MedBasics2 PG 0601 - TMHP remove/Medicaid Basics...Medicaid Basics Part 2 Workshop Participant Guide Prior Authorization Submissions Prior authorizations can be submitted to TMHP on

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Participant Guide

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2010 0628 — CPT only copyright 2008 American Medical Association. All rights reserved. 1

Medicaid Basics Part 2 Workshop Participant Guide

Contents

Prior Authorization ............................................................................................................... 3What is Prior Authorization? ................................................................................................ 3Precertifi cation ..................................................................................................................... 3Examples .............................................................................................................................. 3Prior Authorization Submissions .......................................................................................... 5Submitting Online Prior Authorization Requests ................................................................. 5Search for an Existing Prior Authorization and Review Status .............................................. 7Online Radiology Prior Authorization Requests ................................................................... 9Radiology Prior Authorization Request Form ..................................................................... 10THSteps Dental Mandatory Prior Authorization Request Form ......................................... 11

Claims Filing........................................................................................................................ 12Claims ............................................................................................................................... 12TMHP Claims Processing Procedures ............................................................................... 12Electronic Claims .............................................................................................................. 13Claim Form Determination ............................................................................................... 16Claim Filing Instructions for TexMedConnect ................................................................... 17Saving a Claim ................................................................................................................... 19CMS-1500 Paper Claim Form ........................................................................................... 20UB-04 CMS-1450 Paper Claim Form ............................................................................... 21Family Planning 2017 Paper Claim Form .......................................................................... 22Filing Paper Claims ............................................................................................................ 23Tips on Expediting Paper Claims ....................................................................................... 23

Medicare Crossover Claims ................................................................................................. 25Medicare Crossover Reimbursement of Part B.................................................................... 25

Th ird Party Resources (TPR) .............................................................................................. 26

Filing Deadlines ................................................................................................................... 29Filing Deadine Calendar for 2010 ...................................................................................... 30

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2 CPT only copyright 2008 American Medical Association. All rights reserved. — 2010 0628


Remittance and Status Report ............................................................................................. 31Accessing R&S Reports ...................................................................................................... 32R&S Report Sections ......................................................................................................... 34Electronic Remittance and Status (ER&S) Agreement ....................................................... 37ER&S Agreement - Submission Instructions ...................................................................... 38Electronic Funds Transfer (EFT) Authorization Agreement ................................................ 39Electronic Funds Transfer (EFT) Information .................................................................... 40

Appeals ................................................................................................................................. 41Appeal Methods ................................................................................................................ 41Electronic Appeals .............................................................................................................. 42Automated Inquiry System (AIS) Appeals .......................................................................... 43Paper Claim Appeals .......................................................................................................... 44HHSC Administrative Appeals ......................................................................................... 45Complaints by Providers .................................................................................................... 46

Child Abuse Reporting ........................................................................................................ 48DSHS Child Abuse Reporting Form .................................................................................. 48

Waste, Abuse, and Fraud ..................................................................................................... 50Defi nitions ......................................................................................................................... 50Most Frequently Identifi ed Fraudulent Practices ................................................................ 50Identifying and Preventing Waste, Abuse, and Fraud .......................................................... 50Reporting Waste, Abuse, and Fraud ................................................................................... 51

Medicaid Vendor Drug Program (VDP) ............................................................................. 52

Resources ............................................................................................................................. 53Instructions for Using the TMHP Website ......................................................................... 53Online Fee Lookup ............................................................................................................ 56Online Provider Lookup .................................................................................................... 58Provider Information Change Form ................................................................................... 64

Communication With TMHP ............................................................................................. 65TMHP Telephone and Fax Communication ...................................................................... 65Prior Authorization Request Telephone and Fax Communication ...................................... 66Prior Authorization Status Telephone Communication ...................................................... 66Written Communication With TMHP .............................................................................. 67Helpful Links .................................................................................................................... 70Steps to Resolve Your Medicaid Questions ......................................................................... 71Common Claim Denial Codes ........................................................................................... 72Acronyms ........................................................................................................................... 73



Prior Authorization

What is Prior Authorization?

Prior authorization is the process of obtaining advanced approval of coverage for a health-care service. A prior autho-rization is processed and created by TMHP for Medicaid Primary Care Case Management (PCCM) clients and for Medicaid clients who are NOT enrolled in a Medicaid managed care plan.

Some of the services that are benefi ts of Texas Medicaid are infrequent or very costly. To verify that these items are medically necessary, TMHP requires providers to request prior authorization for the service. Providers can submit a request for prior authorization on the TMHP website, by fax or mail, or in some cases by phone. Th ese requests are reviewed by a team of nurses with TMHP’s prior authorization group who review the request for completeness and proof of medical necessity. If the medical necessity of an item or service is in question, it can be forwarded to one of the medical directors for review.

If a service or item requires a prior authorization, and the provider fails to obtain it, the claim for that service will be denied. Authorization is a condition of reimbursement, not a guarantee of payment.

Precertifi cation

A precertifi cation is prior authorization, that is processed and created by a managed care organization. Precertifi ca-tion is the process of obtaining certifi cation of coverage from a health-care plan for routine hospital stays, continued hospital stays, and outpatient procedures. Th is process involves reviewing criteria to determine benefi t coverage.

Examples

Examples of services that require prior authorization (this is not an all-inclusive list):

Home Health:

Skilled Nursing (SN) Visits•

Home Health Aide•

Physical Th erapy•

Occupational Th erapy•

Durable Medical Equipment (DME)/Medical Supplies •

Oxygen Th erapy •

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Chest Physiotherapy Devices•

System In-Home Use •

Wheelchair/Scooter/Stroller •

Total Parenteral Nutrition (TPN)•

Enteral Equipment and Supplies •

THSteps Dental

Some therapeutic services•

Orthodontic services•

Comprehensive Care Inpatient Psychiatric (CCIP):

Psychiatric Hospital Initial Admission•

Psychiatric Inpatient Extended Stay •

Comprehensive Care Program (CCP):

CCP ECI for Initial/Renewal Outpatient Th erapy •

CCP Outpatient Th erapy (PT, SLP, or OT) •

Extension of Outpatient Th erapy •

Donor Human Milk Request •

Pulse Oximeter •

Texas Medicaid Palivizumab (• Synagis)

Apnea Monitor •

Bed/Crib •

Formula•

Photo Th erapy•

Private Duty Nursing (PDN)•

Ambulance:

Nonemergency Transports•

Out-of-State Emergency Transports•

Special Medical Prior Authorizations (SMPA):

Extended Outpatient Psychotherapy/Request •

Transcutaneous electrical nerve stimulators (TENS)•

Doctor of Dentistry Practicing as a Limited Physician•

For information about online radiology prior authorizations, refer to Volume 1, Section 5.3.3 in the 2010 Texas Medicaid Provider Procedures Manual (TMPPM). For information about prior authorization requests on Medicaid secondary claims, refer to Section 5.1.3 in Volume 1 of the 2010 TMPPM. For more information about prior authorization, refer to your specifi c provider section in the 2010 TMPPM.

Note: Prior Authorization forms can be found in the 2010 TMPPM.



Prior Authorization Submissions

Prior authorizations can be submitted to TMHP on paper via fax or mail. Prior authorization mailing addresses and fax numbers are located on pages 65 and 66 of this participant guide.

Most prior authorization requests can be submitted electronically through the TMHP website at www.tmhp.com. Exceptions include THSteps dental services and services for the Children with Special Health Care Needs (CSHCN) Services Program. For other exceptions, refer to the 2010 TMPPM.

Note: Providers must maintain paper hard copies of the required prior authorization/precertifi cation forms on fi le regard-less of submission method.

Submitting Online Prior Authorization Requests

Go to the TMHP website at www.tmhp.com. 1.

Click the link, “2. Submit a Prior Authorization.”

Enter your username and password in the pop-up box. 3.

Texas Medicaid providers who do not have an existing account must set up a provider administrator account to access online claim submission and the other secure functions of the website.

On the fi rst screen, complete the following information.4.

Provider/Supplier ID – : Select the requesting provider or supplier’s valid National Provider Identifi er (NPI)/Atypical Provider Identifi er (API) from the drop-down menu. Th e menu’s selections are based on the access granted to the user by the provider administrator.

Client ID: – Enter the valid nine-digit client ID for which the prior authorization is being requested.

Authorization Area: – Select the appropriate authorization area for the request. Authorization areas included in the prior authorization system include Home Health, CCP, CCIP, SMPA, Ambulance, and PCCM.

Submission Type: – Select the appropriate submission type for the request.

Requested Authorization Dates: – Use the calendar drop-down function or type in the dates in a mm/dd/yyyy format for dates of service for which you are requesting the authorization.



Click the 5. Next Step button.

When the button is clicked, the system verifi es client eligibility for the requested prior authorization dates and checks for duplicate prior authorizations.

On the next screen, verify the information on the screen that has been automatically populated by the system.6.

Complete the remaining information. Questions are based on the services or items requested.7.



Read the terms and conditions and acknowledge consent by checking the 8. We Agree checkbox.

Certifi cation and Terms and Conditions: Before submitting each prior authorization request, the provider and authorization request submitter must read, understand, and agree to the certifi cation and terms and conditions of the prior authorization request.

Submit the Request.9.

Submit the Request: After the “We Agree” checkbox is checked, the “Submit Request” button at the bottom of the page becomes enabled. To submit the request to TMHP, click the “Submit Request” button. After the button has been selected, the prior authorization is checked against a series of validation edits, which confi rm that all required fi elds have been populated.

Once a request is complete and passes all of the validation edits, the prior authorization request is saved, and the user is given a prior authorization number (PAN).

Note: Receipt of the PAN does not mean that the prior authorization has been approved. Providers must check the status to determine if their authorization has been approved. TMHP will issue a response to an authorization within 3 business days.

Attachments to Online Prior Authorization Requests

Currently, attachments cannot be submitted with online prior authorization requests. If it is necessary to submit an attachment with a prior authorization request, providers must send the request and attachments by mail or fax. Providers that submit attachments to an authorization request that was submitted through the online portal must include the PAN on the attachments.

Search for an Existing Prior Authorization and Review Status

Users can search for a prior authorization and review prior authorization status on the TMHP website at www.tmhp.com. Th is functionality is available for all prior authorizations that are currently in the TMHP system, including PCCM.

Go to the TMHP website at www.tmhp.com.1.

Click “2. Search/Extend an Existing Prior Authorization.”

Th e next screen gives you two choices: fi nding an existing authorization request by entering a prior authoriza-tion number or searching by NPI/API numbers and dates. For this example, we will search using NPI numbers and dates.

Click the “3. Or Search for a Request” button.

Select the provider’s or supplier’s valid NPI from the drop-down menu.4.

Enter the valid nine-digit client ID. 5.

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Th is is an optional fi eld. If this fi eld is not populated, the search is completed for all of the potential clients in the TMHP system.

Use the drop-down calendar function or type in the dates for which prior authorization 6. was requested. Th e prior authorization date is required in the “From” fi eld. Th e prior au-thorization date is optional for the “Th rough” fi eld.

If the “Th rough” fi eld is not populated with a date, the search defaults to the current date.

Click the “7. Search” button.

A list of prior authorization requests that meet the criteria is displayed.

To view a specifi c prior authorization request, click on the blue, underlined number in the 8. “Auth #” fi eld.

Each prior authorization request will have at least two statuses—the complete status of the entire prior authorization request and the status of each detail.

Th e status can be found in the “Status” fi eld within the Authorization Information section of the prior authorization request being viewed. Th e complete prior authorization request has one of the following four statuses:

In Process:• TMHP has received the prior authorization request but is still in the process of reviewing it. It has not yet been determined whether the prior authorization will be ap-proved.

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Pending:• TMHP has received and reviewed the prior authorization request and has determined that more information is necessary before fi nalizing the status. TMHP staff will contact the requesting provider or supplier by telephone, fax, or mail for additional information.

Approved:• TMHP has approved at least one procedure detail in the prior authorization request. Refer to the procedure details section to identify which procedure details have been approved.

Denied:• TMHP has denied the prior authorization request. TMHP has sent the requesting provider or supplier correspondence about the denial by mail or fax.

Online Radiology Prior Authorization Requests1

Prior authorization is now available online for computed tomagraphy (CT), computed tomog-raphy angiography (CTA), magnetic resonance imaging (MRI), and magnetic resonance an-giography (MRA). Prior authorization for outpatient, nonemergent CT, CTA, MRI, or MRA is required for Texas Medicaid fee-for-service (FFS) and PCCM.

MedSolutions, Inc. performs radiology authorization services on behalf of TMHP. Radiology prior authorization requests may be submitted through the MedSolutions website at www.medsolutionsonline.com.

Providers can also access the MedSolu-tions website through the TMHP website at www.tmhp.com by clicking the “Submit Radiology Prior Authorization” link under the “I would like to...” heading on the right side of the homepage.

Providers may also submit radiology prior au-thorization requests by telephone, fax, or mail as follows:

Telephone: • 1-800-572-2116

Fax:• 1-800-572-2119

Mail:•

Texas Medicaid & Healthcare Partnership730 Cool Springs Blvd., Suite 800

Franklin, TN 37067

Note: Telephone requests for radiology prior authorization must be submitted by calling this dedicated TMHP toll-free telephone number.

1 Source: 2010 Texas Medicaid Provider Procedures Manual, Volume 1, Section 5.3.3.1



Radiology Prior Authorization Request Form This form is used to obtain prior authorization for elective outpatient services or update an existing outpatient authorization. All fields marked with an asterisk (*) are required. The information in Section 2 is only required for updated or retroactive authorizations. Forms that are submitted without all of the required information will be returned for correction.

Telephone number: 1-800-572-2116 Fax number: 1-800-572-2119 *Date of Request: / /

Please check the appropriate action requested:

CT Scan CTA Scan MRI Scan MRA Scan PET Scan Cardiac Nuclear Scan Update/change codes from original PA request

Client Information

*Name: *Medicaid number: *Date of Birth: / /

Facility Information

*Name: Reference number:

*Address:

TPI: *NPI:

Taxonomy: Benefit Code:

Requesting/Referring Physician Information

*Name: License number:

*Address:

*Telephone: *Fax number:

TPI: *NPI:


Section 1

Service Types *Outpatient Service(s) Emergent/Urgent Procedure

Date of Service: / / *Procedures Requested:

Diagnosis Codes *Primary: Secondary:

*Clinical documentation supporting medical necessity for a radiology procedure includes treatment history, treatment plan, medications, and previous imaging results:

*Requesting/Referring Physician (Signature Required):

*Print Name: *Date: / /

Section 2—Updated Information (when necessary) *Date of Service: / / *Procedures Requested:

Diagnosis Codes *Primary: Secondary:

*Clinical documentation supporting medical necessity for a procedure code change includes treatment history, treatment plan, medications, and previous imaging results:

*Requesting/Referring Physician (signature required):

*Print Name: *Date: / /

Physician must complete and sign this form prior to requesting authorization.

Requesting/Referring Physician License No.:

*Requesting/Referring Physician NPI: Requesting/Referring Physician TPI:

Effective Date_02012010/Revised Date_10012009

SAMPLEEEELEmber: LLLLELLLE*Fax number:

PLP* PPPLPBenefit CoPPPLMPMPEmergent/

MPMP*ProcMMMMMg medical necessity for a radiolo

AMASArring Physician (Signature ReSASAormationS/ SS



THSteps Dental Mandatory Prior Authorization Request Form


Submit to:

THSteps Dental

Prior Authorization Unit

PO Box 202917

Austin, TX 78720-2917

Note: All information is required—print clearly or type Patient Information

Name: Date of Birth: / /

Address:

Medicaid Number: Gender: M F

Check the following diagnostic tools submitted for review with the authorization rrequest:

Restorative and intermediate care facility for the mentally retarded (ICF-MR)

Panorex FM X-ray Periapicals Documentation Photos

Orthodontic case, I certify all primary dentition have been exfoliated (D8080).

Models HLD Panorex Documentation Cephlometric X-ray

FM X-ray Photos Other

Date of service diagnostic tools were produced: Proposed treatment plan: Procedure Code Tooth

Number or Letter

Surface Charge

Note: All information is required—print clearly or type Signature of dentist: Date: / /

Printed or typed name of dentist: Dentist telephone:

Dentist address:

Performing Dentist Identifying Numbers

TPI: NPI:


SAMPLEGende

EEEe Ea Eu Et Eh EEEEzEaEtEiEoEEEEDocum PhotLEEEEexfoliated (D8080). LEDocumentation PPPLLLPLPL

e produced:

MPMPTooth Number or etter

Surface MMMPAMMAMAMAMMMAMMAMAMAMMMAMMAMAMAMAM

SAAAASAAAASAAAASAAAASSSThis form cannot be submitted online. Submit paper

forms to the address above.



Claims Filing

Claims2

A claim is a request for reimbursement for services rendered. Claims are submitted to TMHP. Because Texas Med-icaid cannot make payments to clients, the provider who performs the service must fi le an assigned claim. Federal regulations prohibit providers from charging clients a fee for completing or fi ling Medicaid claim forms. Providers are not allowed to charge TMHP for fi ling claims. Th e cost of claims fi ling 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 reimbursement.

Claims can be fi led electronically or by paper. Many claims are submitted to TMHP electronically through TexMed-Connect. When providers fi le claims electronically, claims are processed more quickly and accurately which results in faster reimbursement.

TMHP Claims Processing Procedures

Medicaid claims are subject to the following procedures:

TMHP verifi es all required information is present. •

At the end of each week, claims that are fi led under the same provider identifi er and program and that are • ready for disposition are paid to the provider with an explanation of each payment or denial. Th e explanations are included in 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 fi le is also available for those providers who wish to import claim dispositions into a fi nancial system. An R&S Report is generated for providers that have weekly claim or fi nancial activity whether or not they received payment. Th e report identifi es pending, paid, denied, and adjusted claims. If no claim activity or outstanding account receivables exist for the provider during the time period, that provider’s R&S Report is not generated for the week.

Procedure Coding3

Th e procedure coding system used by Texas Medicaid is called the Healthcare Common Procedure Coding System (HCPCS). HCPCS provides health-care providers and third-party payers a common coding structure that uses a fi ve-character numeric or alphanumeric base for all codes.

2 Source: 2010 Texas Medicaid Provider Procedures Manual, Volume 1, Section 6.1

3 Source: 2010 Texas Medicaid Provider Procedures Manual, Volume 1, Section 6.3.3



HCPCS consists of two levels of codes, including the Current Procedural Terminology (CPT®) Professional Edition (Level I) and the HCPCS codes approved and released by Centers for Medicare & Medicaid Services (CMS) (Level II).

Modifi ers describe and qualify the services provided. A modifi er is placed after the fi ve-digit procedure code. Up to two modifi ers may apply per service. Refer to the service-specifi c sections of the 2010 TMPPM for additional modi-fi er requirements.

Benefi t Code

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

Providers that participate in the following programs must use the associated benefi t code when submitting claims and prior authorization requests:

Program Benefi t Code

Comprehensive Care Program (CCP) CCP

CSHCN Services Program CSN

THSteps Medical EP1

THSteps Dental DE1

Family Planning Agencies* FP3

Hearing Aid Dispensers HA1

Maternity MA1

County Indigent Health Care Program CA1

Early Childhood Intervention (ECI) Providers ECI

Tuberculosis (TB) Clinics TB1

Texas Medicaid Program Home Health DME DM2

CSHCN Services Program DME DM3

Case Management Mental Retardation (MR) Providers MH2

*Agencies only: Benefi t codes should not be used for individual family planning providers.

National Drug Code (NDC)4

All Texas Medicaid FFS, PCCM, and Family Planning providers must submit an NDC for professional or outpa-tient electronic and paper claims for physician-administered prescription drugs. Procedure codes in the A code series do not require an NDC.

More information on NDC can be found in Volume 1, Section 6.3.4 of the 2010 TMPPM.

Electronic Claims

Providers that submit electronic claims are required to complete the Benefi t Code fi eld (when applicable), Address fi eld, and Taxonomy Code fi eld.

Group billing providers are not required to submit a taxonomy code on all electronic claims.

4 Source: 2009 Texas Medicaid Provider Procedures Manual, Section 6.3.4

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Billing providers that are not associated with a group are required to submit a taxonomy code on all electronic claims. TMHP will reject claims for non-group billing providers (individuals and facilities) that are submitted without a taxonomy code.

Claims may be submitted electronically to TMHP through billing agents who interface directly with the TMHP EDI Gateway. TMHP uses the HIPAA-compliant American National Stan-dards Institute (ANSI) ASC X12 4010A fi le format through secure socket layer (SSL) and virtual private networking (VPN) connections for maximum security. Providers must retain all claim and fi le transmission records, which they may be required to submit for pending research on missing claims or appeals.

Electronic Claim Acceptance

Providers should verify that their electronic professional claims were accepted by Texas Medic-aid for consideration of reimbursement by referring to their Claim Response report, which is in the 27S batch response fi le (e.g., fi le name E085LDS1.27S). Providers should also check their Accepted and Rejected reports in the rej and acc batch response fi les (e.g., E085LDS1.REJ and E085LDS1.ACC) for additional information. Only claims that have been accepted and appear on the Claim Response report (27S fi le) will be considered for reimbursement and made avail-able for claim status inquiry. Rejected claims must be corrected and resubmitted to be consid-ered for reimbursement.

Electronic Rejections

Th e most common reasons for electronic professional claim rejections are:

Client information does not match:• Client information does not match the patient control number (PCN) on the TMHP eligibility fi le. Th e name, date of birth, sex, and nine-digit Medicaid Identifi cation number must be an exact match with the client’s identifi cation 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 the Automated Inquiry System (AIS) at 1-800-925-9126 to verify client information. A lack of complete client eligibil-ity information causes a rejection and possible delayed payment. To prevent delays when submitting claims electronically:

Always include the fi rst and last name of the client on the claim in the appropriate –fi elds.

Always enter the client’s complete, valid nine-digit Medicaid Identifi cation number. –Valid Medicaid Identifi cation numbers begin with 1, 2, 3, 4, or 5. (CSHCN Services Program client numbers begin with a 9.)

When submitting claims for newborns, use the guidelines provided. –

Referring/Ordering Physician fi eld blank or invalid:• Th e referring physician’s NPI must be present on claims for consultations, laboratory, or radiology. If using third party software, consult the software vendor for this fi eld’s location on the electronic claims entry form.

Performing Physician ID fi eld blank or invalid:• When the billing provider identifi er is a group practice, the performing provider identifi er for the physician who performed the service must be entered. If using third-paty software, consult the software vendor for this fi eld’s location on the electronic claim form.

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Facility Provider fi eld blank or invalid:• When place of service (POS) is anywhere other than home or offi ce, the facility’s provider identifi er must be present. If the provider identi-fi er is not known, enter the name and address of the facility. If using third-party software, consult the software vendor for this fi eld’s location on the electronic claims entry form.

Invalid Type of Service or Invalid Type of Service/Procedure code combination:• Some procedure codes require a modifi er to denote the procedure’s type of service (TOS).

Resubmission of TMHP Electronic Data Interchange Rejections

To meet the fi ling deadline, providers that receive a TMHP Electronic Data Interchange (EDI) rejection may resubmit an electronic claim within 95 days of the DOS. A paper appeal may also be submitted with a copy of the rejection report within 120 days of the rejection report. A copy of the rejection report must accompany each corrected claim that is submitted on paper.

TMHP EDI Batch Numbers, Julian Dates

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

JJJ—Julian date:• Th e three J characters represent the Julian date that the fi le was received by the TMHP EDI Gateway. Th e fi rst character (J) is displayed as a letter, where E = 0, F = 1, G = 2, and H = 3. Th e last two characters (JJ) are displayed as numbers. All three char-acters (JJJ) together represent the Julian date.

Y—Year:• Th e Y character represents the last digit of the calendar year when the TMHP EDI Gateway receives the fi le. For example, a “9” in this position indicates the year 2009.

SSSS - Sequences number:• Th is is a unique 4-character sequence number assigned by EDI to the claim fi led.

Note: Th is new, unique sequence number will allow an increase in the number of claims pro-cessed through the TMHP EDI Gateway each day.

For example, the batch ID E089LDS1 means that the TMHP EDI gateway received the fi le on January 8, 2009.



Claim Form Determination

CMS-1500

Th e following provider types may bill electronically or use the CMS-1500 paper claim form when requesting reim-bursement:

Ambulance•

Ambulatory surgical center (ASC) (freestanding)•

Blind and visually impaired children (BVIC)•

Early Childhood Intervention (ECI)•

Case Management for Children and Pregnant • Women (CPW)

Certifi ed nurse-midwife (CNM) •

Certifi ed registered nurse anesthetist (CRNA)•

Certifi ed respiratory care practitioner (CRCP)•

Chemical dependency treatment facilities •

Chiropractor •

Clinical nurse specialist (CNS) •

Dentist (doctor of dentistry practicing as a limited • physician)

DME or durable medical equipment–home health • services supplier (CCP and home health services)

Family planning agency that does not also receive • funds from Title V, X, or XX

Federally Qualifi ed Health Center (FQHC)• (Note: FQHCs can use CMS-1500 or CMS-1450, but must use CMS-1500 when billing THSteps.)

Genetic service agency•

Hearing aid •

In-home total parenteral nutrition (TPN) supplier•

Laboratory •

Licensed dietitian (CCP only)•

Licensed clinical social worker (LCSW)•

Licensed professional counselor (LPC)•

Maternity service clinic (MSC) •

Mental health (MH) rehabilitative services •

Nurse practitioner (NP) •

Occupational therapist (CCP only)•

Optician/optometrist/opthamologist •

Orthotic and prosthetic supplier (CCP only) •

Physical therapist •

Physician (group and individual)•

Physician assistant (PA)•

Tuberculosis clinic •

Podiatrist •

Private duty nurse (PDN) (CCP only)•

Psychologist •

Radiology •

School Health and Related Services (SHARS) •

Speech language pathologist (CCP only) •

THSteps medical•

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UB-04 CMS-1450

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

ASCs (hospital-based) •

Comprehensive outpatient rehabilitation facilities (CORFs) (CCP only) •

FQHCs (• Note: Must use CMS-1500 when billing THSteps.)

Home health agencies•

Hospitals•

Inpatient (acute care, rehabilitation, military, and psychiatric hospitals) –

Outpatient –

Renal dialysis center •

Rural Health Clinics (RHCs) (freestanding and hospital-based)•

ADA Dental

Providers billing for dental services and Intermediate Care Facility for Persons with Mental Retardation (ICF-MR) dental services may bill electronically or use the 2006 American Dental Association (ADA) claim form.

TMHP is responsible for reimbursing all THSteps dental claims except for THSteps dental claims for Foster Care clients. Th ese claims are processed and reimbursed by Delta Dental.

For DOS of June 1, 2010 and after, send claims and Prior Authorization requests to:

Delta Dental of California State Government ProgramsP.O. Box 537030

Sacramento, CA 95853-7030

If providers have questions or concerns, please contact the Provider Call Center toll-free tele-phone ine at:

• STAR Health- 866-287-3252

• STAR+PLUS- 866-512-8274

• Advantage by Superior- 866-512-8305

Family Planning 2017

Th is claim form is used by Title V, X, and/or XX providers billing for Family Planning services, and includes fi elds for pregnancy and birth control.

Claim Filing Instructions for TexMedConnect

Go to the TMHP website at www.tmhp.com.1.

Click the link, “2. Access TexMedConnect.”

Log into the system by entering your username and password.3.

Select “4. Claims Entry” from the navigation panel on the left hand side of the screen.

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Select the appropriate billing provider information.5.

A list of NPI/API and related data such as taxonomy, physical address, and benefi t code selections is displayed based on the user’s logon information.

Enter the Medicaid Identifi cation number for the claim (optional).6.

Th e system populates most of the required fi elds on the Client tab.

Note: If you do not enter the Medicaid Identifi cation number, you must to enter all required fi elds manually on the Client tab.

Select the appropriate claim type from the drop-down menu.7.

Click 8. Proceed to Step 2.

Th e Claims Entry screen appears for the selected claim type.

Proceed through each tab and enter claim information.9.

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On the “Other Insurance/Submit Claim” tab, select the source of payment. 10.

Read the terms and conditions and check the “11. We Agree” box.

Click “12. Submit”.

Note: Th e TexMedConnect Acute Care user manual and computer based training can be found on the TMHP website.

Saving a Claim

Claims cannot be submitted until all required information has been entered correctly. Th e fol-lowing message screen appears if the information has been entered incorrectly.

Error fi elds are indicated with red exclamation marks.

Once all required fi elds have been completed, the claim can be submitted by clicking on the last tab, “Other Insurance/Submit Claim.”

At the bottom of the screen, four choices will be available:

Save Draft:• Adds claim to the draft list for completion at a later time.

Save Template:• Adds claim to the template list for quicker claims creation in the future.

Save to Batch:• Adds claim to the pending claims list for batch submission.

Submit:• Submits one claim at a time.

Note: After a claim is submitted, an Internal Claim Number (ICN) is generated.



CMS-1500 Paper Claim Form

1a. INSURED’S I.D. NUMBER (For Program in Item 1)

4. INSURED’S NAME (Last Name, First Name, Middle Initial)

7. INSURED’S ADDRESS (No., Street)

CITY STATE

ZIP CODE TELEPHONE (Include Area Code)

11. INSURED’S POLICY GROUP OR FECA NUMBER

a. INSURED’S DATE OF BIRTH

b. EMPLOYER’S NAME OR SCHOOL NAME

d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorizepayment of medical benefits to the undersigned physician or supplier forservices described below.

SEX

F

HEALTH INSURANCE CLAIM FORM

OTHER1. MEDICARE MEDICAID TRICARE CHAMPVA

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary

to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignmentbelow.

SIGNED DATE

ILLNESS (First symptom) ORINJURY (Accident) ORPREGNANCY(LMP)

MM DD YY15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.

GIVE FIRST DATE MM DD YY14. DATE OF CURRENT:

19. RESERVED FOR LOCAL USE

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line)

FromMM DD YY

ToMM DD YY

1

2

3

4

5

625. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT?

(For govt. claims, see back)

31. SIGNATURE OF PHYSICIAN OR SUPPLIERINCLUDING DEGREES OR CREDENTIALS(I certify that the statements on the reverseapply to this bill and are made a part thereof.)

SIGNED DATE

SIGNED

MM DD YY

FROM TO

FROM TO

MM DD YY MM DD YY

MM DD YY MM DD YY

CODE ORIGINAL REF. NO.

$ CHARGES

28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE

$ $ $

PICA PICA

2. PATIENT’S NAME (Last Name, First Name, Middle Initial)

5. PATIENT’S ADDRESS (No., Street)

CITY STATE

ZIP CODE TELEPHONE (Include Area Code)

9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)

a. OTHER INSURED’S POLICY OR GROUP NUMBER

b. OTHER INSURED’S DATE OF BIRTH

c. EMPLOYER’S NAME OR SCHOOL NAME

d. INSURANCE PLAN NAME OR PROGRAM NAME

YES NO

( )

If yes, return to and complete item 9 a-d.

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

20. OUTSIDE LAB? $ CHARGES

22. MEDICAID RESUBMISSION

23. PRIOR AUTHORIZATION NUMBER

MM DD YY

CA

RR

IER

PA

TIE

NT

AN

D IN

SU

RE

D IN

FO

RM

AT

ION

PH

YS

ICIA

N O

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YES NO

YES NO

1. 3.

2. 4.

DATE(S) OF SERVICEPLACE OFSERVICE

PROCEDURES, SERVICES, OR SUPPLIES(Explain Unusual Circumstances)

CPT/HCPCS MODIFIER

DIAGNOSISPOINTER

FM

SEXMM DD YY

YES NO

YES NO

YES NO

PLACE (State)

GROUPHEALTH PLAN

FECABLK LUNG

Single Married Other

3. PATIENT’S BIRTH DATE

6. PATIENT RELATIONSHIP TO INSURED

8. PATIENT STATUS

10. IS PATIENT’S CONDITION RELATED TO:

a. EMPLOYMENT? (Current or Previous)

b. AUTO ACCIDENT?

c. OTHER ACCIDENT?

10d. RESERVED FOR LOCAL USE

Employed Student Student

Self Spouse Child Other

(Medicare #) (Medicaid #) (Sponsor’s SSN) (Member ID#) (SSN or ID) (SSN) (ID)

( )

M

SEX

DAYSOR

UNITS

F. H. I. J.24. A. B. C. D. E.

PROVIDER ID. #

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a.

EMGRENDERING

32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH #

NUCC Instruction Manual available at: www.nucc.org

c. INSURANCE PLAN NAME OR PROGRAM NAME

Full-Time Part-Time

17b. NPI

a. b. a. b.

NPI

NPI

NPI

NPI

NPI

NPI

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05

G.EPSDTFamilyPlan

ID.QUAL.

NPI NPI

CHAMPUS

( )

1500

APPROVED OMB-0938-0999 FORM CMS-1500 (08/05)

SAMPLE

SASSASSSSAMSSSSSSS

SURED’S POLICY GRO

ED’S DATE OF B

AME OR SCHO

IS THERE ANO

S Fmedical or other information neces

to the party who accepts assignmen

ATE

MPMMMAMAMMMMIF PATIENT HAS HAD SAME OR SIMILGIVE FIRST DATEMMMMMM DD Y

Y (Relate Items 1, 2, 3 or 4 to Item 24E b

SSSSSSSSSSSSSSToD YY

MPLELEM DD Y

PLEPPLPL

AMAMPLPLEPPLEL

AMYE

3.

4

EPLACE OFSERVICE

PROCE(Exp

PT/H

NO

CE (State)

PLOCAL USE

AAASASASSAB. C. D.

PPLa

AMAMAMMMAMAMAMAMMMAMEMG

c. INSURANCE PLAN N

NPI

AMAMAMAMMMAMSSSS2

3

4

5

Refer to Volume 1, Section 6.5 in the 2010 Texas Medicaid Provider Procedures Manual for

instructions related to the CMS-1500 Claim Form.



UB-04 CMS-1450 Paper Claim Form __ __ __

1 2 4 TYPEOF BILL

FROM THROUGH5 FED. TAX NO.

a

b

c

d

DX

ECI

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

A

B

C

A B C D E F G HI J K L M N O P Q

a b c a b c

a

b c d

ADMISSION CONDITION CODESDATE

OCCURRENCE OCCURRENCE OCCURRENCE OCCURRENCE SPAN OCCURRENCE SPANCODE DATE CODE CODE CODE DATE CODE THROUGH

VALUE CODES VALUE CODES VALUE CODESCODE AMOUNT CODE AMOUNT CODE AMOUNT

TOTALS

PRINCIPAL PROCEDURE a. OTHER PROCEDURE b. OTHER PROCEDURE NPICODE DATE CODE DATE CODE DATE

FIRST

c. d. e. OTHER PROCEDURE NPICODE DATE DATE

FIRST

NPI

b LAST FIRST

c NPI

d LAST FIRST

UB-04 CMS-1450

7

10 BIRTHDATE 11 SEX 12 13 HR 14 TYPE 15 SRC

DATE

16 DHR 18 19 20

FROM

21 2522 26 2823 27

CODE FROM

DATE

OTHER

PRV ID

THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.

b

.INFO

BEN.

CODEOTHER PROCEDURE

THROUGH

29 ACDT 30

3231 33 34 35 36 37

38 39 40 41

42 REV. CD. 43 DESCRIPTION 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49

52 REL51 HEALTH PLAN ID

53 ASG.54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI

57

58 INSURED’S NAME 59 P.REL 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

66 67 68

69 ADMIT 70 PATIENT 72 73

74 75 76 ATTENDING

80 REMARKS

OTHER PROCEDURE

a

77 OPERATING

78 OTHER

79 OTHER

81CC

CREATION DATE

3a PAT.CNTL #

24

b. MED.REC. #

44 HCPCS / RATE / HIPPS CODE

PAGE OF

APPROVED OMB NO. 0938-0997

e

a8 PATIENT NAME

50 PAYER NAME

63 TREATMENT AUTHORIZATION CODES

6 STATEMENT COVERS PERIOD

9 PATIENT ADDRESS

17 STAT STATE

DX REASON DX 71 PPS

CODE

QUAL

LAST

LAST

National UniformBilling CommitteeNUBC

™

OCCURRENCE

QUAL

QUAL

QUAL

CODE DATE

A

B

C

A

B

C

A

B

C

A

B

C

A

B

C

a

b

a

b

SAMPLEEELELEPLPL

MPMPMAMAMSAMSASASS

EE

SASASASS

EEEEEPLEP

AMSAS

46 SERV.V UN 47 TOT

51 ALTHL PLA

OF

10

11

12

13

14

15

16

17


instructions related to the UB-04 CMS-1450 Claim

Form.



Family Planning 2017 Paper Claim Form

2a. Billing Provider TPI Family Planning 2017 Claim Form

V 1. Family Planning Program: XIX XX

1a. Full Pay Title X Partial Pay Only No Pay 2b. Billing Provider NPI

3. Provider Name 4. Eligibility Date (V or XX )(MM/DD/CCYY)

5. Family Planning No. (Medicaid PCN if XIX)

6. Patient’s Name (Last Name, First Name, Middle Initial) 7. Address (Street, City, State) 7a. ZIP code

8. County of Residence 9. Date of Birth (MM/DD/CCYY)

10. Sex F M

11. Patient Status New Patient Established Patient

12. Patient's Social Security Number - -

13. Race (Code #) White (1) Black (2) AmIndian/AlaskaNat (4) Asian (5) Unk/NotRep (6) NatHawaii/PacIsland (7) More than one race (8)

13a. Ethnicity

Hispanic (5) Non-Hispanic (0)

14. Marital Status

(1) Married (2) Never Married (3) Formerly Married

15. Family Income (All) $

15a. Family Size

16. Number Times Pregnant 17. Number Live Births 18. Number Living Children

19. Primary Birth Control Method Before Initial Visit

20. Primary Birth Control Method at End of This Visit

21. If No Method Used at End of This Visit, Give Reason (Required only if #20 = r)22. Is There Other Insurance Available?

Y N

a=Oral Contraceptive f= Hormonal Implant k=Intrauterine device (IUD) p=Other method b=1-Month hormonal injection g=Male condom l=Vaginal ring q=Method unknown c=3-Month hormonal injection h=Female condom m=Fertility awareness method (FAM) r=No method (if used d=Cervical cap/diaphragm i=Hormonal/Contraceptive patch n=Sterilization for #20, must e=Abstinence j=Spermicide (used alone) o=Contraceptive sponge complete #21)

a=Refused c=Inconclusive Preg Test e=Infertile g=Medical b=Pregnant d=Seeking Preg f=Rely on Partner

23. Other Insurance Name and Address If Y, Complete Items 23 – 25a

24a. Insured’s Policy/Group No. 24b. Benefit Code 25. Other Insurance Pd. Amt. 25a. Date of Notification $

27a. Referring Other ID 26. Name of Referring Provider

27b. Referring NPI

28. Level of Practitioner Physician Nurse Mid Level Other

29. Diagnosis Code (Relate Items 1,2,3,or 4 to Item 32D by Line # in 32E)1. ______________._________ 3. ______________._________

2. ______________._________ 4. ______________._________

30. Authorization Number 31. Date of Occurrence (MM / DD / CCYY)

32. A B C D E F G HDates of Service

From ToMM DD CCYY MM DD CCYY

Placeof

Service

Type of

Service

Procedures, Services, or Supplies

CPT/HCPCS Modifier

Dx.Ref.(29)

Units or Days (Quantity)

No. of Participants (Teen Counseling)

$ Charges Performing Provider #

TPI1 NPI

TPI2 NPI

TPI3 NPI

TPI4 NPI

TPI5 NPI

33. Federal Tax ID Number/EIN 34. Patient’s Account No. (optional) 35. Patient Co-Pay Assessed (V, X or XX)$

36. Total Charges

38. Name and Address of Facility Where Services Were Rendered (If Other Than Home or Office)

37. Signature of Physician or Supplier Date:Signed:

38a. NPI 38b. Other ID

39. Physician’s, Supplier’s Billing Name, Address, Zip Code & Phone No.

SAMPLEt

E14. Marital St

(1) Married (2) Never MEELE15a. Family Size

LELELmber LiviLEPLPL

MPmonal Implant k=Intrauteri

Male condom l=VaginaFemale condom m=Fe

i=Hormonal/Contraceptij=Spermicide (used alo

c=Inconclusive Pre d=Seeking Preg

3. Other Insurance Name and AMPAA

24b. Benefit Code

AMAAMAM7a. RAMAMSAMAMAAAARelate Items 1,2,3,or 4 to Item 32D

______

______ SASSS2

3

4

5


instructions related to the Family Planning 2017

Claim Form.

NO

TES



Filing Paper Claims

When submitting paper claims, providers, except those on prepayment review, should send paper claims to TMHP at the following address:

Texas Medicaid & Healthcare PartnershipClaims

PO Box 200555Austin, TX 78720-0555

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

Texas Medicaid & Healthcare PartnershipAttention: Prepayment Review MC–A11 SURS

P.O. Box 203638Austin, Texas 78720-3638

Tips on Expediting Paper Claims5

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

General requirements

All paper claims must be submitted with a Texas Provider Identifi er (TPI) and NPI for • the billing and performing providers. All other provider fi elds on the claim forms require an NPI only. If an NPI and TPI are not included in the billing and performing provider fi elds, or if an NPI is not included on all other provider identifi er fi elds, the claim will be denied.

Use original claim forms. Don’t use copies of claim forms.•

Detach claims at perforated lines before mailing.•

Use 10 x 13 inch envelopes to mail claims. Don’t fold claim forms, appeals, or correspondence.•

Don’t use labels, stickers, or stamps on the claim form.•

Don’t send duplicate copies of information.•

Use 8 ½ x 11 inch paper. Don’t use paper smaller or larger than 8 ½ x 11 inches. •

Don’t mail claims with correspondence for other departments.•

Data Fields

Print claim data within defi ned boxes on the claim form.•

Use black ink but not a black marker. Don’t use red ink or highlighters.•

Use all capital letters.•

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

Use a laser printer for best results. Don’t use a dot matrix printer, if possible.•


NO

TES



Don’t use dashes or slashes in date fi elds.•

Attachments

Use paper clips on claims or appeals if they include attachments. Don’t use glue, tape, or • staples.

Place the claim form on top when sending new claim, 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).

Don’t total the billed amount on each claim form when submitting multipage claims for • the same client.

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

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



Medicare Crossover Claims6

6 Sources: 2010 Texas Medicaid Provider Procedures Manual, Volume 1, Section 2.6.

When a service is a benefi t of both Medicare and Medic-aid, the claims must be fi led with Medicare fi rst. Provid-ers should not fi le a claim with Medicaid until Medicare has dispositioned the claim. Th e payment received from Medicare and the coinsurance and/or deductible pay-ment from Medicaid must be considered payment in full. Medicaid pays the client’s Part A and B deductibles and coinsurance liabilities on valid Medicare claims. Th ese guidelines exclude clients living in a nursing facil-ity.

Providers must accept Medicare assignment to receive coinsurance and deductible amounts from Medicaid services provided to clients. If a provider has accepted a Medicare assignment, the provider may receive pay-ment of the Medicare deductible and coinsurance from TMHP on behalf of the qualifi ed Medicare benefi ciary (QMB) or Medicaid qualifi ed Medicare benefi ciary (MQMB) client.

Providers that accept Medicare or Medicaid assignment cannot legally require the client to pay the Medicare coinsurance and/or deductible amounts.

Medicare primary claims fi led to Medicare Administra-tive Contractors (MACs) may be transferred electroni-cally to TMHP through a Coordination of Benefi ts Contractor (COBC) for claims processed as assigned. Providers should contact their MAC for more informa-tion. Th is benefi t allows providers to receive disposition from both carriers while only fi ling the claim once. Providers allow 60 days from the date of Medicare’s disposition for a claim to be shown on the Medicaid R&S Report. Claims totally denied by Medicare are not automatically transferred to TMHP.

For crossover claims that are not transferred electroni-cally, providers must submit a paper claim to TMHP.

For dual-eligible clients who are enrolled in a Type C Medicare Advantage Plan, the provider needs to work with the Medicare Advantage Plan for crossover claims and copayments.

Medicare Crossover

Reimbursement of Part B

Th e payment of the Medicare Part B coinsurance and deductibles for Texas Medicaid clients who are Medicare benefi ciaries is based on the following:

If the Medicaid client is eligible for Medicaid only as • a QMB, Medicaid pays the Medicare Part B coin-surance/deductible on valid Medicare claims.

If the Medicaid client is not a QMB, Medicaid pays • the client’s Part B:

Deductible liability on valid, assigned Medicare –claims.

Coinsurance liability on valid, assigned Medi- –care claims that are within the amount, dura-tion, and scope of Texas Medicaid, and would be covered by Medicaid when the services are provided if Medicare did not exist. Medicaid payment of a client’s coinsurance/deductible li-abilities satisfi es the Medicaid obligation to pro-vide coverage for services that Medicaid would have paid in the absence of Medicare coverage.



Th ird Party Resources (TPR)

Texas Medicaid maintains an eff ective third party resources program that helps reduce Med-icaid costs by shifting claims expenses to third-party payers. Th ird-party payers are entities or individuals that are legally responsible for paying the medical claims of Medicaid clients. As a condition of eligibility, Medicaid clients assign their rights (and the rights of any other eligible individuals on whose behalf the client has legal authority under state law to assign such rights)

to medical support and payment for medical care from any third party to Medicaid.

Federal law and regulations require states to ensure Medicaid clients use all other resources available to them to pay for all or part of their medical care before turning to Medicaid. Medicaid pays only after the third party has met its legal obligation to pay (i.e., Medicaid is the payer of last resort unless the client is covered by the CSHCN Services Program).

A third party is any individual, entity, or program that is, or may be, liable to pay for any medical assistance provided to a client under the approved state Medicaid plan. Although there are many third parties which may be obligated to pay for services, providers need mainly to be concerned with other insurance (OI) identifi ed by the client.

With some exception, all OI, including Medicare, must pay before submission to Medicaid for reimbursement. Non-TPR sources are secondary to Texas Medicaid and may only pay benefi ts after Texas Medicaid. Th e following are the most common non-TPR sources. If providers have questions about others not listed, they may contact a provider relations representative.

Department of Assistive and Rehabilitative Services (DARS), Blind Services •

Texas Kidney Health Care Program •

Crime Victims’ Compensation Program •

Muscular Dystrophy Association •

CSHCN Services Program •

Texas Band of Kickapoo Equity Health Program •

Maternal and Child Health (Title V) •

State Legalization Impact Assistance Grant (SLIAG) •

Adoption Agencies •

Home and Community-based Waivers Programs through DADS •

As a condition of Medicaid eligibility, all other medical

insurance information must be reported to the

program, including prescription insurance. If the other

insurance is canceled, if new insurance coverage is

obtained, or if there are general questions regarding

third party resources the Medicaid Third Party

Resources (TPR) hotline (1-800-846-7307) is available

for updating records and answering questions.

NO

TES



OI is to be billed fi rst, and the provider is to wait for payment/disposition before fi ling to Medicaid. If Medicaid is billed before the OI, the claim will be denied with EOB 00260: Client is covered by other insurance which must be billed prior to this program. Th e OI information that is on fi le will be printed on the R&S Report. If claim is paid by Medicaid, and afterward the provider fi nds out the client has OI, the provider must refund to Medicaid the paid amount before fi ling to the OI.

TMHP will process and pay health maintenance organization (HMO) copays for private and Medicare HMOs as well as private and Medicare preferred provider organization (PPO) co-pays. Th e client must be eligible for reimbursement under Medicaid guidelines.

Submitting OI Claims

OI claims can be submitted electronically, through TexMedConnect or third-party software. Th e format of third-party software can diff er, so it is recommended that when using such soft-ware providers contact their vendor to determine which fi elds to use to enter other insurance information.

OI claims can also be submitted on paper with CMS-1500 and UB04 paper claim forms. Use boxes 9, 11, 19, and 29 on the CMS-1500, and use Occurrence codes on the UB04.

Provide complete other insurance information, including the following:

Name and address of Other Insurance Company•

Policy & group number info •

OI phone number (if available)•

Specifi c information on payment or denial•

Specifi c date of payment or denial•

Specifi c date of disposition•

PPO discount is not required •

Note: When dealing with Private HMO and PPO claims, providers should bill copayments to Medicaid, not the client.

110-Day Rule

A provider can submit a claim to Medicaid if the primary payer (OI) has not paid the claim in 110 days. Th e provider is still required to provide complete OI information as well as indicat-ing that they are using the 110-day rule. Provider has from the 110th day from OI submission to 365th day from DOS to fi le the claim to Medicaid.

365-Day Rule

Regardless of OI status - TMHP must receive a completed claim within 365 from DOS.

Verbal Denial7

Providers may call the OI resource and receive a verbal denial. Providers have 95 days from the date of the verbal denial to fi le the claim to Medicaid or the CSHCN Services Program. Th e


Note: Providers

are not required

to bill OI for

certain services.

Refer to page

28 for a list of

exceptions.

NO

TES



OI record can either be updated when the provider fi les the claim or calls the TPR Customer Service at 1-800-846-7307.

Role of the THMP TPR Unit

TMHP cannot make changes to the demographic or eligibility information of a client. Provid-ers are encouraged to call the Th ird Party Resources (TPR) Unit (1-800-846-7307) to give updated other insurance information on a client such as termination of coverage or new insurance coverage. After information has been updated in TMHP’s system by the TPR Unit, the provider is responsible for submitting an appeal for other insurance denial.

When calling the TPR Unit to give updated other insurance information, the TPR Call Center Representative will inform the caller if the update has been successfully completed and claims can be resubmitted. If the TPR Call Center Representative is not able to immediately update the other insurance information they will inform the caller that the verifi cation and update process may take up to 20 business days.

Exceptions

THSteps Medical Program:• Providers should bill TMHP fi rst. TMHP will seek payment from the other insurance source. If the provider chooses to bill the OI, the provider must follow these rules: Claims involving OI, including Medicare must be received within 95 days of the date of disposition. When a service is billed to a third party and no response has been received, the provider must allow 110 days to elapse before submitting a claim to TMHP; however, the federal 365-day fi ling requirement must still be met.

THSteps Dental Program:• Providers should bill TMHP fi rst. TMHP will seek payment from the other insurance source. If the provider chooses to bill the OI, the provider must follow these rules: Claims involving OI, including Medicare must be received within 95 days of the date of disposition. When a service is billed to a third party and no response has been received, the provider must allow 110 days to elapse before submitting a claim to TMHP; however, the federal 365-day fi ling requirement must still be met.

Family Planning Services:• Providers do not have to bill OI; they may bill TMHP directly. Federal regulations protect the client’s confi dential choice of birth control and family plan-ning services. Confi dentiality is jeopardized when seeking information from TPRs.

Case Management for Children and Pregnant Women (CPW):• Providers do not have to bill OI; they may bill TMHP directly.

Personal Care Services (PCS):• Providers do not have to bill OI; they may bill TMHP directly.

Note: Third party

payer pharmacy

billing was

implemented for

Medicaid clients

January 20, 2009.



Filing Deadlines

Texas Medicaid and the CSHCN Services Program share many of the same fi ling deadlines. Th e table below shows the most common deadlines.

MedicaidCSHCN Services

Program

New Claims: All claims, except where noted in the provider manuals, must be received within 95 days of the date of service.

Other Insurance: Claims involving OI, including Medicare, must be received within 95 days of the date of disposition. When a service is billed to a third party and no response has been received, providers must allow 110 days to elapse before submitting a claim to TMHP; however, the federal 365-day fi ling requirement must still be met.

Appeals: Appeals must be received within 120 days of the date of the R&S Report on which the denial appears

Exceptions to the 95-Day Filing Deadline

Th e Texas Health and Human Services Commission (HHSC) considers exceptions only when one of the following situations exists:

Catastrophic events1. that substantially interfere with normal business operations of the provider, damage to or destruction of the provider’s business offi ce or records by a natural disaster, or destruction of the provider’s busi-ness offi ce or records by circumstances that are clearly beyond the provider’s control including, but not limited to, criminal activity.

Delay or error in the eligibility determination of a client or delay because of 2. erroneous written information from HHSC, another state agency, or health-insuring agent.

Delay because of 3. electronic claim or system implementation problems. Providers that request an exception based on this circumstance must submit a written repair statement, invoice, or computer- or modem-generated error reports.

Submission of claims within the 365-day federal fi ling deadline 4. when services are authorized retroactively.

Client eligibility is determined retroactively and the provider is not notifi ed of retroactive coverage. Providers 5. requesting an exception must include a written, detailed explanation of the facts and activities that illustrate the provider’s eff orts in requesting eligibility information for the client.

For a complete list of fi ling deadlines and fi ling deadline exceptions, please refer to Volume 1, Section 6.1.3 of the 2010 TMPPM and Section 5.1.5 of the CSHCN Services Program Provider Manual.



01/0

1 (0

01)

04/0

6 (0

96)

05/0

3 (1

23)

01/0

2 (0

02)

04/0

7 (0

97)

05/0

3 (1

23)

01/0

3 (0

03)

04/0

8 (0

98)

05/0

3 (1

23)

01/0

4 (0

04)

04/0

9 (0

99)

05/0

4 (1

24)

01/0

5 (0

05)

04/1

2 (1

02)

05/0

5 (1

25)

01/0

6 (0

06)

04/1

2 (1

02)

05/0

6 (1

26)

01/0

7 (0

07)

04/1

2 (1

02)

05/0

7 (1

27)

01/0

8 (0

08)

04/1

3 (1

03)

05/1

0 (1

30)

01/0

9 (0

09)

04/1

4 (1

04)

05/1

0 (1

30)

01/1

0 (0

10)

04/1

5 (1

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00)

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33)

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62)

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63)

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0 (3

64)

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94)

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19)

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1 (3

65)

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95)

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2 (1

22)

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1 (0

01)

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6 (0

96)

05/0

2 (1

22)

Date

of S

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120

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NO

TES



Remittance and Status Report8

Th e 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. Th e R&S Report also identifi es accounts receivables established as a result of inappropriate payment. Th ese receivables are recouped from claim submissions. All claims for the same provider identifi er 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 Report to determine payments and denials received.

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

Providers must retain copies of all R&S Reports for a minimum of fi ve years. Providers must not use R&S Report originals for appeal purposes but must submit copies of the R&S Reports with appeal documentation. If claims that are submitted to TMHP on paper or electronically do not appear on a R&S Report within two to three weeks of submission, providers must check their EDI Transmission reports for claim rejections. Paper billers may have had claims returned to them.

R&S Report Delivery Options9

TMHP off ers three options for the delivery of the R&S Report. Although providers can choose any of the following methods, a newly-enrolled provider is initially set up to receive a PDF ver-sion of the R&S Report.

PDF version:• Th e PDF version of the R&S Report is an exact replica of the paper R&S Report. Th e PDF version of the R&S Report can be downloaded by registered users of the TMHP website at www.tmhp.com. Th e report is available each Monday morning, im-mediately following the weekly claims cycle. Payments associated with the R&S Report are not released until all provider payments are released on the Friday following the weekly claims cycle. Providers who use the PDF version will not receive paper copies of the R&S Report.

8 Source: 2010 Texas Medicaid Provider Procedures Manual, Volume 1, Section 6.11




Paper version:• Paper R&S Reports can be mailed to providers the Friday following the weekly claims cycle. Reimbursement checks are mailed with the paper R&S Report, if the provider has not elected EFT.

Note: Additional copies of paper R&S Reports will be charged to the provider if requested more than 30 days after the original R&S Report was issued. Th ere is an initial charge of $9.75 for the request (additional hours = $9.75) with a charge of $0.32 per page and applicable sales tax of 8.25 percent.

ANSI 835:• Using HIPAA-compliant EDI standards, the Electronic Remittance & Status (ER&S) report can be downloaded through the TMHP EDI Gateway using TexMedConnect or third party software. Th e ER&S Report is also available each Monday after the completion of the claims processing cycle.

Accessing R&S Reports

Access TexMedConnect on the TMHP website at www.tmhp.com.1.

Enter your user name and password. 2.

Click the “3. R&S” link in the left navigator.

Choose the correct NPI.4.

Select the appropriate program (programs 100 and 200 are combined on the same R&S Report).5.



Choose the appropriate R&S Report by date.6.

NO

TES



R&S Report Sections

R&S Reports include the following sections:

Banner Pages:• Banner messages are used to inform providers of new policies and proce-dures.

Note: Banner messages (and their corresponding bulletin articles) update and take precedence over the TMPPM. Banner messages are published weekly.

Claims – Paid or Denied:• Claims in the “Claims - Paid or Denied” section fi nalized dur-ing the week before the preparation of the R&S Report. Claims are sorted by claim status, claim type, and by order of client names. Th e reported status of each claim will not change unless further action is initiated by the provider, HHSC, or TMHP.

Adjustment to Claims:• Adjustments are listed by claim type, client name, and the client’s Medicaid number.

Financial Transactions:• Th e “Financial Transaction” section of the R&S Report describes any amounts that are added or taken out of the weekly payment. All accounts receivable, IRS levies, payouts, refunds, reissues, and voids appear here.

Claims Payment Summary:• Th e “Claims Payment Summary” section summarizes all payments, adjustments, and fi nancial transactions listed on the R&S Report. Th e section has two categories: one for amounts “Aff ecting Payment Th is Cycle” and one for “Amount Aff ecting 1099 Earnings.”

Claims in Process:• In the “Following Claims are Being Processed” section, the R&S Re-port may list up to fi ve explanation of pending status (EOPS) codes per claim. Th e 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 pur-poses only.

Note: For additional information please refer to Volume 1, Section 6.11.4 of the 2010 TMPPM.



R&S Paid and Denied Claims

Texas Medicaid & Healthcare Partnership

Remittance and Status Report

Date: 02/01/2010

Mail original claim to: TEXAS PROVIDER

Texas Medicaid & Healthcare Partnership PO BOX 848484

P.O. Box 200555 DALLAS, TX 75888-1234

Austin, Texas 78720-0855 (214) 555-4141

Mail all other correspondence to: TPI: 1234567-01

Texas Medicaid & Healthcare Partnership NPI/API: 1234567890

12357-B Riata Trace Parkway Taxonomy: 193400000X

Austin, Texas 78727-6422 Benefit Code:

Report Seq. Number: 35

(800) 925-9126 R&S Number: 2460000

Page 2 Of

_______________________________________________________________________________________________________________________________________________

PATIENT NAME CLAIM NUMBER MEDICAID # PATIENT ACCT # MEDICAL RECORD # MEDICARE # EOB EOB EOB EOB DIAGNOSIS

PATIENT ACCT #

---SERVICE DATES--- -----BILLED----- -----ALLOWED-----

FROM TO TOS PROC QTY CHARGE QTY CHARGE POS PAID AMT EOB EOB EOB EOB EOB MOD MOD

________________________________________________________________________________________________________________________________________________

********************************************* CLAIMS - PAID OR DENIED ***************************************

DOE, JANE 100040010200712345678912 123456789 01147 V700

1300

05/22/2008 05/22/2008 1 T1015 1.0 71.00 .0 .00 5 .00 00013 U7

$71.00 $.00 $.00 CLAIM TOTAL

00139 PAYMENT WAS REDUCED BY 37.95 DUE TO OTHER INSURANCE PAYMENTS

DOE, JANE 100040030200712365478963 123456789 N12505-010017 01147 V6519

08/20/2008 08/20/2008 1 T1015 1.0 71.00 .0 .00 5 .00 00013 AM

$71.00 $.00 $.00 CLAIM TOTAL

_______________________________________________________________________________________________________________________________________________

IF YOU NEED TO APPEAL ANY CLAIM ON THIS PAGE, YOU MAY APPEAL ELECTRONICALLY FOR THE MOST EXPEDITIOUS PROCESSING. OTHERWISE, MAKE

ONE COPY OF THIS PAGE FOR EACH CLAIM TO BE APPEALED, CIRCLE THE CLAIM YOU ARE APPEALING AND DESCRIBE YOUR APPEAL. YOUR APPEAL

MUST BE RECEIVED WITHIN 120 DAYS FROM THE DATE OF THE R&S. FOR INFORMATION REGARDING THE ELECTRONIC PROCESS CALL 1-888-863-3638.



R&S Claims Payment Summary


Remittance and Status Report

Date: 02/01/2010

Mail original claim to: Texas Provider

Texas Medicaid & Healthcare Partnership P.O. BOX 848484

P.O. Box 200555 Dallas, TX 75888-1234

Austin, Texas 78720-0555 (214) 555-4141

Mail all other correspondence to: TPI: 1234567-01

Texas Medicaid & Healthcare Partnership NPI/API: 1234567890

12357-B Riata Trace Parkway Taxonomy: 193400000X

Austin, Texas 78727-6422 Benefit Code:

Report Seq. Number: 33

(800) 925-9126 R&S Number: 99999999

~ Page 39 Of

________________________________________________________________________________________________________________________________________________

PAYMENT SUMMARY FOR TAX ID 123456789

*** AFFECTING PAYMENT THIS CYCLE *** | *** AMOUNT AFFECTING 1099 EARNINGS ***

AMOUNT COUNT | THIS CYCLE YEAR TO DATE

CLAIMS PAID 3,738.10 9 | 3,738.10 35,676.72

|

SYSTEM PAYOUTS 2,437.19 | 2,437.19 2,437.19

|

MANUAL PAYOUTS (REMITTED BY SEPARATE CHECK OR EFT) | 9,242.00 9,242.00

|

AMOUNT PAID TO IRS FOR LEVIES -554.00 |

|

AMOUNT PAID TO IRS FOR BACKUP WITHHOLDING -1,363.93 |

|

ACCOUNTS RECEIVABLE RECOUPMENTS -3,149.88 | -3,149.88 -9,314.02

|

AMOUNTS STOPPED/VOIDED | -310.99 -310.99

|

SYSTEM REISSUES 20,350.91 |

|

CLAIM RELATED REFUNDS | -57.81 -57.81

|

NON-CLAIM RELATED REFUNDS | -6.19 -6.19

|

HELD AMOUNT -4,291.67 |

|

PAYMENT AMOUNT 17,166.72 | 11,892.42 37,666.90

________________________________________________________________________________________________________________________________________________

PENDING CLAIMS 54,913.83

THE AMOUNT OF $4,291.67 WAS HELD AT THE DIRECTION OF THE STATE MEDICAID AGENCY.

**********************PAYMENT TOTAL FOR DIRECT DEPOSIT BY EFT 000000099999999 IN THE AMOUNT OF 17,166.72.**********************



Electronic Remittance and Status (ER&S) Agreement

Before your ER&S Agreement* can be processed, you MUST choose ONE of the following: * These changes affect ONLY the ELECTRONIC version of the Remittance & Status Report. To make

changes to the PAPER version of the R&S report, contact TMHP Provider Enrollment.

Set up INITIALLY (first time). Use Production User ID*: (9 digits)

CHANGE Production User ID FROM: (9 digits)

TO: (9 digits)

REMOVE Production ID Remove: (9 digits)

** The TMHP Production User ID (Submitter ID) is the electronic mailbox ID used for downloading your Electronic Remittance & Status (ER&S) reports. For assistance with identifying and using your Production User ID and password, contact your software vendor or clearinghouse.

This information MUST be completed before your request can be processed.

Provider Name (must match TPI/NPI number) Billing TPI Number Provider Tax ID Number

Provider’s Physical Address Billing NPI Number Provider Phone Number

Provider Contact Name (if other than provider) Provider Contact Title Contact Phone Number

Do not complete this block UNLESS the ER&S will be downloaded by anyone OTHER than the provider.

Name of Business Organization to Receive ER&S Business Organization Phone Number

Business Organization Contact Name Business Organization Contact Phone No.

Business Organization Address Business Organization Tax ID

Check each box after reading and understanding the following statements. If you are unsure about anything that is stated below, contact the TMHP EDI Help Desk at (888) 863-3638. All three statements must be checked before we can process your Electronic Remittance & Status Agreement.

I (we) request to receive Electronic Remittance and Status information and authorize the information to be deposited in the electronic mailbox as indicated above. I (we) accept financial responsibility for costs associated with receipt of Electronic R&S information.

I (we) understand that paper formatted R&S information will continue to be sent to my (our) accounting address as maintained at TMHP until I (we) submit an Electronic R&S Certification Request form.

I (we) will continue to maintain the confidentiality of records and other information relating to recipients in accordance with applicable state and federal laws, rules, and regulations.

Provider Signature Date

Title Fax Number

DO NOT WRITE IN THIS AREA — For Office Use

Input By: Input Date: Mailbox ID: Effective Date_07302007/Revised Date_06012007



ER&S Agreement — Submission Instructions

Before faxing or mailing this agreement, ensure that all required information is completely filled out, and that the agreement is signed.

Incomplete agreements cannot be processed.

Mail to: Texas Medicaid & Healthcare Partnership Attention: EDI Help Desk MC–B14

PO Box 204270 Austin, TX 78720-4270

Fax to: (512) 514-4228 OR

(512) 514-4230




Electronic Funds Transfer (EFT) Authorization Agreement Enter ONE Texas Provider Identifier (TPI) per Form

NOTE: Complete all sections below and attach a voided check or a statement from your bank written on the bank’s letterhead.

Type of Authorization: NEW CHANGE

Provider Name Nine–Character Billing TPI

National Provider Identifier (NPI)/Atypical Provider Identifier (API): Primary Taxonomy Code: Benefit Code:

Provider Accounting Address Provider Phone Number ( ) Ext.

Bank Name ABA/Transit Number

Bank Phone Number Account Number

Bank Address Type Account (check one) Checking Savings

I (we) hereby authorize Texas Medicaid & Healthcare Partnership (TMHP) to present credit entries into the bank account referenced above and the depository named above to credit the same to such account. I (we) understand that I (we) am responsible for the validity of the information on this form. If the company erroneously deposits funds into my (our) account, I (we) authorize the company to initiate the necessary debit entries, not to exceed the total of the original amount credited for the current pay period.

I (we) agree to comply with all certification requirements of the applicable program regulations, rules, handbooks, bulletins, standards, and guidelines published by the Texas Health and Human Services Commission (HHSC) or its health insuring contractor. I (we) understand that payment of claims will be from federal and state funds, and that any falsification or concealment of a material fact may be prosecuted under federal and state laws.

I (we) will continue to maintain the confidentiality of records and other information relating to clients in accordance with applicable state and federal laws, rules, and regulations.

Authorized Signature Date

Title Email Address (if applicable)

Contact Name Phone

Return this form to: Texas Medicaid & Healthcare Partnership

ATTN: Provider Enrollment PO Box 200795

Austin TX 78720–0795

DO NOT WRITE IN THIS AREA — For Office Use

Input By: Input Date:



Electronic Funds Transfer (EFT) Information

Electronic Funds Transfer (EFT) is a payment method to deposit funds for claims approved for payment directly into a provider’s bank account. These funds can be credited to either checking or savings accounts, provided the bank selected accepts Automated Clearinghouse (ACH) transactions. EFT also avoids the risks associated with mailing and handling paper checks, ensuring funds are directly deposited into a specified account.

The following items are specific to EFT:

• Pre–notification to your bank takes place on the cycle following the application processing.

• Future deposits are received electronically after pre–notification. • The Remittance and Status (R&S) report furnishes the details of individual credits

made to the provider’s account during the weekly cycle. • Specific deposits and associated R&S reports are cross–referenced by both the

provider identifiers (i.e., NPI, TPI, and API) and R&S number. • EFT funds are released by TMHP to depository financial institutions each Friday. • The availability of R&S reports is unaffected by EFT and they continue to arrive in

the same manner and time frame as currently received.

TMHP must provide the following notification according to ACH guidelines:

Most receiving depository financial institutions receive credit entries on the day before the effective date, and these funds are routinely made available to their depositors as of the opening of business on the effective date. Please contact your financial institution regarding posting time if funds are not available on the release date.

However, due to geographic factors, some receiving depository financial institutions do not receive their credit entries until the morning of the effective day and the internal records of these financial institutions will not be updated. As a result, tellers, bookkeepers, or automated teller machines (ATMs) may not be aware of the deposit and the customer’s withdrawal request may be refused. When this occurs, the customer or company should discuss the situation with the ACH coordinator of their institution who, in turn should work out the best way to serve their customer’s needs.

In all cases, credits received should be posted to the customer’s account on the effective date and thus be made available to cover checks or debits that are presented for payment on the effective date.

To enroll in the EFT program, complete the attached Electronic Funds Transfer Authorization Agreement. You must return the agreement and either a voided check or a statement from your bank written on the bank’s letterhead to the TMHP address indicated on the form.

Call the TMHP Contact Center at 1–800–925–9126 for assistance.



Appeals

Appeal Methods

An appeal is a request for reconsideration of a previously dispositioned claim. Providers may use one of three methods to appeal Medicaid claims to TMHP:

Electronic•

AIS•

Paper•

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

When appealing a claim, providers must fi rst identify the reason the claim was denied and either correct the claim data or submit additional documentation support-ing the appeal request.

Standard administrative requests and medical appeals must be sent fi rst to TMHP or the claims processing en-tity as a fi rst-level appeal. After the provider has exhaust-ed all aspects of the appeals process for the entire claim, the provider may submit a second-level appeal to HHSC.

A fi rst-level appeal is a provider’s initial standard 1. administrative or medical appeal of a claim that has been denied or adjusted by TMHP. Th is appeal is submitted by the provider directly to TMHP for adjudication and must contain all required infor-mation to be considered. Detailed instructions are found in the program provider manual (2010 Texas Medicaid Provider Procedures Manual, Volume 1, Section 7.1; 2010 CSHCN Services Program Provider Manual, Section 7.1)

A second-level appeal is a provider’s fi nal medical or 2. standard administrative appeal to HHSC of a claim that meets all of the following requirements:

Claim has been denied or adjusted by TMHP. –

Claim has been appealed as a fi rst-level appeal –to TMHP.

Claim has been denied again for the same –reason(s) by TMHP.

Th is appeal is submitted by the provider to HHSC, which may subsequently require TMHP to gather in-formation related to the original claim and the fi rst-level appeal. HHSC is the sole adjudicator of this fi nal appeal.

All providers must submit second-level administrative appeals and exceptions to the 95-day fi ling deadline appeals to HHSC at the following address:

Texas Health and Human Services CommissionHHSC Claims Administrator Contract Management

Mail Code 91XPO BOX 204077

Austin, Texas 78720-4077

CSHCN Services Program requests for administrative review must be submitted to Texas Department of State Health Services (DSHS) at the following address:

CSHCN Services ProgramAdministrative Review

Purchased Health Services Unit, MC-1938Texas Department of State Health Services

PO Box 149347Austin, TX 78714-9347

NO

TES



Electronic Appeals

Claims with a fi nalized status can be appealed directly from TexMedConnect through the TMHP web-site at www.tmhp.com. To appeal a claim, follow these steps:

Click 1. Appeals in the left navigation panel.

Note: Th e user must have appropriate security rights to access this section.

Enter the claim number you want to appeal.2.

Note:If you do not know the claim number, enter information about the claim and click Search. If a match is found, the CSI Search Details screen will appear.

Click 3. Appeal Claim to continue the appeal process.

Most fi elds populate with the claim information. 4.

Note:You can modify the claim information for the appeals. Verify that all required fi elds are completed

Select Appeal type: Adjustment or Void 5.

Verify that all required fi elds are completed6.

NOTE: Not all fi elds are copied from the R&S or CSI

Make changes to the claim data as appropriate to the reason for the appeal you want to submit7.

Read the certifi cation, terms, and conditions and check the We Agree box.8.

You have the option of submitting the appeal, saving the appeal as a draft or saving it to batch, 9. “Submit Claim.”

Note: If the appeal is successfully submitted an ICN number is generated. If there are errors on the appeal,

error messages will appear. If necessary, correct the error and re-submit the appeal.

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Automated Inquiry System (AIS) Appeals10

Th e following appeals may be submitted using AIS:

Client Eligibility:• Th e client’s correct Medicaid identifi cation number, name, and date of birth are required.

Provider Information (Excluding Medicare Crossovers):• Th e correct provider identifi er is required for the billing provider, performing provider, referring provider, and limited provider. Th e name and address of the provider are required for the facility and outside laboratory.

Claim Corrections:• Providers may correct the following:

PCN –

Date of birth –

Date of onset –

X-ray date –

POS –

Quantity billed –

PAN –

Beginning DOS –

Ending DOS –

Th e following appeals may not be appealed through AIS:

Claims listed on the R&S Report as Incomplete Claims•

Claims listed on the R&S Report with $0 allowed and $0 paid•

Claims that require supporting documentation (for example, operative report, medical • records, home health, hearing aid, and dental X-rays)

Diagnosis related groups (DRG) assignment•

Procedure code, modifi er, or diagnosis code•

Medicare crossovers•

Claims listed as pending or in process with EOPS messages•

Claims denied as past fi ling deadline except when retroactive eligibility deadlines apply•

Claims denied as past the payment deadline•

Inpatient hospital claims requiring supporting documentation•

TPR/OI•

Providers may appeal these denials either electronically or on paper.

Refer to: “Disallowed Electronic Appeals”, Volume 1, Section 7.1.1.2 of the 2010 TMPPM to determine whether these appeals can be billed electronically. If these appeals cannot be billed electronically, a paper claim must be submitted.


NO

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AIS Automated Appeals Guide2

To access the AIS automated appeals guide, providers can call 1-800-925-9126 (1-800-568-2413 for CSHCN Services Program). Providers may submit up to three fi elds per claim and 15 appeals per call. If during any step invalid information is entered three times, the call transfers to the TMHP Contact Center for assistance.

Paper Claim Appeals11

After determining a claim cannot be appealed electronically or through AIS, appeal the claim on paper by completing the following steps:

Copy the page of the R&S Report where the claim is paid or denied. A copy of other of-1. fi cial notifi cation from TMHP may also be submitted.

Circle one claim per R&S Report page in black or blue ink.2.

Identify the reason for the appeal.3.

If applicable, indicate the incorrect information on the claim, and provide the corrected 4. information that should be used to appeal it.

Attach a copy of any supporting medical documentation that is required or has been re-5. quested by TMHP.

Attach a completed claim form (Th is is Optional).6.

Reminder: Do not copy supporting documentation on the opposite side of the R&S Report.

Note: It is strongly recommended that providers that submit paper appeals retain a copy of the documentation being sent. It also is recommended that paper documentation be sent by certifi ed mail with a return receipt requested. Th is documentation, along with a detailed listing of the claims en-closed, provides proof that the claims were received by TMHP, which is important if it is necessary to prove that the 120-day appeals deadline has been met. If a certifi ed receipt is provided as proof, the certifi ed receipt number must be indicated on the detailed listing along with the Medicaid number, billed amount, DOS, and a signed claim copy. Th e provider may need to keep such proof regarding multiple claims submissions if the provider identifi er is pending.

Medicare crossovers and inpatient hospital appeals related to medical necessity denials or DRG assignment/adjustment must be submitted on paper with the appropriate documentation.

Submit correspondence, adjustments, and appeals (including routine inpatient hospital claims) to TMHP at the following address:

Texas Medicaid & Healthcare PartnershipAppeals/Adjustments

PO Box 200645Austin, TX 78720-0645


NO

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HHSC Administrative Appeals

An administrative appeal to HHSC is appropriate when a provider has exhausted the appeals process with TMHP. Th is is a request for review of (not a hearing on) claims denied by TMHP or claims processing entity for technical and nonmedical reasons as defi ned in Title 1 Texas Administrative Code (TAC) §354.2201(2). Th ere are two types of administrative appeals:

Exception requests to the 95-day claim fi ling deadline:• A provider’s formal written request for review of (not a hearing on) a claim that is denied or adjusted by TMHP for failure to meet the 95-day claim fi ling deadline. Th is exception should meet the qualifi ca-tions for one of the fi ve exceptions listed in Volume 1, Section 7.3.1 of the 2010 TMPPM and should be submitted directly to HHSC.

Standard Administrative Appeal:• A provider’s formal written request for review of (not a hearing on) a claim or prior-authorization that is denied by TMHP for technical and/or nonmedical reasons.

An administrative appeal must be submitted in writing to HHSC Claims Administrator Contract Management by the provider that delivered the service or is claiming reimbursement for the service. Th e appeal must also be received by HHSC Claims Administrator Contract Management after the appeals process with TMHP or the claims processing entity has been ex-hausted, and must contain evidence of appeal dispositions from TMHP or the claims process-ing entity.

Administrative Appeals

HHSC Claims Administrator Contract Management only reviews appeals that are received within 18 months from the DOS.

All claims must be paid within 24 months from the date of service as outlined in 1 TAC §354.1003. Providers must adhere to all fi ling and appeal deadlines for an appeal to be re-viewed by HHSC Claims Administrator Contract Management. Th e fi ling and appeal dead-lines are described in 1 TAC §354.1003.

Providers may submit HHSC administrative appeals to the following address:


Mail Code-91XPO Box 204077

Austin, Texas 78720-4077

Medical necessity appeals are defi ned as disputes regarding medical necessity of services. Pro-viders must appeal to TMHP and exhaust the appeal/grievance process before submitting an appeal to HHSC.

Medical necessity appeals related to utilization review (UR) decisions made by HHSC’s Offi ce of Inspector General (OIG) UR Department must be appealed to HHSC, not to TMHP.

NO

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Complaints by Providers

A complaint is defi ned as any dissatisfaction expressed in writing by the provider, or on behalf of that provider, concerning any aspect of Texas Medicaid.

Complaints to HHSC for Fee-for-Service (FFS) and PCCM

FFS and PCCM providers may fi le complaints to the HHSC Claims Administrator Contract Management if they fi nd they did not receive full due process from TMHP in the management of their appeal. FFS and PCCM providers must exhaust the appeals/grievance process with TMHP before fi ling a complaint with HHSC Claims Administrator Contract Management.

Th e complaints must be in writing and received by HHSC Claims Administrator Contract Management within 60 calendar days from TMHP’s written notifi cation of the fi nal appeal decision.

When fi ling a complaint, a provider must submit a letter that explains the specifi c reasons the provider believes the fi nal appeal decision by TMHP is incorrect along with copies of the fol-lowing documentation:

All correspondence and documentation from the provider to TMHP, including copies of • supporting documentation submitted during the appeal process.

All correspondence from TMHP to the provider, including TMHP’s fi nal decision letter.•

All R&S Reports of the claims/services in question, if applicable.•

Provider’s original claim/billing record, electronic or manual, if applicable.•

Provider’s internal notes and logs when pertinent.•

Memos from the state or TMHP that indicate any problems, policy changes, or claims’ • processing discrepancies that may be relevant to the complaint.

Other documents, such as receipts (i.e., certifi ed mail), original date-stamped envelopes, • in-service notes, minutes from meetings, etc., if relevant to the complaint.

Receipts can be helpful when the issue is late fi ling. •

Complaint request for Fee-for-Service and PCCM maybe be mailed to HHSC at the following address:


Mail Code 91XPO Box 204077

Austin, TX 78720-4077

Complaints to HHSC – Managed Care Providers

Medicaid managed care providers (HMOs) may fi le complaints to HHSC Health Plan Op-erations if they fi nd they did not receive full due process from the HMOs. HHSC is only responsible for the management of complaints from managed care providers. Appeals/griev-ances, hearings, or dispute resolutions are the responsibility of the health plans. Providers must exhaust their appeals/grievance process with their health plan before fi ling a complaint with HHSC.

NO

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Managed care providers may send complaints to HHSC at the following address:

Texas Health and Human Services CommissionRe: Provider Complaint

Health Plan Management, H-320PO Box 85200

Austin, TX 78708

Foster Care Complaint Procedures

TMHP does not process prior authorization requests or claims for health-care services, includ-ing dental services, provided to children who are in foster care. All services provided to children in foster care are handled through Superior Health Plan. Medicaid providers should send initial questions or claim appeal/inquiries for services provided to children in foster care to Superior Health Plans at:

https://www.superiorhealthplan.com/portal/public/superior/provider/quicklinks/contact_us

Any complaints to regarding Foster Care should be sent to the Health and Human Services Commission at [email protected]

NO

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Child Abuse Reporting12

All Texas Medicaid providers shall make a good faith eff ort to comply with all child abuse reporting guidelines and requirements as outlined in Chapter 261 of the Texas Family Code relating to investigations of child abuse and neglect. All providers shall develop, implement and enforce a written policy and train staff on reporting requirements.

Th is policy needs to be part of your offi ce Policy and Procedure manual and needs to address the appropriate measures your staff is to take when suspected child abuse has occurred.

DSHS Child Abuse Reporting Form

Th e DSHS Child Abuse Reporting Form shall be used in the following manner:

To fax reports of abuse to DFPS (• 1-800-647-7410) or reporting to law enforcement of-fi cials. All documentation of the report must be kept in the client record.

To document reports made by telephone to DFPS (• 1-800-252-5400, 24/7) or law en-forcement; and

To document decisions not to report suspected child abuse based on the existence of an • affi rmative defense.

Providers may report abuse online at www.txabusehotline.org and use a print-out of the report or a copy of the confi rmation from DFPS with the client’s name and date of birth written on it, instead of this form, as documentation in the client record.

Note: Th e website is only for reporting situations that do not require an emergency response.

An emergency is a situation where a child, an adult with disabilities, or a person who is elderly faces an immediate risk of abuse or neglect that could result in death or serious harm.

If the report is an emergency, call 9-1-1 or your local law enforcement agency.

12 Sources: 2010 Texas Medicaid Provider Procedures Manual, Volume 1, Section 1.4.1.2; 2010 CSHCN Services Program Provider Manual, Section 2.3.9

NO

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Online reports can take up to 24 hours to process. Call the Texas Abuse Hotline at 1-800-252-5400 if:

You believe your situation requires action in less than 24 hours. •

You prefer to remain anonymous. •

You have insuffi cient data to complete the required information on the report. •

You do not want an e-mail to confi rm your report. •

For more information on policy; to report abuse; or to obtain the new DSHS Child Abuse Reporting Form please refer to the following links:

Title Website

DSHS Child Abuse Screening, Documenting, and

Reporting Policy

http://tinyurl.com/child-abuse-reporting

DSHS Child Abuse Reporting Form http://tinyurl.com/child-abuse-reporting-form

Texas Abuse, Neglect, and Exploitation Reporting

System

https://www.txabusehotline.org/

NO

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Waste, Abuse, and Fraud13

Defi nitions

Waste:• Practices that allow careless spending and/or ineffi cient use of resources.

Abuse:• Practices that are inconsistent with sound fi scal, business, or medical practices, and result in an unnecessary program cost, or in reimbursement for services that are medically necessary or do not meet professionally recognized standards for health care.

Fraud:• An intentional deceit or misrepresentation made by a person with the knowledge that deception could result in some unauthorized benefi t to himself or some other person. It includes any act that constitutes fraud under applicable federal or state law.

Most Frequently Identifi ed Fraudulent Practices

Billing for services not performed.•

Billing for unnecessary services.•

Upcoding or unsubstantiated diagnosis.•

Billing outpatient services as inpatient services.•

Over-treating/lack of medical necessity.•

Identifying and Preventing Waste, Abuse, and Fraud

Th e HHSC Offi ce of Inspector General (OIG) is responsible for investigating waste, abuse, and fraud in all Health and Human Services (HHS) programs. OIG’s mission is to protect the:

Integrity of HHS programs in Texas.•

Health and welfare of the recipients in those programs.•

OIG oversees HHS activities, providers, and recipients through compliance and enforcement activities designed to:

Identify and reduce waste, abuse, fraud, or misconduct.•

13 Sources: 2010 Texas Medicaid Provider Procedures Manual, Volume 1, Section 1.6; 2010 CSHCN Services Program Pro-vider Manual, Section 2.3.6

NO

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Improve effi ciency and eff ectiveness through the HHS system.•

OIG is required to set up clear objectives, priorities, and performance standards that help:

Coordinate investigative eff orts to aggressively recover Medicaid overpayments.•

Allocate resources to cases with the strongest supportive evidence, and the greatest poten-• tial for recovery of money.

Maximize the opportunities to refer cases to the Offi ce of Attorney General.•

Human Resources code, Chapter 32 Medical Assistance Program (Medicaid), §32.039

(a) (4) A person “should know” or “should have known” information to be false if the person acts in deliberate ignorance of the truth or falsity of the information or in reckless disregard of the truth or falsity of the information, and proof of the person’s specifi c intent to defraud is not required.

When reporting waste, abuse, or fraud, gather as much information as you can.

Examples of provider information include the following:

Name, address, and phone number of the provider•

Name and address of the facility (hospital, nursing home, and home health agency, etc.)•

Medicaid number of the provider and facility•

Type of provider (physician, physical therapist, pharmacist, etc.)•

Names and numbers of other witnesses who can aid in the investigation•

Copies of any documentation you can provide (examples: records, bills, and memos)•

Date of occurrences•

Summary of what happened—include an explanation along with specifi c details of the • suspected waste, abuse, or fraud. For example: Dr. John Doe requires employees to bill for extra quantities or bill higher level of service than actually provided.

Names of recipients for which services are questionable•

Examples of recipient information include the following:

Th e person’s name•

Th e person’s date of birth and Social Security number, if available•

Th e city where the person resides•

Specifi c details about the fraud-such as “Jane Doe failed to report her husband, John Doe, • lives with her and he works at ABC Construction in Anyplace, TX.”

Reporting Waste, Abuse, and Fraud14

Individuals with knowledge about suspected Medicaid waste, abuse, or fraud of provider ser-vices must report the information to the HHSC OIG. To report waste, abuse, or fraud, go to www.hhs.state.tx.us and select Reporting Waste, Abuse, and Fraud. Individuals may also call the OIG hotline at 1-800-436-6184 to report waste, abuse, or fraud if they do not have access to the Internet.


NO

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Medicaid Vendor Drug Program

Medicaid Vendor Drug Program (VDP) makes payments for prescriptions of covered • outpatient drugs.

Written prescription for all Medicaid clients must be written on tamper-resistant prescrip-• tion pads.

Searchable Formulary list available with drug information: • www.txvendordrug.com/dw/FormularySearch.asp

Smart Formulary Medicaid drug formulary and preferred drug list infor mation with links • attached to selected non-preferred drugs that will guide you to the preferred drugs in that therapeutic class. You may access the Smart Formulary at: www.smartformulary.com/tx

Drug authorization can be obtained by prescriber or representative calling • 1-877-PA- TEXAS.

Epocrates - (Free drug information system on Palm • Pilot or pocket PC).

List of pharmacies that off er free delivery on VDP website: • www.txvendordrug.com

Note: VDP also pays prescriptions for the CSHCN Services Program, the Kidney Health Care Pro-gram, and the Children’s Health Insurance Program (CHIP).



Resources

Instructions for Using the TMHP Website

Th e TMHP website at www.tmhp.com was designed to streamline provider participation. Th rough the website, provid-ers can submit claims and appeals, download provider manuals and bulletins, verify client eligibility, view R&S and Panel Reports, and stay informed with current news and updates. Current news articles remain on the TMHP website homep-age for 10 business days and are then moved to the news archive (available from the News Archive link on the left-hand side of the main page).

Searching the TMHP Website

Some providers may fi nd it easier to search the TMHP website using the site’s search function rather than navigating through the news and archive sections. To use the search feature, providers must type the desired keywords into the search box located in the upper right-hand corner of the homepage, and click the green arrow or press Enter. To improve search results, providers should use logical operators (and, or, and not) or enclose search phrases in quotation marks. When phrases are enclosed in quotation marks, the search feature returns only those pages that contain the exact phrase, rather than returning the pages that contain any of the words in the phrase.

In addition to the site’s search feature, providers can use popular search engines, such as Google™, to fi nd information applicable to their provider type. To use Google to search only the TMHP website, follow these steps:

From an internet browser (Internet Explorer, Firefox, etc.), 1. go to www.google.com.

In the search box, type “site:www.tmhp.com” followed by 2. the keyword(s) for the search (see example).

Click 3. Google Search.

Google displays a list of all the pages on the TMHP website that contain the keyword(s).

Providers can use Google’s advanced search (available by clicking the Advanced Search link) to fi lter their results by date, language,



and fi le format. For example, providers can choose to display only those pages updated within the past three months. Providers can also exclude certain words or phrases from their results or specify where on the page the desired term should appear (for example, in the title of the page or in the body of the page).

Information

On the TMHP website, you’ll fi nd:

Provider Manuals and Guides:

Texas Medicaid Provider Procedures • Manual

CSHCN Services Program Provider • Manual

Texas Medicaid Quick Reference • Guide

CMS-1500 Online Claims Submission • Manual

2008 Automated Inquiry System User • Guide-Medicaid

2008 Automated Inquiry System User • Guide-CSHCN Services Program

TexMedConnect instructions for Acute • Care and Long Term Care

Provider Forms:

Medicaid Forms•

CSHCN Services Program Forms•

Enrollment Forms•

Bulletins and Banner Messages:

Medicaid Bulletins•

CSHCN Services Program Bulletins•

Banner Messages•

Software, Fee Schedules, Reference Codes:

Fee Schedules•

Acute Care Reference Codes•

Long Term Care (LTC) Programs Ref-• erence Codes

Workshop Materials•

Computer Based Training (CBT)•



Functions on the TMHP Website

On the TMHP website, you’ll be able to:

Enroll as a provider into TMHP’s system to access the many benefi ts available.•

Attest an API.•

Use TexMedConnect to fi le a • claim electronically, which reduces errors and speeds up the reim-bursement of funds.

Review and print documents, • review user guides, and search through the library for previous workshop materials.

Register for a workshop and view • upcoming events.

Submit a request for an authoriza-• tion.

View the status of a submitted • prior authorization request.

Immediately verify the eligibility • of a client.

View panel reports.•

Look for a Provider.•



Online Fee Lookup

TMHP has developed new functionality for the fee schedules called the Online Fee Lookup (OFL). You can now narrow your search criteria for fees.

You do not need to be logged in to the online portal to use the new functionality; however, to view your specifi c “Contracted” rate, you will need to log in.

From the homepage of the TMHP website, scroll down and click the Fee Schedules link towards the bottom of the right-hand navigation.

From the Fee Schedule home page you can select to view the static fee schedules, or perform a fee search or batch search.

Using the OFL, you can search for fees using four diff erent options:.

A single procedure code•

A list of up to 50 procedure codes•

A range of codes•

All procedure codes that pertain to a specifi c provider type and specialty•

MCOs have two additional options. MCOs can upload Out-of-Network fi les and no longer need to upload the fi les to TexMedConnect.



MCOs will continue to receive error reports if errors are found in the fi les and response fi les will be available within 36 hours.

To access the fee schedule and Out-of-Network Batch Submissions, open Internet Explorer and navigate to the TMHP website at www.tmhp.com.

Fee Schedule OFL Search: Th is allows a user to access the Fee Search to search for reimbursement rates specifi c to a provider’s NPI or API.

Fee Schedule Out-of-Network Batch Submissions: Th is allows a user to submit Out-of-Network fi les to TMHP for processing.

To learn more about the OFL tool, please view the Computer Based Training at: www.tmhp.com/Online%20Learning/CBT%20Library/OFL/index.htm



Online Provider Lookup

Using the Online Provider Lookup Tool (OPL) to Find a Provider

1. Go to www.tmhp.com.

Click the link, “2. Look for a Provider.”

Enter Provider Search Criteria:3.

Health Plan –

TPI –

NPI/API –

Taxonomy–

Benefi t Code –

Last Name/Facility Name –

HMO Plan Name –

Provider Type –

ZIP Code –

Note: Fields marked with a red asterisk are required

Click the “4. more information” link for instructions on how to com-plete the adjacent fi eld.

Click the “5. Search” button to obtain a list of providers that meet the search criteria entered.

Click the “6. Clear Form” button to remove the information and start over



Th e next screen displays a list of providers that meet the search criteria.

Click the “ – View Map” link to display a map of the provider’s location.

Click the provider name to receive detailed information on that provider.7.

Click the “ – Back To Results” link to return to the provider list.

Click the “ – Print” button to display a printer-friendly page for printing.

Click the “ – View Map” link to display a map of the provider’s location.

Click the “ – more information” link for a description of the Primary Care Provider symbol.



Using the Advanced Search in OPL

Selecting the option, “Advanced Search” on the menu bar generates the following screen:

Unlike the basic search option, the advanced search option allows providers to narrow their search using several ad-ditional search options such as:

Accepting new patients•

Provider specialty•

Provider subspecialty•

Extended hours•

Medicaid waiver program•

Other services off ered•

Languages spoken•

Patient age•

Patient gender•

County served by the provider•



Note: Th e online provider look up is not currently available for CSHCN Services Program Providers.

Notice that the criteria entered in the Provider Type fi eld changes the information displayed under “Provider Spe-cialty.”



Updating Address Information

1. Th e provider clicks on the link from the My Account page to change/verify their address information.

Th e provider must click on 2. the “Edit” button to acti-vate a section for editing. Th e provider can:

Update address infor- –mation.

Update phone numbers –and their email address.

Add or remove counties –served.

Update business hours. –

Indicate whether or not –they are accepting pa-tients for each plan in which they participate.

Indicate languages spo- –ken in their offi ce.

Indicate if they off er –additional services.

Limit the gender or age –of clients served.

Save and Cancel buttons 3. appear when an area is active for editing. Th e pro-vider must choose to save the information or cancel their changes before editing any other sections.

Once the information is up-dated by the provider, it should appear with the new informa-tion in the Online Provider Lookup immediately.

Th e more complete a provid-ers’ information is, the better chance they have of appearing in the results of a user’s advanced search.

Note: Information in the grey area of the page cannot be updated online by the provider. To make updates to informa-tion in this area, the provider must attest online for NPI related information, or submit a Provider Information Change (PIC) Form. Reminder: Medicaid Vendor Drug Pharmacy providers should update their vendor drug program information through the VDP Pharmacy Resolution Helpdesk (1-800-435-4165). Additional information about the Texas Vendor Drug Program can be found online at http://tinyurl.com/Vendor-Drug.

nk from the My Account page to change/verify their address information.



Provider Enrollment PO Box 200795 Austin, TX 78720-0795

Instructions for Completing the Provider Information Change Form

Signatures • The provider’s signature is required on the Provider Information Change Form for any and all changes requested

for individual provider numbers.

• A signature by the authorized representative of a group or facility is acceptable for requested changes to group or facility provider numbers.

Address

• Performing providers (physicians performing services within a group) may not change accounting information.

• For Texas Medicaid fee-for-service and the CSHCN Services Program, changes to the accounting or mailing address require a copy of the W-9 form.

• For Texas Medicaid fee-for-service, a change in ZIP Code requires copy of the Medicare letter for Ambulatory Surgical Centers.

• ual practitioner provider numbers can only be made by the individual to whom the

• Performing providers cannot change the TIN.

Provider Demographic Information

e specific practice

limitations accordingly. This will allow clients more detailed information about your practice.

Gen r•

cable) nge. Forms will be returned if this information is not indicated on the Provider

e and TIN changes.

•ealthcare Partnership (TMHP)

Fax: 512-514-4214

Tax Identification Number (TIN)

TIN changes for individnumber is assigned.

An online provider lookup (OPL) is available, which allows users such as Medicaid clients and providers to view information about Medicaid-enrolled providers. To maintain the accuracy of your demographic information, pleasvisit the OPL at www.tmhp.com. Please review the existing information and add or modify any

e al

TMHP must have either the nine-digit Texas Provider Identifier (TPI), or the National Provider Identifier (NPI)/Atypical Provider Identifier (API), primary taxonomy code, physical address, and benefit code (if appliin order to process the chaInformation Change Form.

• The W-9 form is required for all nam

Mail or fax the completed form to:

Texas Medicaid & HProvider Enrollment PO Box 200795 Austin, TX 78720-0795




Provider Information Change Form Texas Medicaid fee-for-service, Children with Special Health Care Needs (CSHCN) Services Program, and Primary Care Case Management (PCCM) providers can complete and submit this form to update their provider enrollment file. Print or type all of the information on this form. Mail or fax the completed form and any additional documentation to the address at the bottom of the page.

Check the box to indicate a PCCM Provider Date : / /

Nine-Digit Texas Provider Identifier (TPI): Provider Name:

National Provider Identifier (NPI): Primary Taxonomy Code:

Atypical Provider Identifier (API): Benefit Code:

List any additional TPIs that use the same provider information:

TPI: TPI: TPI: TPI: TPI: TPI: TPI: TPI: TPI:

Physical Address—The physical address cannot be a PO Box. Ambulatory Surgical Centers enrolled with Traditional Medicaid who change their ZIP Code must submit a copy of the Medicare letter along with this form.

Street address City County State Zip Code Telephone: ( ) Fax Number: ( ) Email:

Accounting/Mailing Address—All providers who make changes to the Accounting/Mailing address must submit a copy of the W-9 Form along with this form.

Street Address City State Zip Code

Telephone: ( ) Fax Number: ( ) Email:

Secondary Address

Street Address City State Zip Code

Telephone: ( ) Fax Number: ( ) Email: Type of Change (check the appropriate box)

Change of physical address, telephone, and/or fax number

Change of billing/mailing address, telephone, and/or fax number

Change/add secondary address, telephone, and/or fax number

Change of provider status (e.g., termination from plan, moved out of area, specialist) Explain in the Comments field

Other (e.g., panel closing, capacity changes, and age acceptance)

Comments:

Tax Information—Tax Identification (ID) Number and Name for the Internal Revenue Service (IRS)

Tax ID number: Effective Date:

Exact name reported to the IRS for this Tax ID:

Provider Demographic Information—Note: This information can be updated on www.tmhp.com.

Languages spoken other than English:

Provider office hours by location:

Accepting new clients by program (check one): Accepting new clients Current clients only No

Patient age range accepted by provider: Additional services offered (check one): HIV High Risk OB Hearing Services for Children

Participation in the Woman’s Health Program? Yes No Patient gender limitations: Female Male Both

Signature and date are required or the form will not be processed. Provider signature: Date: / /

Mail or fax the completed form to: Texas Medicaid & Healthcare Partnership (TMHP) Fax: 512-514-4214



Communication With TMHP

TMHP Telephone and Fax Communication

Contact Telephone/Fax Number

TMHP Contact Center (general information)

Automated Inquiry System (AIS)

1-800-925-9126

or 1-512-335-5986

TMHP Children with Special Health Care Needs (CSHCN) Services Program Contact Center

Automated Inquiry System (AIS)

1-800-568-2413

CSHCN Services Program Fax 1-512-514-4222

Comprehensive Care Program (CCP)

(CCP prior authorization status and general CCP and Home Health Services information)

1-800-846-7470 (voice)

1-512-514-4211 (fax)

Comprehensive Care Inpatient Psychiatric (CCIP) Unit (prior authorization and general informa-

tion)

1-800-213-8877 (voice)

1-512-514-4211 (fax)

Family Planning (Tubal Ligation/Vasectomy Consent Forms) Fax 1-512-514-4229

Health Insurance Premium Payment (HIPP) and Insurance Premium Payment Assistance (IPPA) 1-800-440-0493

Home Health Services (includes durable medical equipment [DME]):

Option 1 – TMHP in-home care customer service

Option 2 – DME supplier with completed Title XIX form

Option 3 – Registered nurse (RN) with completed plan of care (POC)

1-800-925-8957 (voice)

1-512-514-4209 (fax)

Hysterectomy Acknowledgment Statements Fax 1-512-514-4218

Long Term Care (LTC) Operations 1-800-626-4117

LTC—Nursing Facilities 1-800-727-5436

Medicaid Audit/Cost Reports 1-512-506-6117

Medicaid Audit Fax 1-512-506-7811

PCCM Provider Helpline 1-888-834-7226

Radiology Prior Authorization 1-800-572-2116 (voice)

1-800-572-2119 (fax)

Provider Enrollment Fax 1-512-514-4214

Telephone Appeals 1-800-745-4452

Texas Health Steps (THSteps) Dental Inquiries 1-800-568-2460

THSteps Medical Inquiries 1-800-757-5691

Third Party Resources (TPR) (Option 2) 1-800-846-7307

Third Party Resources (TPR) Fax 1-512-514-4225

TMHP Electronic Data Interchange (EDI) Help Desk 1-888-863-3638

TMHP EDI Help Desk Fax 1-512-514-4228

1-512-514-4230



Prior Authorization Request Telephone and Fax Communication

Contact Telephone/Fax Number

Ambulance Authorization (includes out-of-state transfers) 1-800-540-0694

Ambulance Authorization Fax 1-512-514-4205

Home Health Services Fax 1-512-514-4209

CCP Fax 1-512-514-4212

CCIP 1-800-213-8877

CCIP Fax 1-512-514-4211

Outpatient Psychiatric Fax 1-512-514-4213

TMHP Special Medical Prior Authorization Fax (including

transplants)

1-512-514-4213

Personal Care Services (PCS-CCP) status line 1-888-648-1517

PCCM Utilization Management Helpline:

Option 1: Inpatient authorization request or notifi cation

of admission

Option 2: Outpatient authorization request

1-888-302-6167

PCCM Utilization Management Fax 1-512-302-5039

Radiology Services Prior Authorization 1-800-572-2116

Radiology Services Prior Authorization Fax 1-888-693-3210

Special Medicaid Prior Authorization Fax (Including Trans-

plants)

1-512-514-4213

Prior Authorization Status Telephone Communication

Contact Telephone Number

Home Health Services (including DME):

Option 1 – TMHP in-home care customer service

Option 2 – DME supplier with completed Title XIX form

Option 3 – RN with completed POC

1-800-925-8957

CCP 1-800-846-7470

PCCM Utilization Management Helpline:

Option 1 – 1: Inpatient authorization status

Option 2 – 1: Outpatient authorization status

1-888-302-6167 (voice)

1-512-302-5039 (fax)



Written Communication With TMHP

All CMS-1500 forms (excluding ambulance, radiology/laboratory, immunization services, rural health, and mental health rehabilitation) sent to TMHP for the fi rst time, as well as claims being resubmitted because they were initially denied as incomplete claims, must be sent to the following address:

Texas Medicaid & Healthcare PartnershipClaims

PO Box 200555Austin, TX 78720-0555

Th e post offi ce box addresses must be used for the specifi c items listed in the following table:Correspondence Address

Appeals/adjustments of claims (except zero paid/zero al-

lowed on Remittance & Status [R&S] Reports)

Electronically rejected claims past the 95-day fi ling deadline

and within 120 days of electronic rejection report


Appeals/Adjustments

PO Box 200645

Austin, TX 78720-0645

All fi rst-time claims Texas Medicaid & Healthcare Partnership

Claims

PO Box 200555

Austin, TX 78720-0555

Ambulance/CCP requests (prior authorization and appeals) Texas Medicaid & Healthcare Partnership

Comprehensive Care Program (CCP)

PO Box 200735

Austin, TX 78720-0735

CSHCN Services Program claims Texas Medicaid & Healthcare Partnership

CSHCN Services Program Claims

PO Box 200855

Austin, TX 78720-0735

Dental prior authorization requests Texas Medicaid & Healthcare Partnership

Dental Prior Authorization

PO Box 202917

Austin, TX 78720-2917

Home Health Services prior authorizations Texas Medicaid & Healthcare Partnership

Home Health Services

PO Box 202977

Austin, TX 78720-2977

Special Medical Prior Authorization Texas Medicaid & Healthcare Partnership

Special Medical Prior Authorization

12357-B Riata Trace Parkway, Suite 150

Austin, TX 78727

Medicaid audit correspondence Texas Medicaid & Healthcare Partnership

Medicaid Audit

PO Box 200345

Austin, TX 78720-0345

Medical necessity forms 3652, 3618, and 3619, and purpose

code E information


Long Term Care—Nursing Facilities

PO Box 200765

Austin, TX 78720-0765

Medically Needy Clearinghouse (MNC) or Spend Down Unit

correspondence


Medically Needy Clearinghouse

PO Box 202947

Austin, TX 78720-2947



Correspondence Address

Provider Enrollment correspondence Texas Medicaid & Healthcare Partnership

Provider Enrollment

PO Box 200795

Austin, TX 78720-0795

Other provider correspondence Texas Medicaid & Healthcare Partnership

Provider Relations

PO Box 202978

Austin, TX 78720-0978

Send all other written communication to TMHP Texas Medicaid & Healthcare Partnership

(Department)

12357-B Riata Trace Parkway, Suite 150

Austin, TX 78727

TPR/Tort correspondence Texas Medicaid & Healthcare Partnership

Third Party Resources/Tort

PO Box 202948

Austin, TX 78720-2948

Provider Enrollment Contract/Credentialing Texas Medicaid & Healthcare Partnership

PCCM Contracting/Credentialing

PO Box 200795

Austin, TX 78720-4270



Texas Medicaid/CHIP Vendor Drug Program Contact Information

Vendor Drug Program e-mail address [email protected]

Searchable Formulary List http://tinyurl.com/vdp-formulary

Online drug information resource for all state healthcare

programs.

Smart Formulary www.smartformulary.com/txMedicaid only on-line formulary resource and preferred drug list information with links attached to selected non-preferred drugs that will guide you to the pre ferred drugs in that thera-

peutic class.

Epocrates http://www.epocrates.com

Epocrates provides instant access to information on the drugs

covered by Medicaid and preferred drug list on a Palm or

Pocket PC handheld device. To register for the service, go to

the Epocrates website and sign up for Epocrates Rx.

Note: Epocrates is an out-patient Rx on-line Medicaid formu-

lary resource.

Vendor Drug Program Prior Authorization Call Center Hot line 1-877-728-3927 or 1-877-PA-Texas

Note: This number is for prescribing providers or representa-

tives only.

Pharmacy Resolution Desk 1-800-435-4165

Monday-Friday 8:30 am to 5:15 pm CT

This number is for pharmacy providers only.

Vendor Drug Fax Numbers Main/Pharmacy Resolution: 512-491-1958

Formulary: 512-491-1961

Drug Utilization Review (DUR): 512-491-1962

Field Administration: 817-321-8064

Contract Management: 512-491-1974

Vendor Drug Addresses Physical Address:

Health and Human Services Commission

Medicaid/CHIP Vendor Drug Program (H-630)

Building H

11209 Metric Blvd.

Austin, TX 78758

Mailing address:

Health and Human Services Commission

Medicaid/CHIP Vendor Drug Program (H-630)

P.O. Box 85200

Austin, TX 78708-5200

NO

TES



Helpful Links

Item Link

Texas Health and Human Services http://www.hhs.state.tx.us/

The Texas Medicaid & Healthcare Partnership www.tmhp.com

Texas Department of State Health Services http://www.dshs.state.tx.us/

Texas Vendor Drug Program http://tinyurl.com/Vendor-Drug

Preferred Drug List Program http://tinyurl.com/pdl-program

Explanation of Benefi ts Codes http://tinyurl.com/EOB-codes

MRAN Type 30 Form http://tinyurl.com/tmhp-mran-30

MRAN Type 30 Form Instructions http://tinyurl.com/tmhp-mran-30-instructions

Crossover Claim Types 31 and 50 TMHP

Standardized Medicare Remittance Advice Notice

Form

http://tinyurl.com/tmhp-mran-31-50

Crossover Claim Types 31 and 50 TMHP

Standardized Medicare Remittance Advice Notice

Form Instructions

http://tinyurl.com/tmhp-mran-31-50-instructions

STAR http://tinyurl.com/hhsc-star

STAR+Plus http://tinyurl.com/hhsc-starplus

NorthSTAR http://tinyurl.com/dshs-northstar

Star Health http://tinyurl.com/starhealth

PCCM http://tinyurl.com/tmhp-pccm

THSteps Medical http://tinyurl.com/thstepsmed

THSteps http://tinyurl.com/dshs-thsteps

Family Planing http://tinyurl.com/dshs-famplan

Case Management for Children and Pregnant

Women (CPW)

http://tinyurl.com/dshs-cpw

Enhanced Care Program (Disease Management) http://tinyurl.com/hhsc-ecp

The Children with Special Health Care Needs

(CSHCN) Services Program

http://tinyurl.com/tmhp-cshcn

http://tinyurl.com/dshs-cshcn

Medicaid for Breast and Cervical Cancer http://tinyurl.com/dshs-mbcc

Medical Transportation Program (CSHCN Services

Program)

http://tinyurl.com/dshs-mtp-cshcn

Early Childhood Intervention Targeted Case

Management (ECI) Program

http://tinyurl.com/dars-eci



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Common Claim Denial Codes

00103 - Services exceed allowed benefi t limitations:• Client has exhausted benefi ts for the service billed.

00075 - Missing, invalid, or future dates of service:• Claim was submitted without dates of service, incomplete information for the dates of service, or future dates of service.

00100 - A charge was not noted for this service:• Billed amount was either not submitted on the claim or was invalid.

00143 - Client not Eligible:• Th e client ID was included on the claim; however, the client does not have Medicaid eligibility for that DOS or the client associated with that ID had Medicaid either before or after the DOS.

00144 - Th is procedure not covered for this provider type:• Procedure code submitted is not billable for the billing provider.

00164 -Th ese services are not in accordance with Medical Policy:• Services billed fall outside of the medical policy guidelines for the program billed.

00260 - Client is covered by other insurance which must be billed prior to this pro-• gram: Medicaid is the method of last resort. Any other insurance providers must be billed before Medicaid has been. Th is includes Medicare Part A coverage.

00265 - Client is Medicare Part B Eligible:• Your client is eligible for Medicare Part B for the DOS and the service is covered by Medicare Part B, but the claim was not submitted to Medicaid as a crossover with a Medicare EOB attached. In some cases, your claim crossed over directly from Medicare but Medicare denied the line because of an error on the claim that was originally submitted to Medicare.

00266 - QMB Client Eligible for Medicare Crossovers Only:• Qualifi ed Medicare Ben-efi ciary (QMB) – MEDICAID covers the co-insurance and deductible on MEDICARE covered services only after MEDICARE has paid. If service is not covered by Medicare, MEDICAID WILL NOT PAY.

00424 - Billing Provider Not Enrolled on DOS:• Th e billing provider’s Medicaid enroll-ment status is not active.

00345 - Claim Exceeds Filing Time Period:• Th e claim was submitted after 120 days from the fi rst DOS with no proof of timely fi ling attached.

00565 - Received past the 95 day fi ling deadline:• Th e claim was submitted after 95 days from the fi rst DOS with no proof of timely fi ling attached.

00572 - It is mandatory that authorization be obtained. Due to lack of approval, the • service is nonpayable: Th e provider did not request authorization for the service billed, the authorization was not on fi le at the time the service was billed, or the authorization for service billed was denied.

01361 - Exact Duplicate:• Payment has already been made for this claim. Th is often occurs when a claim is resubmitted before the original claim has been paid. Th e original submis-sion pays and the subsequent submission denies as a duplicate. Th is also happens when a provider attempts to adjust or correct an incorrectly paid claim by simply resubmitting the corrected claim.

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Acronyms

Acronym Term

AAP American Academy of Pediatrics

ACD Augmentative Communicative Device

ACIP Advisory Committee on Immunization Practices

ADA American Dental Association

AIS Automated Inquiry System

AMA American Medical Association

ANSI American National Standards Institute

APN Advanced Practice Nurse

BCBS Blue Cross Blue Shield

BiPAP Bi-level Positive Airway Pressure

BJN Budget Job Number

BP Base Plan

CAPD Continuous Ambulatory Peritoneal Dialysis

CBT Computer Based Training

CCP Comprehensive Care Program

CHAMPUS

Civilian Health and Medical Program of the Uniformed Services—now called

TriCare

CHIP Children’s Health Insurance Program

CMS Centers for Medicare & Medicaid Services (formerly HCFA)

CORF Comprehensive Outpatient Rehabilitation Facility

CPAP Continuous Positive Airway Pressure

CPW Case Management for Children and Pregnant Women

CSHCN Children with Special Health Care Needs

CSI Claim Status Inquiry

CSR Customer Service Representative

DADS Department of Aging and Disability Services

DARS Department of Assistive and Rehabilitative Services

DME Durable Medical Equipment

DO Doctor of Osteopathy

DOB Date of Birth

DOS Date of Service

DPM Doctor of Podiatric Medicine

DRG Diagnosis-Related Group

DSHS Department of State Health Services

ECI Early Childhood Intervention

ECP Enhanced Care Program

EDI Electronic Data Interchange

EFT Electronic Funds Transfer

EOB Explanation of Benefi ts

EOPS Explanation of Pending Status

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Acronym Term

EPSDT Early and Periodic Screening, Diagnosis, and Treatment

EQRO External Quality Review Organization

ER&S Electronic Remittance and Status Report

EV Eligibility Verifi cation

FDH First Dental Home

FFS Fee-For-Service

FP Family Planning

FQHC Federally Qualifi ed Health Center

FSS Family Support Services

HASC Hospital-based Ambulatory Surgical Center

HCPCS Healthcare Common Procedure Coding System

HHA Home Health Agency

HHSC Health and Human Services Commission

HIC Health Insurance Claim

HIPAA Health Insurance Portability and Accountability Act

HMO Health Maintenance Organization

ICD-9-CM International Classifi cation of Diseases, Ninth Revision, Clinical Modifi cation

ICHP Institute of Child Health Policy

ICN Internal Control Number (as in 24-digit ICN)

IPPA Insurance Premium Payment Assistance

IPPB Intermittent Positive Pressure Breathing

IPV Intrapulmonary Percussive Ventilation

JRA Juvenile Rheumatoid Arthritis

LCSW Licensed Clinical Social Worker

LMSW Licensed Master Social Worker

LPC Licensed Professional Counselor

LTC Long Term Care

MCO Managed Care Organization

MD Doctor of Medicine

MMIS Medicaid Management Information System

MNP Medically Needy Program

MQMB Medicaid Qualifi ed Medicare Benefi ciary

MRAN Medicare Remittance Advice Notice

MREP Medicare Remit Easy Print

MSRP Manufacturer’s Suggested Retail Price

MTP Medical Transportation Program

NDC National Drug Code

NPI National Provider Identifi er

OI Other Insurance

OIG Offi ce of Inspector General

OPL Online Provider Lookup

OT Occupational Therapy,

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Acronym Term

PACT Program for Amplifi cation for Children of Texas

PAF Physician/Dentist Assessment Form

PAN Prior Authorization Number

PCCM Primary Care Case Management

PCN Patient Control Number

PCS Personal Care Services

PE Presumptive Eligibility

POC Plan of Care

POS Place of Service

PPO Preferred Provider Organization

PT Physical Therapy

R&S Remittance and Status Report

RHC Rural Health Clinic

SA Service Area

SAVERR System or Application, Verifi cation, Eligibility, Referral and Reporting

SSI Supplemental Security Income (Program)

SSL Secure Socket Layer

STAR State of Texas Access reform

TAC Texas Administrative Code

TANF Temporary Assistance to Needy Families (formerly AFDC)

TENS Transcutaneous Electric Nerve Stimulator

THSteps Texas Health Steps Medical and Dental Services

TIERS Texas Integrated Eligibility Redesign System

TMHP Texas Medicaid & Healthcare Partnership

TMPPM Texas Medicaid Provider Procedures Manual

TOS Type of Service

TP Type Program

TPI Texas Provider Identifi er

TPN Total Parenteral Nutrition (i.e., Hyperalimentation)

TPR Third Party Resources

TVFC Texas Vaccines for Children

UB-04 Uniform Bill 04 CMS-1450

VDP Medicaid Vendor Drug Program

VPN Virtual Private Networking

WHP Women’s Health Program

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Th e Medicaid Basics Workshop Participant Guide is produced by TMHP Organizational Development Services. Th is is intended for educational purposes in conjunction with the Medicaid Basics Workshop Series. Providers should consult the Texas Medicaid

Provider Procedures Manual, CSHCN Services Program Provider Manual, bulletins, and banner messages for updates.

Documents

MedBasics2 PG 0601 - TMHP remove/Medicaid Basics...Medicaid Basics Part 2 Workshop Participant Guide Prior Authorization Submissions Prior authorizations can be submitted to TMHP on