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All diagnosis codes that are submitted on a claim must be appropriate for the age of the client as identified in the ICDCM description of the diagnosis code. Claims that are denied because one or more of the diagnosis codes submitted on the claim are not appropriate for the age of the client may be appealed with the correct diagnosis code or documentation of medical necessity to justify the use of the diagnosis code. Diagnosis codes in the following categories are not valid as primary or referenced diagnosis:.

The POS identifies where services are performed. Indicate the POS by using the appropriate code for each service identified on the claim. The two-digit origin and destination codes are still required for claims processing. Use the following codes for POS identification where services are performed:. Skilled nursing facility or intermediate care facility for individuals with an intellectual disability or related conditions. Extended care facility rest home, domiciliary or custodial care, nursing facility boarding home.

The TOS identifies the specific field or specialty of services provided. Professional component for radiology, laboratory, or radiation therapy. Technical component for radiology, laboratory, or radiation therapy. HCPCS provides health-care providers and third-party payers a common coding structure that uses codes designed around a five-character numeric or alphanumeric base.

The procedure codes are updated annually and quarterly. Major updates are made annually and minor updates are made quarterly. Most of the procedure codes that do not replace a discontinued procedure code must go through the rate hearing process. Rate hearings are announced on the HHSC website at www. Claims for services that are provided before the rates are adopted through the rate hearing process are denied as pending a rate hearing EOB until the applicable reimbursement rate is adopted.

The client cannot be billed for these services. Providers are responsible for meeting the initial day filing deadline. Providers must submit the procedure codes that are most appropriate for the services provided, even if the procedure codes have not yet completed the rate hearing process and are denied by Texas Medicaid as pending a rate hearing. Once the reimbursement rates are established in the rate hearing and applied, TMHP automatically reprocesses affected claims.

Providers are not required to appeal the claims unless they are denied for other reasons after the claims reprocessing is complete. The NDC is an digit number on the package or container from which the medication is administered. All Texas Medicaid fee-for-service and Family Planning providers must submit an NDC for professional or outpatient claims submitted with physician-administered prescription drug procedure.

National Drug Unit of Measure: The submitted unit of measure should reflect the volume measurement administered. Block No. This block should include the following elements in the following order:.

Do not enter hyphens or spaces within this number e. In the shaded area, enter the NDC quantity of units administered up to 12 digits, including the decimal point. A decimal point must be used for fractions of a unit e.

In the shaded area, enter the NDC unit of measurement code. Claims will be edited for the value submitted in the NDC quantity field. The Texas file is published at least quarterly. These drug claims are submitted to Medicare, which will cross over to Medicaid for consideration of coinsurance and deductible liabilities. This information applies to all Medicaid providers who serve Medicare-Medicaid dual-eligible clients. Providers may refer to subsection 6. CMS maintains a list of participating manufacturers and their rebate-eligible drug products, which is updated quarterly on the CMS website.

TMHP will republish this list quarterly in a more accessible format. When providers submit claims for clinician-administered drug procedure codes, they must include the National Drug Code NDC of the administered drug as indicated on the drug packaging. While B purchased claims are not eligible for drug rebates, NDCs are required to receive federal funding to pay the claim. TMHP will deny claims for drug procedure codes under the following circumstances:.

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

Providers can find a complete, downloadable list of procedure codes and the corresponding descriptions on the Vendor Drug Program website at www. Vitamins and minerals procedure codes will be listed on a separate tab of the supplemental file. Modifiers describe and qualify the services provided by Texas Medicaid. A modifier is placed after the five-digit procedure code. Up to two modifiers may apply per service. Examples of frequently used modifiers are listed in the following table. Refer to the service-specific sections for additional modifier requirements.

All eligible organizations and covered entities that are enrolled in the federal B Drug Pricing Program to purchase B discounted drugs must use modifier U8 when submitting claims for B clinician-administered drugs.

Providers can refer to the HRSA website at www. Use to indicate that no medical necessity existed for a transport. Use for physician reporting of a discontinued procedure.

Providers who perform the preoperative care only must bill the surgical code with modifier 56 and is reimbursed 10 percent of the global fee. Staged or related procedure or services by the same physician during the postoperative period. Use modifier 76 or 77 for transplant procedures if it is a second transplant of the same organ.

Return to the operating room for a related procedure during the postoperative period. Unrelated procedure or service by the same physician during the postoperative period. Assistant Surgeons. Use modifier 80 and KX together to indicate an assistant surgeon in a teaching facility:. Use when the physician assistant is not enrolled as an individual provider and provides assistance at surgery. Use of this modifier is subject to retrospective review. Oral medication regimens have proven ineffective or are not available.

Use to indicate that the service was part of an annual family planning examination. Use with external causes of injury and poisoning E Codes procedures and morphology of neoplasms M Codes procedures to specify antepartum or postpartum care. Use to describe circumstances in which an office visit was provided at the same time as other separately identifiable services. One of the following modifier combinations must be used by anesthesiologists directing non-CRNA qualified professionals.

Use to indicate that the anesthesia services were performed personally by the anesthesiologist. Use when directing five or more concurrent procedures provided by non-CRNA qualified professionals. Used in emergency circumstances only and limited to 6 units 90 minutes per case for each occurrence requiring five or more concurrent procedures.

Use when directing two, three, or four concurrent procedures provided by non-CRNA qualified professionals. Use when directing one procedure provided by a non-CRNA qualified professional. One of the following modifier combinations must be used by anesthesiologists directing CRNAs. Use when directing five or more concurrent procedures involving CRNA s.

Use when directing two, three, or four concurrent procedures involving CRNAs. Use to indicate the anesthesia was medically directed by the anesthesiologist. Services provided by a health-care professional require one of the following modifiers:. Use to indicate that the services were performed by a clinical psychologist. Use to indicate that the services were performed by a clinical social worker.

Use to indicate that the services were performed by a physician or team member service includes clinical psychiatrist. Use to indicate that the services were performed by an advanced practice registered nurse APRN or CNM rendering services in collaboration with a physician. For home services performed by a RN and provided in areas with a shortage of home health agencies. For home services performed by an LVN and provided in areas with a shortage of home health agencies.

The following modifiers may be used in addition to the modifier identifying the health-care professional that rendered the service:. Use to indicate the encounter is for antepartum care or postpartum care. State-defined modifier for use with case management services. Use by performing physicians, facilities, anesthesiologists, and CRNAs with appropriate procedure code when requesting reimbursement for abortion procedures that are within the scope of the rules and regulations of Texas Medicaid.

Use modifier RB to indicate replacement of prosthetic or nonprosthetic eyeglasses or contact lenses. Use when billing prosthetic eyeglasses or contact lenses with a diagnosis of aphakia. Code to indicate the procedure or service was independent from other services performed on the same day.

Must be used to indicate the necessity of an acute condition for occupational therapy OT , physical therapy PT , osteopathic manipulation treatment OMT , or chiropractic services. THSteps Medical. Nurse practitioner rendering service in collaboration with a physician. THSteps Exceptions to Periodicity. Unusual Anesthesia: Occasionally, a procedure, which usually requires either no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia.

This circumstance may be reported by adding the modifier 23 to the procedure code of the basic service or by use of the separate five-digit modifier code Mandated Services: Services related to mandated consultation or related services e. Informal reciprocal arrangement period not to exceed 14 continuous days. Radiology Services. Obstetric ultrasounds provided in the emergency department or during a hospital observation stay.

Durable Medical Equipment. Other Common Modifiers. The DRG payment was calculated on a per diem basis for an inpatient stay because of patient transfer. The DRG payment was calculated on a per diem basis because the patient exhausted the day inpatient benefit limitation during the stay.

The DRG payment was calculated on a per diem basis because the patient was ineligible for Medicaid during part of the stay. Also used to adjudicate claims with adjustments to outlier payments. A benefit code is an additional data element used to identify state programs. Providers that participate in the following programs must use the associated benefit code when submitting claims and authorizations:. This section contains instructions for completion of Medicaid-required claim forms.

When filing a claim, providers should review the instructions carefully and complete all requested information. A correctly completed claim form is processed faster. This section provides a sample claim form and its corresponding instruction table for each acceptable Texas Medicaid claim form. All providers, except those on prepayment review, should submit paper claims to TMHP to the following address:. Providers on prepayment review must submit all paper claims and supporting medical record documentation to the following address:.

Procedure Codes. The spreadsheets list the procedure code pairs that will not be reimbursed separately if they are billed by the same provider with the same date of service. Column 1 procedure codes may be reimbursed and Column 2 procedure codes will be denied. The spreadsheets also contain a column that indicates whether or not a modifier is allowed for services that may be reimbursed separately.

The website contains the Medicaid MUE edit spreadsheets for hospital services, practitioner services, and supplier services. The spreadsheets list procedure codes and the number of units that may be reimbursed for each procedure code.

Units that are submitted beyond these limitations will be denied. HHSC continue to implement and enforce correct coding initiatives. Providers may see additional claim denials related to NCCI and MUE edits including those services that were prior authorized or authorized with medical necessity documentation.

If a rendered service does not comply with a guideline as defined by NCCI, medical necessity documentation may be submitted with the claim for the service to be considered for reimbursement; however, medical necessity documentation does not guarantee payment for the service. Claims that were submitted with dates of service from October 1, , through June 30, , will not be reprocessed in accordance with the NCCI guidelines; however, any claims with dates of service on or after October 1, , that are appealed or reprocessed for reasons other than NCCI auditing will be subject to NCCI auditing guidelines.

The following coding rule categories are applied to claims that are submitted with dates of service on or after October 1, Coding Rule Category. CMS has assigned to all procedure codes a maximum number of units that may be submitted for a client per day, regardless of the provider.

The maximum number of units for each procedure code is based on the following criteria:. The line item will not be cut back to the allowable quantity. The line item may be appealed with the appropriate quantity for consideration.

NCCI edits are applied to services that are performed by the same provider on the same date of service only and do not apply to services that are performed within the global surgical period. Code combinations are processed based on this effective date.

Termination dates also apply to code pairs in NCCI. Code combinations are refreshed quarterly. Claims that are not filed in accordance with CPT and HCPCS guidelines may be denied, including claims for services that were prior authorized or authorized based on documentation of medical necessity. If a rendered service does not comply with CPT or HCPCS guidelines, medical necessity documentation may be submitted with the claim for the service to be considered for reimbursement; however, medical necessity documentation does not guarantee payment for the service.

The following coding rule categories apply to claims submissions:. Certain services are commonly carried out in addition to the rendering of the primary procedure and are associated with the primary procedures.

Add-on codes are always performed in addition to a primary procedure, and should never be reported as a stand-alone service. When an add-on code is submitted and the primary procedure has not been identified on either the same or different claim, then the add-on code will be denied as an inappropriately-coded procedure. If the primary procedure is denied for any reason, then the add-on code will be denied also.

Revisions typically include adding new procedure codes, deleting procedure codes, and redefining the description of existing procedure codes. These revisions are normally made on an annual basis by the governing entities with occasional quarterly updates.

Claims that are received with deleted procedure codes will be validated against the date of service. If the procedure code is valid for the date of service, the claim will continue processing. If the procedure code is invalid for the date of service, the invalid procedure code will be denied.

Revisions typically include adding new diagnosis codes, deleting diagnosis codes, and redefining the description of existing diagnosis codes. These revisions are normally made on an annual basis.

Claims that are received with invalid diagnosis codes will be validated against the date of service. If the diagnosis code is valid for the date of service, the claim will continue processing.

If the diagnosis code is invalid for the date of service, the procedure that is referenced to the invalid diagnosis code will be denied. Certain diagnosis codes are age-specific. If a diagnosis code that is billed does not match the age of the client on that date of service, all services associated with that diagnosis code will be denied.

Certain diagnosis codes are gender-specific. If the diagnosis code that is billed does not match the gender of the client, all services associated with that diagnosis code will be denied. A duplicate claim is defined as a claim or procedure code detail that exactly matches a claim or procedure code detail that has been reimbursed to the same provider for the same client. Duplicate claims or details include the same date of service, procedure code, modifier, and number of units.

Duplicate claims or procedure code details will be denied. Providers may refer to subsection 9. The CPT manual assigns each procedure code a specific description or definition to describe the service that is rendered. In order to support correct coding, the procedure code definition rules will deny procedure codes based on the appropriateness of the code selection as directed by the definition and nature of the procedure code.

The CPT manual includes specific reporting guidelines that are located throughout the manual and at the beginning of each section. In order to ensure correct coding, these guidelines provide reporting guidance and must be followed when submitting specific procedure codes.

Certain procedure codes, by definition or nature of the procedure, are limited to the treatment of a specific age or age group. For example, procedure code is limited to clients who are 1 through 4 years of age. Certain procedure codes, by definition or nature of the procedure, are limited to the treatment of one gender.

For example, hysterectomy procedure code is limited to female clients. Diagnostic tests and radiology services are procedure codes that include two components: professional interpretation and technical. The technical component describes the technical portion of a procedure, such as the use of equipment and staff needed to perform the service, and is billed with modifier TC. If the professional interpretation and technical components are rendered by the same provider, the total component may be billed using the appropriate procedure code without modifiers 26 and TC.

Reimbursement of diagnostic tests and radiology services is limited to no more than the amount for the total component.

Providers must refer to the appropriate Texas Medicaid fee schedules to determine payable components for diagnostic and radiology services. Procedure codes that are submitted with an inappropriate modifier will be denied. Signatory supervision of the authorized representative is required.

Providers delegating signature authority to a member of the office staff or to a billing service remain responsible for the accuracy of all information on a claim submitted for payment. Initials are only acceptable for first and middle names. The last name must be spelled out. An acceptable example is J. Smith for John Adam Smith. An unacceptable example is J.

Typewritten names must be accompanied by a handwritten signature; in other words, a typewritten name with signed initials is not acceptable. The signature must be contained within the appropriate block of the claim form. For claims prepared by a billing service, the billing service must retain a letter on file from the provider authorizing the service. Because space is limited in the signature block, providers should not type their names in the block.

This requirement excludes THSteps medical providers. The billing provider must obtain all of the required information from the ordering or referring provider before submitting the claim to TMHP. Providers who submit TexMedConnect electronic claims for professional, ambulance, or vision services can provide the claim information in the designated field for the supervising provider of the referring or ordering provider. Claims filed to TMHP must contain only one prior authorization number per claim.

Prior authorization numbers must be indicated on the appropriate electronic field or on the paper claim forms in the indicated block:. If a Medicaid eligible newborn has not been assigned a Medicaid number on the DOS, the provider must wait until a Medicaid client number is assigned to file the claim.

Providers must check Medicaid eligibility regularly to file claims within the required day filing deadline. The approved electronic claims format is designed to list 50 line items.

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

The CMS paper claim form is designed to list six line items in Block If more than six line items are billed on a paper claim, a provider may attach additional forms pages totaling no more than 28 line items. The first page of a multipage claim must contain all the required billing information. The combined total charges for all pages should be listed on the last page in Block The total number of details allowed for an institutional claim by the TMHP claims processing system C21 is C21 merges like revenue codes together for inpatient claims to reduce the lines to 28 or less.

If the C21 merge function is unable to reduce the lines to 28 or less, the claim will be denied, and the provider will need to reduce the number of details and resubmit the claim. C21 merges like revenue codes together to reduce the lines to 28 or less. Providers submitting electronic claims using TexMedConnect may not submit more than 28 lines. If the services exceed the 28 lines, the provider may submit another claim for the additional lines or merge codes. If services exceed the line limitation, the provider may attach additional pages.

The first page of a multipage claim must contain all required billing information. The combined total charges for all pages should be listed on the last page on Line 23 of Block When splitting a claim, all pages must contain the required information. Usually, there are logical breaks to a claim. For example, the provider may submit the surgery charges in one claim and the subsequent recovery days in the next claim. Medicaid present-on-admission POA reporting is required for all inpatient hospital claims that are paid under prospective payment basis methodology.

No hospitals are exempt from this POA requirement. Medicare crossover hospital claims must also comply with the Medicaid requirement to include the POA values. Claims submitted without the POA indicators are denied. POA values are:. POA Value. Depending on the POA indicator value, the DRG may be recalculated, which could result in a lower payment to the hospital facility provider.

If the number of days on an authorization is higher than the number of days allowed as a result of a POA DRG recalculation, the lesser of the number of days is reimbursed. To expedite claims processing, providers must supply all information on the claim form itself and limit attachments to those required by TMHP or necessary to supply information to properly adjudicate the claim.

The following claim form attachments are required when appropriate:. Providers that submit paper crossover claims must submit only one of the approved MRAN formats. If the template and MAP EOB contain conflicting information, the claim will not be processed and will be returned to the provider.

Elective abortions are not benefits of Texas Medicaid. The claims must meet the day deadline from the recoupment disposition date. A recoupment EOB with a disposition date is required. Claims for clients with a primary care provider or designated provider i. Specifications are available to providers developing in-house systems, software developers, and vendors on the TMHP website at www.

Because each software developer is different, location of fields may vary. Contact the software developer or vendor for this information. Claims without this information cannot be processed. Each claim form must have the appropriate signatory evidence in the signature certification block. Providers can purchase CMS paper claim forms from the vendor of their choice. TMHP does not supply the forms. Information is not keyed from attachments.

Superbills or itemized statements are not accepted as claim supplements. The following definitions apply to the provider terms used on the CMS paper claim form:. The referring provider is the individual who directed the patient for care to the provider that rendered the services being submitted on the claim form.

Examples include, but are not limited to the following:. The ordering provider is the individual who requested the services or items listed in Block D of the CMS paper claim form. Examples include, but are not limited to, a provider ordering diagnostic tests, medical equipment, or supplies. The rendering provider is the individual who provided the care to the client.

In the case where a substitute provider was used, that individual is considered the rendering provider. An individual such as a lab technician or radiology technician who performs services in a support role is not considered a rendering provider. The supervising provider is the individual who provided oversight of the rendering provider and the services listed on the CMS paper claim form. A purchased service provider is an individual or entity that performs a service on a contractual or reassignment basis.

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

The instructions describe what information must be entered in each of the block numbers of the CMS paper claim form. Block numbers not referenced in the table may be left blank. They are not required for claim processing by TMHP. If the insured uses a last name suffix e. For special situations, use this space to provide additional information such as:. Enter the date of death in block 9b. Check the appropriate box.

If other insurance is available, enter appropriate information in blocks 11, 11a, and 11b. The other insurance EOB or denial letter must be attached to the claim form. Enter the benefit code, if applicable, for the billing or performing provider. For pregnancy enter the date of the last menstrual period. If the client has chronic renal disease, enter the date of onset of dialysis treatments.

Enter the name First Name, Middle Initial, Last Name and credentials of the professional who referred, ordered, or supervised the service s or supplies on the claim. If multiple providers are involved, enter one provider using the following priority order:. Do not use periods or commas within the name. A hyphen can be used for hyphenated names. Enter the applicable qualifier to identify which provider is being reported.

If there is a Supervising Physician for the referring or ordering provider that is listed in Block 17, the name and NPI of the supervising provider must go in Block Enter the NPI number of the referring, ordering, or supervising provider.

Indicate the services required from the second facility and unavailable at the first facility. The information may be requested for retrospective review.

List no more than 12 diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. For Workers Compensation and other property and casualty claims, this is required when prior authorization, referral, concurrent review, or voluntary certification was received.

If more than one date of service is for a single procedure, each date must be given on a separate line. Select the appropriate POS code for each service from the table under subsection 6. Enter the appropriate condition indicator for THSteps medical checkups. Fully describe procedures, medical services, or supplies furnished for each date given.

Enter the appropriate procedure codes and modifier for all services billed. If a procedure code is not available, enter a concise description. In the shaded area, enter a 1- through digit NDC quantity of unit. In 24 E, enter the diagnosis code reference letter pointer as shown in Form Field 21 to relate the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference number for each service should be listed first, other applicable services should follow.

The reference letter s should be A-L or multiple letters as applicable. Indicate the usual and customary charges for each service listed.

Charges must not be higher than fees charged to private-pay clients. If multiple services are performed on the same day, enter the number of services performed such as the quantity billed. Enter the taxonomy code of the individual rendering services unless otherwise indicated in the provider specific section of this manual.

All providers of Texas Medicaid must accept assignment to receive payment by checking Yes. Indicate the total of all charges on the last claim.

Enter any amount paid by an insurance company or other sources known at the time of submission of the claim. Identify the source of each payment and date in block If the client makes a payment, the reason for the payment must be indicated in block If appropriate, subtract block 29 from block 28 and enter the balance. The physician, supplier, or an authorized representative must sign and date the claim.

This is a required field for services provided in a facility. The facility provider number, name, and address are not optional. The following provider types may bill electronically or use the UB CMS paper claim form when requesting payment:. Provider Types. Specifications are available to providers developing in-house systems and software developers and vendors. Because each software package is different, field locations may vary.

Only 28 details will be processed. Claims without this information in the appropriate fields cannot be processed. The instructions describe what information must be entered in each of the block numbers of the UB CMS paper claim form. Second Digit—Bill Classification except clinics and special facilities :. Used by providers office to identify internal patient account number. Providers that receive a transfer patient from another hospital must enter the actual dates the patient was admitted into each facility.

Use military time 00 to 23 for the time of admission for inpatient claims or time of treatment for outpatient claims. Providers can refer to the National Uniform Billing Code website at www. For inpatient claims, enter the hour of discharge or death. Use military time 00 to 23 to express the hour of discharge. Optional: Accident state. Enter the dates of the previous stay. For charges of the at-home care room and board, enter revenue code Accident hour—For inpatient claims, if the patient was admitted as the result of an accident, enter value code 45 with the time of the accident using military time 00 to Use code 99 if the time is unknown.

For inpatient claims, enter value code 80 and the total days represented on this claim that are to be covered. Usually, this is the difference between the admission and discharge dates. In all circumstances, the number in this block is equal to the number of covered accommodation days listed in Block For inpatient claims, enter value code 81 and the total days represented on this claim that are not covered.

The sum of Blocks 39—41 must equal the total days billed as reflected in Block 6. For inpatient hospital services, enter the description and revenue code for the total charges and each accommodation and ancillary provided. List accommodations in the order of occurrence. List ancillaries in ascending order. The space to the right of the.

Match the appropriate diagnoses listed in Blocks 67A through 67Q corresponding to each procedure. If a procedure corresponds to more than one diagnosis, enter the primary diagnosis. Home Health Services. Outpatient claims must have the appropriate revenue code and, if appropriate, the corresponding HCPCS code or narrative description. If necessary, combine IV supplies and central supplies on the charge detail and consider them to be single items with the appropriate quantities and total charges by dates of service.

Multiple dates of service may not be combined on outpatient claims. Enter the numerical date of service that corresponds to each procedure for outpatient claims. For inpatient services, enter the number of days for each accommodation listed. If applicable, enter the number of pints of blood. When billing for observation room services, the units indicated in this block should always represent hours spent in observation.

Indicate the total of all charges on the last claim and the page number of the attachment for example, page 2 of 3 in the top right-hand corner of the form.

Enter amounts paid by any TPR, and complete Blocks 32, 61, 62, and 80 as required:. This section is used for requesting the day rule for a third party insurance. Optional: Area to capture additional information necessary to adjudicate the claims.

Required when, in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere on the claim data set. Enter the policy number or group number of the other health insurance. Enter the ICDCM diagnosis code in the unshaded area for the principal diagnosis to the highest level of specificity available. Enter the ICDCM diagnosis code in the unshaded area to the highest level of specificity available for each additional diagnosis.

Enter one diagnosis per block, using Blocks A through J only. Optional: The PPS code is assigned to the claim to identify the DRG based on the grouper software called for under contract with the primary payer. Optional: Enter the ICDCM diagnosis code in the unshaded area to the highest level of specificity available for each additional diagnosis. Inpatient claims, services that require an attending provider are defined as those listed in the ICDCM coding manual volume 3, which includes surgical, diagnostic, or medical procedures.

Other operating physician—An individual performing a secondary surgical procedure or assisting the operating physician. Required when another operating physician is involved. Rendering provider—The health-care professional who performed, delivered, or completed a particular medical service or nonsurgical procedure.

The time must be entered in Block Enter the taxonomy code non-NPI number of the billing provider. IV supplies may be combined and billed as one item. Include appropriate quantities and total charges for each combined procedure code used. Using combination procedure codes conserves space on the claim form. Multipage claim forms are processed as one claim for that client if all pages contain 28 or fewer items. Attachments will only be used for clarification purposes.

Because each software package is different, block locations may vary. These forms may be obtained by contacting the ADA at Claims without a provider name, physical address, NPI, and taxonomy code cannot be processed. The following table is an itemized description of the questions appearing on the form.

Thoroughly complete the ADA Dental claim form according to the instructions in the table to facilitate prompt and accurate reimbursement and reduce follow-up inquiries. ADA Block No. The other two boxes are not applicable. May be a parent or legal guardian of the patient receiving treatment. Enter the contact information for the insurance company providing the non-Medicaid coverage.

Enter nine-digit patient number from the Medicaid identification form. Leave blank and skip to Item Used by dental office to identify internal patient account number. Enter the letter s from Box 34 that identified the diagnosis code s applicable to the dental procedure. List the primary diagnosis pointer first. Provide a brief description of the service provided e. Enter usual and customary charges for each service listed. Charges must not be higher than the fees charged to private pay clients.

When other changes applicable to dental services provided must be reported, enter the amount here. Charges may include state tax and other charges imposed by regulatory bodies. Identify the source of each payment date in Block If the client makes a payment, the reason for the payment must be identified in Block For identifying missing permanent dentition only.

Report missing teeth when pertinent to periodontal, prosthodontic fixed and removable , or implant services procedures on a particular claim. Enter up to four applicable diagnosis codes after each letter A-D. Providers are required to check the Other Accident box for emergency claim reimbursement. If the Other Accident box is checked, information about the emergency must be provided in Block Enter the name and physical address of the billing group or individual provider.

Do not enter the name and address of a provider employed within a group. Do not enter the NPI for a provider employed within a group. Enter the area code and number for the billing group or individual Do not enter the telephone number of a provider employed within a group. Enter the taxonomy code assigned to the billing dentist or dental entity.

Do not enter the taxonomy code for a provider employed within a group. Required-Signature of treating dentist or authorized personnel. Enter the NPI for the dentist enrolled as part of a group who treated the patient. Claims must contain the billing providers complete name, physical address, NPI, and taxonomy code. The instructions describe what information must be entered in each of the block numbers of the Claim Form. Check the box for the specific program to which these services are billed:.

For DFPP, the eligibility date can be found on the following forms:. This reflects the location where the client lives. Please use the HHSC county codes. If the client does not have a SSN, or refuses to provide the number, enter Aggregate categories used here are consistent with reporting requirements of the Office of Management and Budget Statistical Direction.

Indicate whether the client is of Hispanic descent by entering the appropriate code number in the box. Ethnicity is independent of race and all clients should be counted as either Hispanic or non-Hispanic. Title XIX: Enter the gross monthly income reported by the client.

Be sure to include all sources of income. If income is received in a lump sum, or if it is for a period of time greater than a month e. If income is paid weekly, multiply weekly income by 4.

If paid every two weeks, multiply amount by 2. If paid twice a month, multiply by 2. DFPP: Use the family size reported on the eligibility assessment tool. Enter the number of times this client has been pregnant. If male, enter zero.

Enter the number of live births for this client. Enter the number of living children this client has. This also must be completed for male clients. Enter the amount paid by the other insurance company. Enter the date of the other insurance payment or denial in this block. Enter the level of practitioner that performed the service. Use this section when billing for complications related to sterilizations, contraceptive implants, or intrauterine devices IUDs.

Medicaid does not accept multiple to-from dates on a single-line detail. Bill only one date per line. If the client is registered at a hospital, the POS must indicate inpatient or outpatient status at the time of service. A decimal point must be used for fractions of a unit. Enter the diagnosis line item reference A-L for each service or procedure as it relates to each ICD diagnosis code identified in Block Diagnosis codes must be entered in Form Field 29 only.

Do not enter diagnosis codes in Form Field 32E. Indicate the charges for each service listed quantity multiplied by reimbursement rate. Members of a group practice except pathology and renal dialysis groups must identify the taxonomy code of the provider within the group who performed the service. Although not required for DFPP claims, if a claim or encounter that was submitted through DFPP is later determined eligible to be paid under Title XIX, the claim will be denied if the performing provider information is missing.

Optional: Members of a group practice except pathology and renal dialysis groups must identify NPI of the provider within the group who performed the service. If the client was assessed a copayment DFPP , enter the dollar amount assessed. Copay cannot be assessed for Title XIX clients. Enter the total of separate charges for each page of the claim. Enter the total of all pages on last claim if filing a multipage claim.

Name and address of facility where services were rendered if other than home or office. For laboratory specimens sent to an outside laboratory for additional testing, the complete name and address of the outside laboratory should be entered. The laboratory should bill Texas Medicaid for the services performed. Enter the NPI of the provider where services were rendered if other than home or office.

Enter the billing provider name, physical address, city, state, ZIP Code, and telephone number. All vision services must be billed on a CMS paper claim form or the appropriate electronic formats. For eyewear claims beyond program benefits, e.

Do not submit form to TMHP. The following table shows the blocks required for vision claims on a CMS paper claim form. Name, provider identifiers, and address of prescribing medical doctor or doctor of optometry. Describe procedures, medical services, or supplies furnished for each date given.

These receivables are recouped from claim submissions. The report is available each Monday morning, immediately following the weekly claims cycle. The EDI delivery method is also available. The title pages include the following information:.

The digit Medicaid ICN for a specific claim. Program Type. Claim Type. Hospital outpatient crossovers, home health crossovers, RHC crossovers. If the claim is a result of an automatic crossover from Medicare, the last ten digits of the Medicare claim number appears directly under the TMHP claim number. Indicates by code the specific service provided to the client. A three-digit code represents a hospital accommodation or ancillary revenue code. For claims paid under prospective payment methodology, it is the code of the DRG.

Indicates the quantity billed per claim detail. Indicates the charge billed per claim detail. Indicates the quantity TMHP has allowed per claim detail. Indicates the charges TMHP has allowed per claim detail.

For inpatient hospital claims, the allowed amount for the DRG appears. A one-digit numeric code identifying the POS is indicated in this column. Refer to subsection 6. Providers using electronic claims submission should continue using the same POS codes. The final amount allowed for payment per claim detail. The total paid amount for the claim appears on the claim total line. All prior authorization forms are for completion and submission by current Medicaid providers only. Enrollment forms are for completion and submission only by providers applying for enrollment in the Nevada Medicaid and Nevada Check Up program.

The following form is for the use of Nevada Medicaid providers to attest the appropriateness of Qualified Clinical Trials in which the recipient is participating. AMA and ADA assume no liability for data contained or not contained on this website and on documents posted herein. Announcements Latest News. Featured Links. Please refer to Web Announcement and Web Announcement for additional information.

Provider Links. Scheduled Site Maintenance. Psychological Testing. Neuropsychological Testing. Developmental Testing. Automated Testing. Inpatient Mental Health Prior Authorization. Residential Treatment Center Concurrent Review. RTC Absence Form. Residential Treatment Center Prior Authorization.

Level of Care Assessment for Nursing Facilities. Partial Denture Delivery Receipt. Denture Delivery Receipt. Prior Authorization Data Correction Form. Request for Termination of Service. Prior Authorization Reconsideration Request.

Provider Voluntary Termination Notice. Nevada Medicaid Hysterectomy Acknowledgement Form.

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USLegal received the following as compared to 9 other form sites. This site uses cookies to enhance site navigation and personalize your experience. You can modify your selections by visiting our Cookie and Advertising Notice. Read less. How It Works. How to fill out and sign fida online? Reviewing the checklist will help. For returning dentists, after you have fully attested to your CAQH ProView profile the first time, re-attesting may only take a few minutes!

This is to ensure your credentialing information remains accurate and usable by the plans you have authorized. You will NOT need to resubmit all your information each time you re-attest. Re-attestation takes most dentists on average 5—10 minutes to complete. When the download option is selected the system renders either a PDF or Word document, and files can then be saved on a computer or printed out. This information can be found on the Credentialing Resources for Office Managers web page.

You control who has access to your information — and participating organizations dental plans are not allowed access without your authorization. When completing your CAQH ProView profile, you will be asked to select which dental plans or other participating organizations you want to give authorization to access your data. ADA and CAQH recommend that you select the global option to ensure all participating payors are able to credential or re-credential you in a timely manner.

Any U. Having trouble logging in or have other questions? CT or via email at msc ada. Office managers and others should not create their own accounts. Staff who are handling credentialing tasks on behalf of dentists can consult the Credentialing Resources page for specific directions. Call Central Time or email msc ada. Dental plans can reach us by emailing sales caqh. Document checklist. Gather these documents before you start.

Dentist guide. How to register and maintain your credentials. Participating dental plans.