to CHIP Perinatal newborns with a family income at or below 198 percent of the FPL.

Transfer claims must be filed with TMHP on an electronic institutional claim or the UB-04 CMS-1450 paper claim form using admission type 1, 2, 3, or 5 in block 14, source of admission code 4 or 6 in block 15, and the actual date and time the client was admitted in block 12 of the UB-04 CMS-1450 paper claim form.

6.20​Forms

The following linked forms can also be found on the Forms page of the Provider section of the TMHP website at www.tmhp.com: