Workshop Participant Guide. Medicaid: Beyond the Basics. Presented by: v

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1 Workshop Participant Guide Medicaid: Beyond the Basics Presented by: v

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3 Contents Texas Medicaid... 4 Medicare... 5 Medicare Participation with Medicaid... 5 Medicare Participation... 5 Medicare and Medicaid Dual Eligibility... 6 Medicare Part A... 6 Medicare Part B... 6 Medicare Part C... 7 Medicare Part D... 8 Medicare Claims... 8 Paper Crossovers Claims... 9 Return to Provider Correspondence Remittance and Status Reports Delivery Options Accessing Remittance and Status Reports Locating PDF R&S Reports R&S Reports: Banner Pages R&S Reports: Claims Paid or Denied How to Read an Internal Control Number (ICN) Program Code Claim Type Media Type R&S Reports: Financial Transactions R&S Reports: The Following Claims Are Being Processed Balancing Your R&S Report R&S Reports: Claims Payment Summary R&S Reports: Explanation of Benefits Codes Messages R&S Reports: Mass Adjustments Mass Adjustments: Adjustments - Paid or Denied Explanation of Benefits Common Claim Denial EOB Codes Prior Authorization Prior Authorization Requests for Clients with other insurance primary to Medicaid Guidelines Prior Authorization Quick Reference Radiology v CPT only copyright 2013 American Medical Association. All rights reserved. 1

4 Ambulance CCP Dental Home Health Special Medical Prior Authorizations (SMPA) Outpatient Services Children with Special Health Care Needs (CSHCN) Services Program Other Important Forms Resources Instructions for Using the TMHP Website Searching the TMHP Website Information on the TMHP Website Functions on the TMHP Website Locating and Searching the Provider Manual Advanced Search Provider Bulletins and Banner Messages Online Provider Lookup Using the Online Provider Lookup (OPL) Tool to Find a Provider Using the Advanced Search in OPL Updating Address Information Online Fee Lookup Static Fee Schedules (OFL) Fee Search (OFL) Batch Search (OFL) ICD-10 Implementation NCCI Compliance Checking for Updates: ICD, HCPCS Procedure Codes, and NCCI guidelines Steps to Resolve Your Medicaid Questions Section 6401 of The Affordable Care Act (ACA) of Texas Women s Health Program (TWHP) Overview Benefits Client Eligibility Provider Education TMHP Computer-Based Training THSteps Provider Education Provider Relations Representatives Hospital Initiatives Overview APR-DRGs APR-DRG Definitions POA Indicator Requirement Potentially Preventable Readmissions (PPR) PPR Calculation Methodology CPT only copyright 2013 American Medical Association. All rights reserved. v

5 Potentially Preventable Complications (PPC) Reporting Resources Child and Elder Abuse, Neglect, or Exploitation DSHS Child Abuse Reporting Form Report Elder Abuse, Neglect, or Exploitation Waste, Abuse, and Fraud Definitions Most Frequently Identified Fraudulent Practices Identifying and Preventing Waste, Abuse, and Fraud Reporting Waste, Abuse, and Fraud Communication With Medicaid and State Programs TMHP Telephone and Fax Communication Prior Authorization Request Telephone and Fax Communication Prior Authorization Status Telephone Communication Written Communication With TMHP Medicaid Vendor Drug Program Pharmacies Can Dispense Limited Home Health Supplies (LHSS) to Medicaid Clients Some Vitamin and Mineral Products to Be Available Through VDP Pharmacies Helpful Links Terms/Acronyms/Abbreviations Frequently Asked Questions (FAQs) Tamper Resistant Prescriptions FAQs v CPT only copyright 2013 American Medical Association. All rights reserved. 3

6 Texas Medicaid Texas Medical Assistance (Medicaid) was implemented on September 1, 1967, under the provisions of Title XIX of the federal Social Security Act and Chapter 32 of the Texas Human Resources Code. The State of Texas and the federal government share the cost of funding Texas Medicaid. The Health and Human Services Commission (HHSC), the single state Medicaid agency, is responsible for the Title XIX Program. The administration of Texas Medicaid is accomplished through contracts and agreements with medical providers; Texas Medicaid & Healthcare Partnership (TMHP), the claims administrator; MAXIMUS, the enrollment broker; various managed care organizations (MCOs); the Institute for Child Health Policy (ICHP), the quality monitor; and state agencies. Texas Medicaid providers are reimbursed for services through contracts with health-insuring contractors, fiscal agents, or direct vendor reimbursements. By signing an HHSC Medicaid Provider Agreement (through the enrollment process) and submitting Medicaid claims, each enrolled provider agrees to abide by the policies and procedures of Medicaid, published regulations, and information and instructions in provider manuals, web articles, and other instructional material furnished to the provider. 4 CPT only copyright 2013 American Medical Association. All rights reserved. v

7 Medicare The Centers for Medicare & Medicaid Services (CMS) administers, at the federal level, Medicare to nearly 40 million Americans. Medicare is the largest health insurance program in the nation, and benefits people who are 65 years of age or older. Medicare also serves some disabled people who are 64 years of age or younger as well as anyone with end-stage renal disease. Medicare Participation with Medicaid Medicare Participation Under federal law, Medicaid is the payer of last resort, so Medicare-eligible services must first be submitted to and dispositioned (paid or denied) by Medicare. Therefore, in order to be eligible to enroll in Texas Medicaid, a provider must be a Medicare-participating provider. Certain types of providers, however, are not required to meet the Medicare participation requirement, including the following: Obstetric and Gynecology (OB/GYN) providers Pediatric providers Texas Health Steps (THSteps) Medical and Dental Services providers Early Childhood Intervention providers Family Planning providers Comprehensive Care Program (CCP) providers Case Management for Children and Pregnant Women program providers Licensed professional counselors (LPCs) Licensed marriage and family therapists (LMFTs) Some types of providers may apply for a waiver of the Medicare participation requirement of the application process. The following types of providers are eligible to apply for this waiver: Audiologist Dentist (D.D.S or D.M.D) Physician Nurse Practitioner/Clinical Nurse Specialist (NP/CNS) Optometrist (OD) Orthotists Physician (MD) Physician Assistant (PA) Podiatrist Prosthetists Note: The provider types are not required to obtain Medicare certification to enroll as a Medicaid provider. However, if Medicare certification is obtained during or after the completion of the Medicaid enrollment application, the provider will be required to submit a new application listing the Medicare certification information for enrollment with Texas State Health-Care Program. Providers who waive v CPT only copyright 2013 American Medical Association. All rights reserved. 5

8 Each provider seeking enrollment must include a valid and current Medicare number in the Texas Medicaid Provider Enrollment Application, and must include with the application a copy of the provider s notice of Medicare participation. Note: Only HHSC can approve the Medicare waiver. Each group and each performing provider of a Medicare group must have a current Medicare provider number. The group enrollment application must include the current and valid Medicare provider number for the group and for each performing provider in the group. Medicaid may reimburse for services provided to Medicare clients who are enrolled in Medicare Part A, B, C or D. However, methods of reimbursement differ. Medicare and Medicaid Dual Eligibility QMB/MQMB There are two categories of dual-eligible clients: Qualified Medicare Beneficiary (QMB) and Medicaid Qualified Medicare Beneficiary (MQMB). The Medicare Catastrophic Coverage Act of 1988 requires Medicare premiums, deductibles, and coinsurance payments to be reimbursed for individuals determined to be QMBs or MQMBs who are enrolled in Medicare Part A and meet certain eligibility criteria (see 1 Texas Administrative Code (TAC) and ). Medicaid Qualified Medicare Beneficiaries (MQMBs) are eligible for Medicaid benefits that are not benefits of Medicare in addition to Medicaid reimbursement of Medicare deductible and/ or coinsurance. Qualified Medicare Beneficiary QMB clients are not eligible for Medicaid benefits other than the Medicare deductible and coinsurance liabilities. Medicare Part A Medicare Part A provides inpatient care to clients who are in hospitals, critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also provides hospice care and some home health care. The payment of the Medicare Part A coinsurance and deductibles for Medicaid clients who are Medicare beneficiaries is based on the following: If the Medicare payment amount equals or exceeds the Medicaid payment rate, Medicaid does not pay the Medicare Part A coinsurance/deductible on a Medicare crossover claim. If the Medicare payment amount is less than the Medicaid payment rate, Medicaid pays the Medicare Part A coinsurance/deductible, but the amount of the payment is limited to the lesser of the coinsurance/deductible or the amount remaining after the Medicare payment amount is subtracted from the Medicaid payment rate. Medicare Part B Medicare Part B provides medically necessary physician services and outpatient care. For Medicare crossover claims, Texas Medicaid reimburses the lesser of the following: The coinsurance and deductible payment The amount remaining after the Medicare payment amount is subtracted from the allowed Medicaid fee or encounter rate for the service (If this amount is less than the deductible, then the full deductible is reimbursed instead.) If the Medicare payment is equal to or exceeds the Medicaid allowed amount or encounter payment for the service, Texas Medicaid does not make a payment for coinsurance. 6 CPT only copyright 2013 American Medical Association. All rights reserved. v

9 For Medicare Part B cost sharing obligations, all deductible obligations will be reimbursed at 100 percent of the deductible amount owed, even if the cost sharing comparison results in a lower payment. If Medicaid does not reimburse the full deductible or coinsurance, the provider is not allowed to charge the client. Medicare Part C Medicare Advantage Plans (Part C) provides all of the client s Part A and Part B services and generally provides additional services. Medicare Part C provides services to clients through private insurance companies that have been approved by Medicare. Note: In addition to the coinsurance and/or deductible, Medicaid may also reimburse for Medicaidonly services for MQMBs and Medicare Part B premiums for QMBs. Contracted HHSC now contracts with the Medicare Advantage Plans (MAPs) and offers a per-client-permonth payment. The payment to the MAP includes all costs associated with the Medicaid cost sharing for dual-eligible clients. MAPs that contract with HHSC will reimburse providers directly for the cost sharing obligations that are attributable to dual-eligible clients who are enrolled in the MAP. These reimbursements are included in the capitated rate paid to the MAP and must not be submitted to TMHP or charged to a Medicaid client. Providers are responsible for identifying the client s MAP contract number and Plan ID. The Plan ID identifies the product line that has been contracted with HHSC. MAPs that are contracted with HHSC reimburse providers directly for the cost-sharing obligations that are attributable to dual-eligible clients who are enrolled in the MAPs. To see a list of contracted MAPs, or to check a client s enrollment in a MAP that is contracted with HHSC, see the Contracted MAPs link provided on the TMHP.com -Medicare Dual-Eligibility page. Non-Contracted For dual eligible clients who are enrolled in a Part C non-contracted MAP, TMHP is responsible for processing and reimbursement of claims. Texas Medicaid reimburses professional and outpatient facility crossover claims the lesser of the following: The coinsurance and deductible amounts The amount remaining after the Medicare payment amount is subtracted from the allowed Medicaid fee or encounter rate for the service Exception: Texas Medicaid will reimburse coinsurance liability for MQMB clients on valid, assigned Medicare claims that are within the amount, duration, and scope of the Medicaid program, and would be covered by Medicaid when the services are provided, if Medicare did not exist. If the Medicare payment is equal to or exceeds the allowed Medicaid fee or encounter rate for the service, Texas Medicaid will not make a payment for coinsurance and deductible. Important: Medicaid payment of a client s coinsurance/deductible liabilities satisfies the Medicaid obligation to provide coverage for services that Medicaid would have paid in the absence of Medicare coverage. The client has no liability for any balance or Medicare coinsurance and deductible related to Medicaid-covered services. A list of MAPs that have contracted with HHSC is available in the Medicare section of the TMHP website at The list is updated as additional plans initiate contracts. v CPT only copyright 2013 American Medical Association. All rights reserved. 7

10 Full Amount of Part B and Part C Coinsurance and Deductible Reimbursed Exceptions Texas Medicaid reimburses the full amount of the Medicare Part B and Part C (noncontracted MAPs only) coinsurance and deductible for the following services: All ambulance services Services rendered by psychiatrists, psychologists, and licensed clinical social workers Procedure codes R0070 and R0075 for services rendered by physicians Medicare Part D Medicare Part D offers optional drug benefits to all Medicare beneficiaries through private drug plans (PDPs) or Medicare HMOs. For dual-eligible clients, the Texas Medicaid Vendor Drug Program (VDP) reimburses VDPcontracted pharmacies for some of the categories of the outpatient wrap-around prescription drugs. Wrap-around drugs are drugs that are not a benefit of Medicare Part D. To be reimbursed by Medicaid, the drug must be listed on the HHSC Medicaid formulary list. The Texas Drug Code Index Formulary Drug Search lists all state health-care program formulary information and preferred drugs. The Enhanced Formulary List provides Medicaid-only formulary information, and it includes links from selected non-preferred drugs to the preferred drugs in that therapeutic class and clinical edit criteria. Epocrates provides access to free drug information through a variety of mobile devices, including mobile telephones. To learn more about the basic-level Medicare prescription drug plans available in Texas, refer to the Texas MedicareRx website at Medicare Claims When a service is a benefit of Medicare and Medicaid, claims must be submitted to Medicare first. Providers should not submit a claim to Medicaid until Medicare has dispositioned the claim. The reimbursement received from Medicare and the coinsurance or deductible reimbursement from Medicaid must be considered payment in full. Medicaid reimburses the beneficiary s Part A and B deductibles and coinsurance liabilities on valid Medicare claims. These guidelines exclude clients who are living in a nursing facility. Note: Medicare Crossover Claims cannot be submitted electronically using TexMedConnect or by telephone using the Automated Inquiry System (AIS). 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 reimbursement of the Medicare deductible and coinsurance from TMHP on behalf of the QMB or MQMB client. Providers accepting Medicare or Medicaid assignment cannot legally require the client to pay the Medicare coinsurance and/or deductible amounts. For crossover claims that are not transferred electronically, providers must submit a paper claim to TMHP. 8 CPT only copyright 2013 American Medical Association. All rights reserved. v

11 Paper Crossovers Claims Providers are allowed to submit Medicare primary paper claims to TMHP for reimbursement of coinsurance or deductible for claims that fail to cross over from Medicare electronically. Providers may only submit paper crossover claims or appeals to TMHP. The following paper crossover claims may be submitted to TMHP: The Medicare Remittance Advice (RA) or Remittance Notice (RN), which is issued by Medicare The appropriate, completed paper CMS-1500 or UB-04 CMS-1450 paper claim form The appropriate TMHP Standardized Medicare and MAP Remittance Advice Notice Form (i.e., MRAN/MAP template). (The MRAN/MAP template is optional when certain conditions are met.) Providers that receive paper MRANs from Medicare or a Medicare intermediary or MRANs using the CMS-approved software MREP, for professional services, or PC-Print, for institutional services, may submit these MRANs to TMHP. Providers that submit these MRANs are not required to submit the TMHP Standardized MRAN Form. Providers that cannot retrieve the MRAN from MREP or PC-Print, or who don t receive a paper MRAN from Medicare or a Medicare intermediary, must submit the TMHP Standardized MRAN Form. Providers that submit paper crossover claims must submit only one of the approved MRAN formats MREP, PC-Print, paper MRAN from Medicare or a Medicare intermediary, or TMHP Standardized MRAN form along with a completed claim form. Paper crossover claims that contain multiple MRAN forms with conflicting information are returned to the provider or denied. Providers that receive paper Medicare Remittance Advice Notices (MRANs) from Medicare or a Medicare intermediary or MRANs using the CMS-approved software Medicare Remit Easy Print (MREP), for professional services, or PC-Print, for institutional services, may submit these MRAN to TMHP. Providers that submit these MRANs are not required to submit the TMHP Standardized MRAN Form. Providers that cannot retrieve the MRAN from MREP or PC-Print, or who don t receive a paper MRAN from Medicare or a Medicare intermediary, must submit the TMHP Standardized MRAN Form. Providers that submit paper crossover claims must submit only one of the approved MRAN formats MREP, PC-Print, paper MRAN from Medicare or a Medicare intermediary, or TMHP Standardized MRAN form along with a completed claim form. Paper crossover claims that contain multiple MRAN forms with conflicting information are returned to the provider or denied. The TMHP Standardized MRAN form and form instructions are available in the current TMPPM and on the TMHP website at the following links: MRAN Type 30 Providers who bill professional services on the CMS-1500 paper claim form may submit the Crossover Claim Type 30 template with a copy of a completed claim form. Form and instructions: Form Crossover Claim Type 30.pdf v CPT only copyright 2013 American Medical Association. All rights reserved. 9

12 Note: The TMHP Standardized MRAN form must be typed or computer generated. Handwritten forms are not accepted and are returned to the provider. MRAN Type 31 Providers who bill inpatient and outpatient crossover claims on a UB-04 CMS-1450 paper claim form may submit the Crossover Claim Type 31 template with a copy of a completed claim form. Form and instructions: Form Crossover Claim Type 31.pdf MRAN Type 50 Providers who bill inpatient crossover claims on a UB-04 CMS-1450 paper claim form may submit the Crossover Claim Type 50 template with a copy of a completed claim form. Form and instructions: Form Crossover Claim Type 50.pdf 10 CPT only copyright 2013 American Medical Association. All rights reserved. v

13 Crossover Professional Claim Type 30 TMHP Standardized Medicare and Medicare Advantage Plan (MAP) Remittance Advice Notice Form 1 Billing Provider NPI/API: 2 Billing Provider TPI: 3 Billing Provider Name: 4 Billing Provider Medicare ID: 5 Medicaid Client Number: 6 Medicare Paid Date: 7 Client Last Name: 8 Client First Name: 9 Medicare ICN: 10 Client HIC Number: 11 Detail(s) Information Dtl # a. Perf Prov TPI b. Perf Prov NPI c. From DOS d. To DOS e. POS f. Units g. CPT h. Mods i. Charges j. k. l. m. n. Allow Ded Coins Paid Reason Code SAMPLE Totals Information a. Charges b. Allow c. Ded d. Coins e. Paid f. Total Pages of 13 Medicare Prev Paid Important: By submitting these forms to TMHP, the provider attests that the information included in the form exactly matches the Medicare RA or RN that was received from Medicare or the MAP. If the information on this crossover claim type form does not exactly match the information on the RA or RN, the claim may be denied. Save As Effective / Revised v CPT only copyright 2013 American Medical Association. All rights reserved. 11

14 Crossover Professional Claim Type 30 TMHP Standardized Medicare and Medicare Advantage Plan (MAP) Remittance Advice Notice Form Instructions Providers that bill professional services on the CMS-1500 paper claim form may submit the Crossover Professional Claim Type 30 template with a copy of a completed claim form. The Remittance Advice (RA) or Remittance Notice (RN) from Medicare, the CMS-approved software Medicare Remit Easy Print (MREP), or the MAP is required when submitting the Crossover Professional Claim Type 30 template. All fields (excluding Medicaid information fields) on the form must be completed using the RA or RN that was received from Medicare or the MAP. Important: All details from the Medicare or MAP RA or RN must be included in the template even if a deductible or coinsurance is not due. The TMHP Standardized MRAN Submission Form must be typed or computer-generated. Handwritten forms will not be accepted and will be returned to the provider. The following are the requirements for the Crossover Professional Claim Type 30 template: # Field Description Guidelines 1 Billing Provider NPI/API Enter the National Provider Identifier (NPI) for the billing provider. 2 Billing Provider TPI Enter the Medicaid Texas Provider Identifier (TPI) number of the billing provider. 3 Billing Provider Name Enter the billing provider s name. 4 Billing Provider Medicare ID 5 Medicaid Client Number Enter the Medicare Provider ID number of the billing provider listed on the Medicare or MAP RA/RN. Enter the client s nine-digit Medicaid number from the Medicaid identification form. 6 Medicare Paid Date Enter the Medicare Paid Date listed on the Medicare or MAP RA/RN. 7 Client Last Name Enter the client s last name listed on the Medicare or MAP RA/RN. 8 Client First Name Enter the client s first name listed on the Medicare or MAP RA/RN. 9 Medicare ICN Enter the Medicare Internal Control Number (ICN) listed on the Medicare or MAP RA/RN. 10 Client HIC Number Enter the client s identification number listed on the Medicare or MAP RA/RN. 11 Details Information 11a Perf Prov NPI/API Enter the National Provider Identifier (NPI) for the performing provider 11b Perf Prov TPI Enter the Texas Provider Identifier (TPI) number of the performing provider 11c From DOS Enter the first date of service (DOS) for each procedure in a MM/DD/YYYY format. 11d To DOS Enter the last DOS for each procedure in a MM/DD/YYYY format. 11e POS Enter the place of service (POS) listed on the MAP Remittance Advice/Remittance Notice. 11f Units Enter the number of units (quantity billed) from the Medicare or MAP RA/RN. 11g CPT Enter the appropriate Current Procedural Terminology (CPT) procedure code for each procedure/service listed on the Medicare or MAP RA/RN Note: The procedure code listed on the Standardized MRAN Template may not match the procedure code listed on the claim form attached. 11h Mods Enter the modifier (when applicable) listed on the Medicare or MAP RA/RN for each detail. 11i Charges Enter the Medicare charges (billed amount) listed on the Medicare or MAP RA/RN for each detail. 11j Allow Enter the Medicare allowed amount listed on the Medicare or MAP RA/RN for each detail. 11k Ded Enter the Medicare deductible amount listed on the Medicare or MAP RA/RN for each detail. 11l Coins Enter the Medicare coinsurance amount listed on the Medicare or MAP RA/RN for each detail. 11m Paid Enter the Medicare paid amount listed on the Medicare or MAP RA/RN for each detail. Effective / Revised CPT only copyright 2013 American Medical Association. All rights reserved. v

15 Crossover Professional Claim Type 30 TMHP Standardized Medicare and Medicare Advantage Plan (MAP) Remittance Advice Notice Form Instructions 11n Reason Code Enter Medicare s reason code listed on the Medicare or MAP RA/RN for each detail. 12 Totals Information 12a Total Charges Enter the Medicare total charges (billed amount) listed on the Medicare or MAP RA/RN. Note: A provider may attach additional template forms (pages) as necessary. The combined total charges for all pages should be listed on the last page. All other forms must indicate Continue in this block. 12b Total Allow Enter the Medicare total allowed amount listed on the Medicare or MAP RA/RN. 12c Total Ded Enter the Medicare total deductible amount listed on the Medicare or MAP RA/RN. 12d Total Coins Enter the Medicare total coinsurance amount listed on the Medicare or MAP RA/RN. 12e Total Paid Enter the Medicare total paid amount listed on the Medicare or MAP RA/RN. 12f Total Pages If the crossover claim contains more than 7 detail line items, use multiple pages to identify up to 28 detail line items for the claim as necessary. Add the number of the page in the first blank line and the total page count in the second blank line (e.g., 1 of 3, 2 of 3, 3 of 3 ). This field is only required if multiple pages are necessary to capture all billed detail line items. If multiple pages are necessary, Boxes 1-10 must be completed on each page submitted. 13 Medicare Prev Paid Enter the Medicare previous paid amount listed on the Medicare or MAP RA/RN. Effective / Revised v CPT only copyright 2013 American Medical Association. All rights reserved. 13

16 1 Medicare Paid Date: Crossover Outpatient Facility Claim Type 31 TMHP Standardized Medicare and Medicare Advantage Plan (MAP) Remittance Advice Notice Form 2 Provider Name: 3 NPI/API: 4 TPI: 5 Medicare ID: 6 Street Address: City: State: Zip: 7 Bill Type: 8 From DOS: 9 Through DOS: 10 Client Last Name: 11 Client First Name: 12 Medicare HIC: 13 Medicare ICN: 14 Total Charges: 15 Covered Charges: 16 Non Covered Charges/Reason Code: 17 Deductible: 18 Blood Deductible: 19 Coinsurance: 20 Paid Amount Medicare: 21 Detail(s) Information a. Rev Cd b. CPT/Mods d. From DOS e. Units f. Charges g. Allow h. Ded i. Coins j. Blood Ded k. Paid l. Reason Code SAMPLE 22 Totals Information a. Charges b. Allow c. Ded d. Coins e. Blood Ded f. Paid g. Total Pages of Important: By submitting these forms to TMHP, the provider attests that the information included in the form exactly matches the Medicare RA or RN that was received from Medicare or the MAP. If the information on this crossover claim type form does not exactly match the information on the RA or RN, the claim may be denied. Save As Effective / Revised CPT only copyright 2013 American Medical Association. All rights reserved. v

17 Crossover Outpatient Facility Claim Type 31 TMHP Standardized Medicare and Medicare Advantage Plan (MAP) Remittance Advice Notice Form Instructions Providers that bill outpatient crossover claims on the UB-04 CMS-1450 paper claim form may submit the Crossover Outpatient Facility Claim Type 31 template with a copy of a completed claim form. The Remittance Advice (RA) or Remittance Notice (RN) from Medicare, the CMS-approved software PC-Print, or the MAP is required when submitting the Crossover Outpatient Facility Claim Type 31 template. All fields (excluding Medicaid information fields) on the form must be completed using the RA or RN that was received from Medicare or the MAP. Important: All details from the Medicare or MAP RA or RN must be included in the template even if a deductible or coinsurance is not due. The TMHP Standardized MRAN Submission Form must be typed or computer-generated. Handwritten forms will not be accepted and will be returned to the provider. The following are the requirements for the Crossover Outpatient Facility Claim Type 31 template: # Field Description Guidelines 1 Medicare Paid Date Enter the Medicare Paid Date listed on the Medicare RA/RN. 2 Provider Name Enter the billing provider s name. 3 NPI/API Enter the National Provider Identifier (NPI)/Atypical Provider Identifier (API) for the billing providers. 4 TPI Enter the Texas Provider Identifier (TPI) for the billing provider. 5 Medicare ID Enter the Medicare Provider ID of the billing provider number listed on the Medicare or MAP RA/RN. 6 Street Address, City, State, ZIP Enter the billing provider s street address, city, state, and ZIP code in the appropriate fields. 7 Bill Type Enter the Medicare Bill Type listed on the Medicare or MAP RA/RN. Note: The Medicare Bill Type may not match the type of bill (TOB) listed on the claim form. 8 From DOS Enter the first date of service (DOS) for all procedures in a MM/DD/YYYY format. 9 Through DOS Enter the last DOS for all procedures in a MM/DD/YYYY format. 10 Client Last Name Enter the patient s last name listed on the Medicare or MAP RA/RN. 11 Client First Name Enter the patient s first name listed on the Medicare or MAP RA/RN. 12 Medicare HIC Enter the patient s Medicare Health Insurance Claim (HIC) number (Medicare Identification number) listed on the Medicare or MAP RA/RN. 13 Medicare ICN Enter the Medicare Internal Control Number (ICN) listed on the Medicare or MAP RA/RN. 14 Total Charges Enter the Medicare total charges (billed amount) listed on the Medicare or MAP RA/RN. 15 Covered Charges Enter the covered charges listed on the Medicare or MAP RA/RN. 16 Non Covered Charges/Reason Code Enter the noncovered charges listed on the MAP RA/RN followed by the reason code listed on the Medicare RA/RN. 17 Deductible Enter the Medicare deductible amount listed on the Medicare or MAP RA/RN. 18 Blood Deductible Enter the blood deductible listed on the Medicare or MAP RA/RN for inpatient claims, if applicable. Note: Outpatient claims do not require a blood deductible amount. 19 Coinsurance Enter the Medicare coinsurance amount listed on the Medicare or MAP RA/RN. 20 Medicare Paid Amount Enter the Medicare paid amount listed on the Medicare or MAP RA/RN. 21 Detail(s) Information 21a Rev Cd 21b CPT Enter the appropriate Current Procedural Terminology (CPT) procedure code for each Effective / Revised v CPT only copyright 2013 American Medical Association. All rights reserved. 15

18 Crossover Outpatient Facility Claim Type 31 TMHP Standardized Medicare and Medicare Advantage Plan (MAP) Remittance Advice Notice Form Instructions procedure/service listed on the Medicare or MAP RA/RN Note: The procedure code listed on the Standardized MRAN Template may not match the procedure code listed on the claim form attached. 21c Mods Enter the modifier (when applicable) listed on the Medicare or MAP RA/RN for each detail. 21d From DOS Enter the first date of service (DOS) for each procedure in a MM/DD/YYYY format. 21e Units Enter the number of units (quantity billed) from the Medicare or MAP RA/RN. 21f Charges Enter the Medicare charges (billed amount) listed on the Medicare or MAP RA/RN for each detail. 21g Allow Enter the Medicare allowed amount listed on the Medicare or MAP RA/RN for each detail. 21h Ded Enter the Medicare deductible amount listed on the Medicare or MAP RA/RN for each detail. 21i Coins Enter the Medicare coinsurance amount listed on the Medicare or MAP RA/RN for each detail. 21j Blood Ded Enter the Medicare blood deductible amount listed on the Medicare or MAP RA/RN for each detail. 21k Paid Enter the Medicare paid amount listed on the Medicare or MAP RA/RN for each detail. 21l Reason Code Enter Medicare s reason code listed on the Medicare or MAP RA/RN for each detail. 22 Totals Information 22a Total Charges Enter the Medicare total charges (billed amount) listed on the Medicare or MAP RA/RN. Note: A provider may attach additional template forms (pages) as necessary. The combined total charges for all pages should be listed on the last page. All other forms must indicate Continue in this block. 22b Total Allow Enter the Medicare total allowed amount listed on the Medicare or MAP RA/RN. 22c Total Ded Enter the Medicare total deductible amount listed on the Medicare or MAP RA/RN. 22d Total Coins Enter the Medicare total coinsurance amount listed on the Medicare or MAP RA/RN. 22e Total Blood Ded Enter the Medicare total blood deductible amount listed on the Medicare or MAP RA/RN. 22f Total Paid Enter the Medicare total paid amount listed on the Medicare or MAP RA/RN. 22g Total Pages If the crossover claim contains more than 10 detail line items, use multiple pages to identify up to 28 detail line items for the claim as necessary. Add the number of the page in the first blank line and the total page count in the second blank line (e.g., 1 of 3, 2 of 3, 3 of 3. This field is only required if multiple pages are necessary to capture all billed detail line items. If multiple pages are necessary, Boxes 1-6 must be completed on each page submitted. Effective / Revised CPT only copyright 2013 American Medical Association. All rights reserved. v

19 Crossover Inpatient Hospital Claim Type 50 TMHP Standardized Medicare and Medicare Advantage Plan (MAP) Remittance Advice Notice Form 1 Medicare Paid Date: 2 Provider Name: NPI/API: TPI: Medicare ID: 3 Street Address: 4 City: State: Zip: 5 Bill Type 6 From DOS 7 Through DOS 8 Client Last Name 9 Client First Name 10 Medicare HIC 11 Medicare ICN 12 Total Charges 13 Covered Charges 14 Non Covered Charges/Reason Code 15 DRG Amount 16 Deductible 17 Blood Deductible SAMPLE 18 Coinsurance 19 Medicare Paid Amount 20 DRG Code Important: By submitting these forms to TMHP, the provider attests that the information included in the form exactly matches the Medicare RA or RN that was received from Medicare or the MAP. If the information on this crossover claim type form does not exactly match the information on the RA or RN, the claim may be denied. Save As Effective / Revised v CPT only copyright 2013 American Medical Association. All rights reserved. 17

20 Crossover Inpatient Hospital Claim Type 50 TMHP Standardized Medicare and Medicare Advantage Plan (MAP) Remittance Advice Notice Form Instructions Providers that bill inpatient crossover claims on the UB-04 CMS-1450 paper claim form may submit the Crossover Inpatient Hospital Claim Type 50 template with a copy of a completed claim form. The Remittance Advice (RA) or Remittance Notice (RN) from Medicare, the CMS-approved software PC-Print, or the MAP is required when submitting the Crossover Inpatient Hospital Claim Type 50 template. All fields (excluding Medicaid information fields) on the form must be completed using the RA or RN that was received from Medicare or the MAP. Important: All details from the Medicare or MAP RA or RN must be included in the template even if a deductible or coinsurance is not due. The TMHP Standardized MRAN Submission Form must be typed or computer-generated. Handwritten forms will not be accepted and will be returned to the provider. The following are the requirements for the Crossover Inpatient Hospital Claim Type 50 template: # Field Description Guidelines 1 Medicare Paid Date Enter the Medicare Paid Date listed on the Medicare RA/RN. 2 Provider Name Enter the billing provider s name. NPI/API/TPI Enter the National Provider Identifier (NPI)/Atypical Provider Identifier (API)/Texas Provider Identifier (TPI) for the billing provider. Note: NPI/TPI or API/TPI. Medicare ID Enter the Medicare Provider ID of the billing provider number listed on the Medicare or MAP RA/RN. 3 Street Address Enter the billing provider s street address. 4 City Enter the billing provider s city. State Enter the billing provider s state. ZIP Enter the billing provider s ZIP code. 5 Bill Type Enter the Medicare Bill Type listed on the Medicare or MAP RA/RN. Note: The Medicare Bill Type may not match the type of bill (TOB) listed on the claim form. 6 From DOS Enter the first date of service (DOS) for all procedures in a MM/DD/YYYY format. 7 Through DOS Enter the last DOS for all procedures in a MM/DD/YYYY format. 8 Client Last Name Enter the patient s last name listed on the Medicare or MAP RA/RN. 9 Client First Name Enter the patient s first name listed on the Medicare or MAP RA/RN. 10 Medicare HIC Enter the patient s Medicare Health Insurance Claim (HIC) number (Medicare Identification number) listed on the Medicare or MAP RA/RN. 11 Medicare ICN Enter the Medicare Internal Control Number (ICN) listed on the Medicare or MAP RA/RN. 12 Total Charges Enter the Medicare total charges (billed amount) listed on the Medicare or MAP RA/RN. 13 Covered Charges Enter the covered charges listed on the Medicare or MAP RA/RN. 14 Non Covered Charges/Reason Code Enter the noncovered charges listed on the MAP RA/RN followed by the reason code listed on the Medicare RA/RN. 15 DRG Amount Enter the diagnosis-related group (DRG) amount listed on the Medicare or MAP RA/RN for inpatient claims, if applicable. Note: Outpatient claims do not require a DRG amount. 16 Deductible Enter the Medicare deductible amount listed on the Medicare or MAP RA/RN. 17 Blood Deductible Enter the blood deductible listed on the Medicare or MAP RA/RN for inpatient claims, if applicable. Note: Outpatient claims do not require a blood deductible amount. 18 Coinsurance Enter the Medicare coinsurance amount listed on the Medicare or MAP RA/RN. 19 Medicare Paid Amount Enter the Medicare paid amount listed on the Medicare or MAP RA/RN. 20 DRG Code Enter the DRG code listed on the Medicare or MAP RA/RN for inpatient claims, if applicable. Note: Outpatient claims do not require a DRG code. Effective / Revised CPT only copyright 2013 American Medical Association. All rights reserved. v

21 Return to Provider Correspondence Claims are returned to providers for a number of reasons. When TMHP receives a claim or appeal, it is initially reviewed by a document preparation clerk. If the document preparation clerk determines that the claim cannot be processed as received, the claim is sorted as Return to Provider (RTP) correspondence and it is scanned into the system. Once the claim is scanned into the system, a mailroom specialist retrieves the RTP correspondence and performs a second review of the claim. If the claim does not meet the sort criteria, the mailroom specialist will manually enter the patient control number (PCN) and provider information into the system along with the return reason. A quality analyst performs a final review of every claim. If the quality analyst also determines that the claim does not meet the sort criteria, the claim is processed as RTP correspondence using the provider information and the reason(s) previously entered by the mailroom specialist. An RTP letter is generated and the RTP letter, claim, and supporting documentation are sent back to the submitting provider. The examples below represent the most frequently used RTP messages. These messages are printed in the Your correspondence is being returned for the following reason(s) section of the RTP letter. 1. The MRAN that was submitted is not in the approved format. All paper Medicare crossover claims must be submitted with one of the following HHSC-approved MRANs, MRAN printed from Medicare Remit Easy Print (MREP) (professional services) or PC-Print (institutional services), paper MRAN received from Medicare or a Medicare intermediary or the TMHP Standardized MRAN Form. 2. The TPI on the attached claim(s) is missing or invalid. Refer to the Claims Filing sections of the Texas Medicaid Providers Procedure Manual (TMPPM) or the CSHCN Services Program Provider Manual. 3. A completed claim form must be attached to crossover claims. 4. The only acceptable R&S Reports are those generated by TMHP. Providers must follow the appeals process outlined in the TMPPM or the CSHCN Services Program Provider Manual. 5. The attached R&S Report is not legible or is not aligned and cannot be scanned into the system for processing. Correct the R&S Report prior to resubmission. 6. The service(s) were filed on an incorrect claim form. Refer to the TMPPM or the CSHCN Services Program Provider Manual and resubmit the corrected claim and applicable documentation, if any. 7. Medicare paper claims (including Medicare denials) must be filed with a completed claim form and one of the approved Medicare Remittance Notice. v CPT only copyright 2013 American Medical Association. All rights reserved. 19

22 8. The R&S Report submitted contains Explanation of Pending Status (EOPS) codes. EOPS codes indicate that your claim is currently in process and should not be resubmitted to TMHP. You must submit an R&S Report that indicates the claim has been finalized (paid or denied) and contains EOB codes. 9. Attach a completed claim form with your Rejection Report circling only one claim per page, using only black ink for claims that have been electronically rejected. For Rejection Reports containing multiple claims per page, you must make multiple copies of the Rejection Report and circle only one claim per page. Note: The electronic rejection report submitted must contain a TMHP Batch Number. 10. For items listed in the Financial section of the R&S Report that you wish to have reprocessed; copy, complete, and attach the Refund Information Form and a check in the appropriate amount to the R&S Report. The Refund Information Form can be found in Forms Appendix of the TMPPM or the CSHCN Services Program Provider Manual. 11. TMHP cannot identify the enclosed documents because they are not accompanied by a claim or a R&S Report. Resubmit the information on the appropriate claim form. For submissions other than claims and appeals, refer to the TMPPM or the CSHCN Services Program Provider Manual for the appropriate department information. 12. TMHP cannot process multiple Medicare primary claims indicated on the same page. Providers must indicate only one claim per form, using only black ink when using any of the HHSC-approved MRANs. 13. TMHP cannot process multiple claims indicated on the same R&S Report page. Circle one claim per page on the R&S Report using only black ink. If you have multiple claims on the same page on the R&S Report, you must make multiple copies and circle only one claim per page. 14. The attached claim(s) is not legible or is not aligned and cannot be scanned into the system for processing. Correct the claim(s) prior to resending. 15. The attached MRAN is not legible or is not aligned and cannot be scanned into the system for processing. Correct the MRAN prior to resending. 16. The attachment is not legible or is not aligned and cannot be scanned into the system for processing. Correct the attachment prior to resending. 17. The attached claim(s) or document(s) are damaged and cannot be processed. Correct the claim or document prior to resending. 18. Claims filed secondary to Medicare on an approved HHSC MRANs form, must not have any details crossed out. Medicaid must process secondary claims in their entirety. 19. The attached dental claim(s) cannot be processed because the Request for Predetermination/ Preauthorization field was checked. For authorization requests, refer to the Appendices of the TMPPM and the CSHCN Services Program Provider Manual for the appropriate form. 20. The client name or date of service on the claim does not match the client name and/or date of service on the attachment. Resubmit the claim with an attachment that has the same client name and/or date of service. 21. The attached claim(s) or document(s) was submitted on paper smaller or larger than 8½ x 11. Resubmit on the correct sized paper. 20 CPT only copyright 2013 American Medical Association. All rights reserved. v

23 22. Information on the attached claim(s) or document(s) is highlighted, or printed in red ink. Resubmit the claim or document using black ink and do not highlight any information. 23. Providers must not cross out any details on the R&S Report or MRAN. Resubmit the R&S Report or MRAN circling one claim per page using black ink. 24. The attached claims were not separated from each other. Resubmit after separating each claim. Medicaid: Beyond the Basics Participant Guide 25. TMHP does not accept handwritten TMHP Standardized MRAN forms. Resubmit a typed or computer-generated TMHP Standardized MRAN form. 26. The attached Durable Medical Equipment (DME) Certification of Receipt Form is incomplete. One or more of the following fields is missing: Client Name, Medicaid ID, Telephone Number, Provider Name, National Provider Identifier (NPI), Texas Provider Identifier (TPI), Date of Service (DOS), Procedure Code, Prior Authorization Number, and/or Serial Number. Complete all fields on the form, indicate N/A for fields that are not applicable, and resubmit the completed form. 27. Your resubmission is being returned due to repeated incorrect claims submissions. If you would like assistance with the claims submission process refer to the TMPPM or the CSHCN Services Program Provider Manual. Additional assistance is available by calling the TMHP Contact Center at or the TMHP-CSHCN Contact Center at TMHP cannot process your R&S Report because the submitted R&S Report does not include the complete claim information. Resubmit a complete R&S Report with all the necessary claim information including the Internal Control Number (ICN). v CPT only copyright 2013 American Medical Association. All rights reserved. 21

24 Mailroom 12357B Riata Trace Parkway Austin, Texas Address Julian Date Clerk# Mailroom Date Any and all information and/or documentation submitted in response to this letter must be received by Texas Medicaid & Healthcare Partnership (TMHP) within 120 days from the date of this letter. Information and/or documentation not received within 120 days will cause your claims to deny. You must attach a copy of this letter with each claim re-submission to show proof of timely filing. No further action will be taken by TMHP until the information requested below has been provided and/or corrected. Your correspondence is being returned for the following reason(s): Not enrolled in the Texas Medicaid Program or need an additional provider number for a new location? Visit for an enrollment application or call TMHP Customer Service at (option 3#). DO 1) Use 10x13 inch envelopes to mail claims. 2) Circle only one claim per page, when sending Remittance Advice (RA) from Medicare. Claims Normally filed on a UB92 must accompany the Medicare RA. 3) Use black ink only (not a black marker). 4) Place the claim form on top when sending new claims, followed by any medical records or attachments. 5) Number pages appropriately when sending attachments, (e.g. 1 of 2, 2 of 2). 6) Paper clip claims or appeals if they include attachments. 7) Detach claims at perforated lines before mailing. 8) Indicate continuation when multiple claims for the same client. DON T 1) Fold claims, appeals or correspondence. 2) Send duplicate copies of information. 3) Use red ink. Red ink does not scan and is difficult to read. 4) Use paper sizes smaller or larger than 8-1/2 x 11. Scan equipment will only accept 8-1/2 x 11 paper, including memos and photos. 5) Mail claims with correspondence for other departments as this may delay processing the claims. 6) Use glue, tape or staples. 7) Use highlighters. Scan equipment will not pick up highlighted information. Circle the information instead. 8) Total each claim when the claim is a continuation of multiple claims for the same client. PROVIDER LETTER21.doc 03/04 22 CPT only copyright 2013 American Medical Association. All rights reserved. v

25 Remittance and Status Reports The Remittance and Status (R&S) Report provides information on pending, paid, denied, and adjusted claims. TMHP provides weekly R&S Reports to give providers detailed information about the status of claims submitted to TMHP. The R&S Report also identifies accounts receivables established as a result of inappropriate reimbursement. These receivables are recouped from claim submissions. All claims for the same provider identifier and program are processed and reimbursed at the end of the week, either by a single check or electronically 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 reimbursements and denials received. Note: Providers receive a single R&S Report that details Texas Medicaid activities and provides individual program summaries. Combined provider reimbursements are made based on the provider s settings for Texas Medicaid fee-for-service. Providers must retain copies of all R&S Reports for a minimum of five years. Providers must not use R&S Report originals for appeal purposes, but must submit copies of the R&S Report pages with appeal documentation. Delivery Options TMHP offers two options for the delivery of the R&S Report. Although providers may choose any of the following methods, a newly-enrolled provider is initially set up to receive a portable document format (PDF) version of the R&S Report. Portable document format (PDF) version. The PDF version of the R&S Report can be downloaded by registered users of the TMHP website at The report is available each Monday morning, immediately following the weekly claims cycle. Reimbursements associated with the R&S Report are not released until all provider reimbursements are released on the Friday following the weekly claims cycle. The PDF version of the R&S Report is available on the TMHP website for up to 90 days. Note: In the event of a holiday, reimbursements associated with the R&S Report are released the following business day. Electronic version (American National Standards Institute [ANSI] 835): The Electronic Remittance & Status (ER&S) Report. Using Health Insurance Portability and Accountability Act (HIPAA)-compliant EDI standards, the ER&S Report can be downloaded through the TMHP EDI Gateway using TexMedConnect or third party software. The ER&S Report is also available each Monday after the completion of the weekly claims processing cycle. The ER&S Report file is in ANSI 835 format, which is not a valid format for appeals. v CPT only copyright 2013 American Medical Association. All rights reserved. 23

26 Accessing Remittance and Status Reports Locating PDF R&S Reports 1. Go to and click providers in the top menu bar. 2. Click Go to TexMedConnect. 3. Enter your User name and Password and click OK. 24 CPT only copyright 2013 American Medical Association. All rights reserved. v

27 4. Click R&S in the left-side navigation pane. 5. Click the appropriate NPI/API. 6. Click the appropriate program. (Programs 100 and 200 are combined in one R&S Report.) v CPT only copyright 2013 American Medical Association. All rights reserved. 25

28 7. Click the file with the date of the R&S Report that you are looking for. Note: For more information about accessing and searching for R&S Reports, refer to the R&S Report computer-based training (CBT) in the TMHP Learning Management System at 26 CPT only copyright 2013 American Medical Association. All rights reserved. v

29 R&S Reports are made up of several sections that appear in the following order: Medicaid: Beyond the Basics Participant Guide Banner Messages Claims Paid or Denied Adjustments Financial Transactions Pending Status Claims Claims Payment Summary Explanation of Benefits Codes Messages v CPT only copyright 2013 American Medical Association. All rights reserved. 27

30 R&S Reports: Banner Pages Texas Medicaid & Healthcare Partnership Remittance and Status Report Date: 02/01/2013 Mail original claim to: TEXAS PROVIDER Texas Medicaid & Healthcare Partnership PO BOX P.O. Box DALLAS, TX Austin, Texas (214) Mail all other correspondence to: TPI: Texas Medicaid & Healthcare Partnership NPI/API: B Riata Trace Parkway Taxonomy: X Austin, Texas Benefit Code: Report Seq. Number: 35 (800) R&S Number: ~ Page 1 Of BANNER PAGE (01/24/12 THROUGH 02/14/12) *****ATTENTION ALL MEDICAID PROVIDERS***** Effective for dates of service on or after September 1, 2011, the Texas Medicaid Program is implementing benefit changes for respiratory syncytial virus (RSV) prophylaxis palivizumab (Synagis). Details of these changes are available on the TMHP website at and will also be available in the January/February 2012 Texas Medicaid Bulletin, No For more information, call the TMHP Contact Center at TEXAS PROVIDER YOUR AIS NUMBER IS PO BOX FOR AIS INQUIRY CALL TOLL FREE 1-(800) DALLAS, TX THE PROVIDER MANUAL PROVIDES DETAILS. (214) PHYSICAL ADDRESS ON RECORD: TEXAS PROVIDER PO BOX DALLAS, TX (214) CPT only copyright 2013 American Medical Association. All rights reserved. v

31 R&S Reports: Claims Paid or Denied Medicaid: Beyond the Basics Participant Guide Texas Medicaid & Healthcare Partnership Remittance and Status Report Date: 02/01/2013 Mail original claim to: TEXAS PROVIDER Texas Medicaid & Healthcare Partnership PO BOX P.O. Box DALLAS, TX Austin, Texas (214) Mail all other correspondence to: TPI: Texas Medicaid & Healthcare Partnership NPI/API: B Riata Trace Parkway Taxonomy: X Austin, Texas Benefit Code: Report Seq. Number: 35 (800) R&S Number: ~ 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 V /22/ /22/ T U7 $71.00 $.00 $.00 CLAIM TOTAL PAYMENT WAS REDUCED BY DUE TO OTHER INSURANCE PAYMENTS DOE, JANE N V /20/ /20/ T 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 v CPT only copyright 2013 American Medical Association. All rights reserved. 29

32 How to Read an Internal Control Number (ICN) Program Type Media Year Julian Batch # Sequence Program Code 001 Long Term Care 100 Traditional Medicaid 200 Managed Care 300 DSHS Family Planning Program 400 Children with Special Health Care Needs 999 Program Type Could Not Be Determined Based On Information on the Claim Claim Type 020 Physician Supplier/Genetics 021 Dental 023 Outpatient Hospital/HHA 030 Physician Crossover 031 Outpatient Crossover 040 Inpatient Hospital 050 Inpatient Crossover 056 DSHS Family Planning Program 058 Family Planning Title XIX (Filed on 2017 Form) 099 MMIS Conversion Default Claim Type 999 All Claim Types (Default/Summary Claim Type Value For Reporting Purposes) Media Type 010 Paper 011 Paper Adjustment 020 TexMedConnect 021 TexMedConnect Adjustment 030 Electronic 031 Electronic Adjustment 041 AIS Adjustment 051 Mass Adjustment 061 Crossover Adjustment 071 Retroactive Eligibility Adjustment 080 State Action Request 081 State Action Request Adjustment 090 Phone 100 Fax 110 Mail 120 Encounters 121 Encounters Adjustment The Julian Date is the date that the claim is scanned into the system as received. This date is the sequential numbering of the days of the year. This is what is used to calculate the filing deadline for the claim. The batch number is an internal TMHP number.the sequence number is used by TMHP to identify a particular claim within a batch. 30 CPT only copyright 2013 American Medical Association. All rights reserved. v

33 R&S Reports: Adjustments Paid or Denied Medicaid: Beyond the Basics Participant Guide Texas Medicaid & Healthcare Partnership Remittance and Status Report Date: 02/01/2013 Mail original claim to: TEXAS PROVIDER Texas Medicaid & Healthcare Partnership PO BOX P.O. Box DALLAS, TX Austin, Texas (214) Mail all other correspondence to: TPI: Texas Medicaid & Healthcare Partnership NPI/API: B Riata Trace Parkway Taxonomy: X Austin, Texas Benefit Code: Report Seq. Number: 35 (800) R&S Number: ~ Page 4 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 ********************************************* ADJUSTMENTS - PAID OR DENIED *************************************** ADJUSTMENT CLAIM: DOE, JANE /17/ /17/2012 W D J $ $.00 $.00 ADJUSTMENT CLAIM TOTAL THE CLAIM REPORTED ABOVE IS AN ADJUSTMENT TO PREVIOUS CLAIM WHICH APPEARS ON R&S DATED 01/14/2011 ORIGINAL CLAIM: DOE, JANE /17/ /17/2012 W D J $ $62.50 $60.94 ORIGINAL CLAIM TOTAL A RECEIVABLE HAS BEEN ESTABLISHED IN THE AMOUNT OF THE ORIGINAL PAYMENT: $ FUTURE PAYMENTS WILL BE REDUCED OR WITHHELD UNTIL SUCH AMOUNT IS PAID IN FULL. ************************************************************************************************************************************** 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 v CPT only copyright 2013 American Medical Association. All rights reserved. 31

34 R&S Reports: Financial Transactions All claim refunds, reissues, voids/stops, recoupment, backup withholdings, levies, and payouts appear in this section of the R&S Report. The Financial Transactions section does not use the R&S Report form headings. Additional subheadings are printed to identify the financial transactions. The following examples are types of financial items: 32 CPT only copyright 2013 American Medical Association. All rights reserved. v

35 R&S Reports: The Following Claims Are Being Processed Medicaid: Beyond the Basics Participant Guide v CPT only copyright 2013 American Medical Association. All rights reserved. 33

36 R&S Reports: Claims Payment Summary Texas Medicaid & Healthcare Partnership Remittance and Status Report Date: 02/01/2013 Mail original claim to: TEXAS PROVIDER Texas Medicaid & Healthcare Partnership PO BOX P.O. Box DALLAS, TX Austin, Texas (214) Mail all other correspondence to: TPI: Texas Medicaid & Healthcare Partnership NPI/API: B Riata Trace Parkway Taxonomy: X Austin, Texas Benefit Code: Report Seq. Number: 35 (800) R&S Number: ~ Page 13 Of PAYMENT SUMMARY FOR DIRECT DEPOSIT BY EFT IN THE AMOUNT OF *** AFFECTING PAYMENT THIS CYCLE *** *** AMOUNT AFFECTING 1099 EARNINGS *** AMOUNT COUNT THIS CYCLE YEAR TO DATE CLAIMS PAID , SYSTEM PAYOUTS MANUAL PAYOUTS (REMITTED BY SEPARATE CHECK OR EFT) AMOUNT PAID TO IRS FOR LEVIES AMOUNT PAID TO IRS FOR BACKUP WITHHOLDING ACCOUNTS RECEIVABLE RECOUPMENTS AMOUNTS STOPPED/VOIDED SYSTEM REISSUES CLAIM RELATED REFUNDS NON-CLAIM RELATED REFUNDS HELD AMOUNT PAYMENT AMOUNT , APPROVED TO PAY/DENY CLAIMS PENDING CLAIMS **********************PAYMENT TOTAL FOR CHECK IN THE AMOUNT OF *********************** 34 CPT only copyright 2013 American Medical Association. All rights reserved. v

37 R&S Reports: Explanation of Benefits Codes Messages Medicaid: Beyond the Basics Participant Guide T Texas Medicaid & Healthcare Partnership Remittance and Status Report Date: 02/01/2013 Mail original claim to: TEXAS PROVIDER Texas Medicaid & Healthcare Partnership PO BOX P.O. Box DALLAS, TX Austin, Texas (214) Mail all other correspondence to: TPI: Texas Medicaid & Healthcare Partnership NPI/API: B Riata Trace Parkway Taxonomy: X Austin, Texas Benefit Code: Report Seq. Number: 35 (800) R&S Number: ~ Page 14 Of EXPLANATION OF BENEFITS CODES MESSAGES THE FOLLOWING ARE THE DESCRIPTIONS OF THE EOB CODES THAT APPEAR ON THIS REMITTANCE AND STATUS REPORT A CHARGE WAS NOT NOTED FOR THIS SERVICE PROCEDURE PAYMENT BASED ON PROGRAM/BENEFIT PLAN, DATE OF SERVICE AND A MAXIMUM PAYMENT AMOUNT SET BY CMS OR HHSC THIS SURGERY/SERVICE/SITUATION DESCRIBED IS NOT ON THE AUTHORIZATION LETTER AND IS NOT PAYABLE PAID ACCORDING TO THE TEXAS MEDICAID REIMBURSEMENT METHODOLOGY-TMRM (RELATIVE VALUE UNIT TIMES STATEWIDE CONVERSION FACTOR) IT IS MANDATORY THAT AUTHORIZATION BE OBTAINED. DUE TO THE LACK OF APPROVAL, THE SERVICE IS NON-PAYABLE PROCEDURE PAYMENT BASED ON PROGRAM/BENEFIT PLAN, DATE OF SERVICE AND IS CALCULATED AT THE DETAIL BILLED AMOUNT THIS PAYMENT WAS REDUCED 2.5% IN ACCORDANCE WITH THE 78TH TEXAS LEGISLATURE, ARTICLE II OF HOUSE BILL 1, AND SECTION 2.03 OF HOUSE BILL PLEASE REFER TO OTHER EOB MESSAGES ASSIGNED TO THIS CLAIM FOR PAYMENT/DENIAL INFORMATION. THE FOLLOWING ARE THE DESCRIPTIONS OF THE EOP CODES THAT APPEAR ON THIS REMITTANCE AND STATUS REPORT 00I03 OUR FILES INDICATE AN AUTHORIZATION INFORMATION MISMATCH. v CPT only copyright 2013 American Medical Association. All rights reserved. 35

38 R&S Reports: Mass Adjustments Mass Adjustments: Adjustments - Paid or Denied 36 CPT only copyright 2013 American Medical Association. All rights reserved. v

39 Balancing Your R&S Report The weekly Remittance and Status (R&S) Report provides detailed information about the status of claims that have been submitted to TMHP. The report provides information on pending, paid, denied, and adjusted claims and identifies accounts receivables established as a result of appeals filed by the provider, adjustments received from Medicare, utilization review, and mass adjustments initiated by TMHP. These receivables are recouped from claim payments. This guide will show you how to balance your R&S Report when recoupments are taken. Source: Balancing Your RS Report.pdf v CPT only copyright 2013 American Medical Association. All rights reserved. 37

40 To balance your R&S Report when recoupments are taken, follow these steps: 1 Go to the Paid/denied Claims section of your R&S Report. On the ToTal for medicaid line, locate the Paid amt BILLED ALLOWED----- QTY CHARGE QTY CHARGE PAID AMT. TOTAL FOR MEDICAID $2, $ $ Next, locate the Paid amt. for Managed Care in the Paid/denied section: TOTAL FOR MANAGED CARE $12, $8, $8, Go to the adjustment Paid/denied section. On the ToTal for medicaid line, locate the Paid amt, which will show the total amount paid for traditional Medicaid adjustments: TOTAL FOR MEDICAID $41, $26, $26, Locate the Paid amt for Managed Care in the adjustments Paid/denied section: TOTAL FOR MANAGED CARE $16, $4, $4, CPT only copyright 2013 American Medical Association. All rights reserved. v

41 5 Add these four amounts together. The total will equal the number in the amount column on the Claims Paid line at the top of the financial summary Page: *** AFFECTING PAYMENT THIS CYCLE *** AMOUNT COUNT CLAIMS PAID $39, Go to the financial TransaCTions section of your R&S Report. The section will list all of the original claims that were listed in the adjustment Paid/denied section and the amount of each that was applied to the recoupment. $ $8, $26, , $39, *********************** FINANCIAL TRANSACTIONS ********************** ACCOUNTS RECEIVABLE YOUR PAYMENT WAS REDUCED BY THE APPLIED AMOUNTS SHOWN BELOW FOR THE REASONS INDICATED. The last page of the financial TransaCTions section will show the total accounts receivable on the ToTal line: TOTAL $21, Subtract the total accounts receivable (listed in step 6) from the total paid claims amount (step 5). The final amount should equal the number on the PaymenT amount line. If the total paid claims amount is more than the total accounts receivable, you will receive a payment and the accounts receivable will be paid. If the total paid claims amount is less than the total accounts receivable, the accounts receivable balance will be carried over to the next week s R&S Report. $39, $21, $18, PAYMENT AMOUNT $18, v CPT only copyright 2013 American Medical Association. All rights reserved. 39

42 Explanation of Benefits An Explanation of Benefits (EOB) is an explanation of benefits in response to the submission of a claim. EOBs provide information about claim disposition and/or reimbursement. In addition to the EOB code, TMHP provides many different messages to assist providers with submission instructions on a processed claim. Common Claim Denial EOB Codes EOB 01140: UNABLE TO ASSIGN PROGRAM/BENEFIT PLAN Steps to correct: 1. Verify the client s information matches eligibility. 2. Ensure the client was eligible for the date of service. 3. Validate the billing provider is enrolled in the client s program. 4. Verify the provider s enrollment is active. 5. Confirm the provider is enrolled as a Billing Provider and not as a Performing Only provider participating in a group. EOB 01361: PROF/OUTPT DUPLICATE Steps to correct: 1. Search for past claims that are in the paid status. 2. Verify if and when original claim was received before you submit another claim. 3. If necessary, appeal the paid claim. EOB 00207: SERVICE NOT A BENEFIT Step to correct: Verify that services billed are covered for the program billed. EOB 00100: BILLED AMOUNT REQUIRED This denial is usually associated with dual eligible Medicare claims that are not crossing over successfully. Step to correct: Submit a paper claim that includes all of the following: 1. The Medicare Remittance Advice (RA) or Remittance Notice (RN), which is issued by Medicare. 2. The appropriate, completed paper CMS-1500 or UB-04 CMS-1450 paper claim form. 40 CPT only copyright 2013 American Medical Association. All rights reserved. v

43 3. The appropriate TMHP Standardized Medicare and MAP Remittance Advice Notice Template Form. (The TMHP MRAN template is optional if you submit the original paper version from Medicare.) EOB 00565: RECEIVED PAST THE 95-DAY FILING DEADLINE Steps to correct: 1. Verify the claim was submitted within 95 days from the first DOS. 2. Appeal claim with proof of timely filing attached. (i.e., R&S of past claim, Postal or Express carrier receipt with tracking information.) v CPT only copyright 2013 American Medical Association. All rights reserved. 41

44 Prior Authorization Some Medicaid services require a prior authorization as a condition for reimbursement. Information about whether a service requires a prior authorization, as well as the prior authorization criteria, guidelines, and timelines for the service, is contained in the appropriate handbooks in the TMPPM that contains the service. Prior authorization is not a guarantee of reimbursement. Even if a prior authorization has already been approved, reimbursement can be affected for a variety of reasons (e.g., the client is ineligible on the DOS or if the claim is incomplete). In most circumstances, prior authorization must be approved before the service is provided. Prior authorization for urgent and emergency services that are provided after business hours, on a weekend, or on a holiday must be requested on the next business day. Some services may allow different time lines to obtain an authorization for urgent and emergent conditions. The provider should consult the appropriate provider manual for additional information. Business hours are Monday through Friday, from 8:00 a.m. to 5:00 p.m., Central Standard Time. Prior authorization requests that do not meet these deadlines may be denied. To avoid unnecessary prior authorization denials, the request must contain correct and complete information, including documentation for medical necessity. The documentation of medical necessity must be maintained in the client s medical record. The requesting provider may be asked for additional information to clarify or complete a request for prior authorization. Before submitting a prior authorization request or providing an authorized service, the provider must verify the client s eligibility using TexMedConnect or AIS. Any service provided while the client is not eligible cannot be reimbursed by Texas Medicaid. Providers are responsible for knowing which services require prior authorization. Prior authorizations may be requested electronically using TexMedConnect on the TMHP website, by telephone, by fax, or by mail, depending on the type of authorization being requested. A prior authorization number (PAN) is a TMHP-assigned number establishing that a service or supply has been determined to be medically necessary and for which federal financial participation (FFP) is available. If prior authorization is granted, the potential service provider (i.e., the DME supplier, pharmacy DME supplier provider, registered nurse [RN], or therapist) receives a letter or notification of approval via the TMHP website, that includes the PAN, the procedures prior authorized, the amount authorized, and the length of the authorization. Providers are notified in writing when additional information is needed to process the request for prior authorization of services. Most prior authorization departments also send client notification letters. All requested information on the form must be completed. If an incomplete authorization request is received, it will be returned to the provider or it will be entered into the system as pending, and a letter will be faxed or mailed to the provider. 42 CPT only copyright 2013 American Medical Association. All rights reserved. v

45 Prior Authorization Requests for Clients with other insurance primary to Medicaid Medicaid: Beyond the Basics Participant Guide If a Medicaid client has other health insurance, the provider must submit claims to the client s other insurance prior to billing Medicaid. If a Medicaid-covered service requires prior authorization by Medicaid, the prior authorization must be requested before providing the service whether the other insurance requires prior authorization or not. Medicaid will deny the claim if it isn t dispositioned by the other insurance. One exception is that THSteps Medical and Dental providers are not required to bill other insurance before billing Medicaid. The provider has several billing options. For complete details, see the TMPPM, Children s Services Handbook, Medical Claims Section, and Dental Third Party Resources (TPR) section. If a client s primary health-care benefit is Medicare, providers must always confirm with Medicare whether a service is a benefit for the client. If a service that requires prior authorization from Medicaid is a Medicare benefit and Medicare approves the service, prior authorization from TMHP is not required for reimbursement of the coinsurance or deductible. If Medicare denies the service, then Medicaid prior authorization is required. TMHP must receive a prior authorization request within 30 days of the date of Medicare s final disposition. The Medicare Remittance that contains Medicare s final disposition must accompany the prior authorization request. If a service that requires prior authorization for Medicaid is not a benefit of Medicare, providers may request a prior authorization from TMHP before they receive a denial from Medicare. If the service is a Medicaid-only service, prior authorization is required. Guidelines When submitting authorization requests, providers should use the following guidelines or refer to the TMPPM. 1. Use legible forms. When faxing or mailing an authorization request, providers must use a form that is legible. Illegible copies of forms will be returned to the provider. 2. Ensure that the current authorization request form is being used. Requests received on out-ofdate forms will be returned to the provider. 3. Ensure that all fields on the form are complete and legible. If an illegible authorization is received, it will be returned to the provider. 4. Ensure that the physician s signature and dates on the form are original and hand written (stamped signatures and dates are not accepted). 5. Submit the authorization request to the correct department. Authorizations received by the wrong department will be returned to the provider. Note: If no response has been received within three business days after the date that the prior authorization was submitted, providers are encouraged to call TMHP or resubmit the request. v CPT only copyright 2013 American Medical Association. All rights reserved. 43

46 Prior Authorization Quick Reference Prior Authorization Department Ambulance Authorization Unit Comprehensive Care Program (CCP) Authorization Unit Description Telephone Fax Mailing Address The Ambulance Authorization Unit processes requests for nonemergency transport. Ambulance authorizations are received by telephone, by fax, and electronically through the TMHP website. The Comprehensive Care Program (CCP) Authorization Unit considers any health-care service or item, for a Texas Medicaid client who is birth through 20 years of age, when the service or item is not covered under another Medicaid benefit and when such service or item is medically necessary and federal financial participation (FFP) is available. The CCP Authorization Unit also considers expanded coverage for current Texas Medicaid services or items when those services or items are subject to limitations (e.g., diagnosis restrictions or quantity). The CCP unit reviews authorization requests received by fax, mail, and submitted electronically through the TMHP website; the CCP unit does not review requests received by telephone (For requests from hospitals only) (Use for CCP authorization status and general information. This telephone number may not be used to request authorization) (512) N/A (512) CCP - Texas Medicaid & Healthcare Partnership PO Box Austin, TX Note: Personal Care Services can only be authorized by DSHS. Home Health Authorization Unit The Home Health unit reviews authorization requests for some services received by telephone, by fax, by mail, and electronically through the TMHP website. Prior authorizations may be requested for expendable medical supplies, DME, intermittent skilled nursing and aide visits, and occupational or physical therapy visits. Note: All Home Health services that require prior authorization may be requested electronically through the TMHP website. Refer to the current TMPPM, Vol. 1, General Information for a list of Home Health prior authorizations that may be requested electronically through the TMHP website (Use to request prior authorization) (Use for Home Health authorization status and general information. This telephone number may not be used to request authorization) (512) Texas Medicaid & Healthcare Partnership Home Health Services PO Box Austin, TX CPT only copyright 2013 American Medical Association. All rights reserved. v

47 Prior Authorization Department Personal Care Services (PCS) Description Telephone Fax Mailing Address PCS are support services provided to clients who meet the definition of medical necessity and require assistance with the performance of activities of daily living, instrumental activities of daily living, and health-related functions due to a physical, cognitive, or behavioral limitation related to a client s disability or chronic health condition (Use for PCS authorization status and general information. This telephone number may not be used to request authorization) N/A N/A Radiology Services Prior/Retro Authorization Unit Comprehensive Care Inpatient Psychiatric Authorization Unit (CCIP) PCS are provided by someone other than the legal responsible adult of the client who is a minor child or the legal spouse of the client. Note: PCS authorizations can only be submitted to TMHP by DSHS. All computed tomography (CT), computed tomography angiography (CTA), magnetic resonance (MR), magnetic resonance angiography (MRA), positron emission tomography (PET), and cardiac nuclear imaging requests are submitted to MedSolutions at (telephone), or (fax). MedSolutions is the TMHP subcontractor that issues radiology authorizations. Comprehensive Care inpatient Psychiatric Unit Processes Inpatient Psychiatric Hospital/Facility (Freestanding) services requests for medically necessary items and services ordinarily furnished by a Medicaid psychiatric hospital/facility or by an approved out-of-state hospital under the direction of a psychiatrist for the care and treatment of inpatient psychiatric clients who are birth through 20 years of age at the time of the service request and service delivery. (CCIP processes requests for traditional Medicaid clients.) CCIP prior authorizations may be submitted by fax, by mail, or electronically through the TMHP website. Notifications of late admissions maybe submitted by telephone Texas Medicaid & Healthcare Partnership 730 Cool Springs Blvd, Suite 800 Franklin, TN (512) Comprehensive Care Program Prior Authorization B Riata Trace Parkway, Suite 150 Austin, Texas v CPT only copyright 2013 American Medical Association. All rights reserved. 45

48 Prior Authorization Department Substance Abuse Unit Dental Authorization Unit Special Medical Authorization Unit Children with Special Health Care Needs Services Program (CSHCN) Authorization Unit Description Telephone Fax Mailing Address The Substance Abuse unit reviews prior authorizations received by fax for substance use disorder services. In addition, substance use disorder services requests may be submitted electronically. The Dental Authorization Unit processes all requests for prior authorization for dental services and orthodontia. All requests for prior authorization are received by mail to the TMHP mailroom. Requests for orthodontia must include the request form, X- rays or photographs. The Special Medical Prior Authorization unit reviews prior authorization requests for extended outpatient psy chotherapy and counseling services and/or procedures that are not reviewed by any of the other TMHP prior authorization units. (i.e., ambulance, home health, dental) All Special Medical Prior Authorization requests may be submitted by mail, or electronically through the TMHP website. All CSHCN Services Program requests for authorization and prior authorizations must be submitted on a program-approved form and must contain all information necessary for the program to make a determination about coverage. Only complete authorization requests will be accepted by the program. CSHCN providers must mail or fax written authorization requests, along with all other applicable documentation. Refer to section 4 of the current CSHCN Services Program Procedural Manual for additional information regarding authorization and prior authorization Use for Substance Abuse authorization status and general information. This telephone number may not be used to request authorization. (512) N/A N/A N/A Texas Medicaid & Healthcare Partnership Dental Prior Authorization Unit PO Box Austin, TX N/A (512) Texas Medicaid & Healthcare Partnership Special Medical Prior Authorization Department B Riata Trace Parkway, Suite 150 Austin, TX N/A (512) TMHP-CSHCN Services Program Authorization Department B Riata Trace Parkway Ste #150 MC-A11 Austin, TX Note: Outpatient prescription medication prior authorization is obtained by the prescriber or the prescriber representative by calling the Texas Prior Authorization Call Center at PA-TEXAS ( ). 46 CPT only copyright 2013 American Medical Association. All rights reserved. v

49 Prior Authorization Forms by Department Please refer to tmhp.com website under forms section for reference material. Radiology Radiology Prior Authorization Request: (Refer to the TMPPM, Radiology, Laboratory, and Physiological Lab Services Handbook) Ambulance Nonemergency Ambulance Prior Authorization Request Texas Medicaid and CSHCN Services Program (Refer to the TMPPM, Ambulance Services Handbook) CCP CCP Prior Authorization Request Form CCP Prior Authorization Private Duty Nursing 6-Month Authorization CCP ECI Request for Initial/Renewal Outpatient Therapy Donor Human Milk Request Form External Insulin Pump Home Health Plan of Care (POC) Nursing Addendum to Plan of Care (CCP) (7 Pages) CCIP Psychiatric Inpatient Initial Admission Request Form Psychiatric Inpatient Extended Stay Request Form Pulse Oximeter Form Request for CCP Outpatient Therapy CCP Prior Authorization Request for Non-Face-to-Face Clinician-Directed Care Coordination Services (2 Pages) Specialist or Subspecialist Telephone Consultation Form for Non-Face-to-Face Clinician-Directed Care Coordination Services-Comprehensive Care Program (CCP) Wheelchair/Scooter/Stroller Seating Assessment Form (CCP/Home Health Services) (6 Pages) Texas Medicaid Palivizumab (Synagis) Prior Authorization Request Dental THSteps Dental Mandatory Prior Authorization Request Form THSteps Dental Criteria for Dental Therapy under General Anesthesia (2 Pages) Home Health Home Health Services Plan of Care (POC) Instructions Home Health Services Plan of Care (POC) Home Health Services Prior Authorization Checklist Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form Instructions (2 pages) Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form External Insulin Pump Addendum to Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form Medicaid Certificate of Medical Necessity for Chest Physiotherapy Device Form-Initial Request Medicaid Certificate of Medical Necessity for Chest Physiotherapy Device Form-Extended Request Medicaid Certificate of Medical Necessity for CPAP/BiPAP or Oxygen Therapy v CPT only copyright 2013 American Medical Association. All rights reserved. 47

50 Statement for Initial Wound Therapy System In-Home Use (2 pages) Statement for Recertification of Wound Therapy System In-Home Use Ventilator Service Agreement Wheelchair/Scooter/Stroller Seating Assessment Form (CCP/Home Health Services) (6 pages) Special Medical Prior Authorizations (SMPA) Medicaid Certificate of Medical Necessity for Reduction Mammaplasty Request for Extended Outpatient Psychotherapy/Counseling Form Special Medical Prior Authorization (SMPA) Request Psychological/Neuropsychological Testing Request Outpatient Services Obstetric Ultra Prior Authorization Request Texas Medicaid Form Children with Special Health Care Needs (CSHCN) Services Program Additional Nutritional Assessment, Counseling, and Products Form and Instructions Augmentative Communication Devices (ACDs) Form and Instructions Chest Physiotherapy Devices Form and Instructions Stem Cell or Renal Transplant Form and Instructions Dental or Orthodontia Services Form and Instructions Diapers, Pull-ups, Briefs, or Liners Form and Instructions Durable Medical Equipment (DME) Form and Instructions External Insulin Pump Form and Instructions Hospice Services Form and Instructions Inpatient Psychiatric Care Form and Instructions Inpatient Hospital Admission For Use by Facilities Only Form and Instructions Inpatient Rehabilitation Admission Form and Instructions Medical Foods Form and Instructions Omalizumab Form and Instructions Palivizumab (Synagis) Form and Instructions Pulse Oximeter Devices Form and Instructions Renal Dialysis Treatment Form and Instructions Respiratory Care Certified Respiratory Care Practitioner (CRCP) Form and Instructions Inpatient Surgery For Surgeons Only Form and Instructions Outpatient Surgery For Outpatient Facilities and Surgeons Form and Instructions Apnea Monitor Form and Instructions Hemophilia Blood Factor Products Form and Instructions Non-Face-to-Face Clinician-Directed Care Coordinated Services Form and Instructions Specialist or Subspecialist Telephone Consultation Form for Non-Face-to-Face Clinician-Directed Care Coordination Services Extension of Outpatient Therapy (TP2) Form and Instructions Initial Outpatient Therapy (TP1) Form and Instructions) Authorization and Prior Authorization Request 48 CPT only copyright 2013 American Medical Association. All rights reserved. v

51 Other Important Forms Sterilization Consent Form Instructions (2 pages) (Refer to the TMPPM, Gynecological and Reproductive Health, Obstetrics, and Family Planning Services Handbook) Sterilization Consent Form (English) (Refer to the TMPPM, Gynecological and Reproductive Health, Obstetrics, and Family Planning Services Handbook) Sterilization Consent Form (Spanish) (Refer to the TMPPM, Gynecological and Reproductive Health, Obstetrics, and Family Planning Services Handbook) Abortion Certification-Statements (Refer to the TMPPM, Gynecological and Reproductive Health, Obstetrics, and Family Planning Services Handbook) Hysterectomy Acknowledgement Form (Refer to the TMPPM, Gynecological and Reproductive Health, Obstetrics, and Family Planning Services Handbook) v CPT only copyright 2013 American Medical Association. All rights reserved. 49

52 Resources Instructions for Using the TMHP Website The TMHP website at is designed to streamline provider participation. Using the website, providers can do the following; submit claims and appeals, view and download current provider manuals, verify client eligibility, view R&S Reports and panel reports, and stay informed with current news and updates. Current news remains on the TMHP website homepage for 10 business days and is then moved to the past news articles. Searching the TMHP Website Some providers may find it easier to search the TMHP website using the site s search function rather than navigating through the news and past news articles sections. To use the search feature, type the desired keywords into the search box located in the top bar of the homepage, and click the icon or press Enter. To improve search results, 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. Information on the TMHP Website Provider manuals and guides are separated into their associated program and can be located by clicking the appropriate program name in the yellow tool bar and then clicking Reference Material in the menu. 50 CPT only copyright 2013 American Medical Association. All rights reserved. v

53 Provider Manuals and Guides: Texas Medicaid Provider Procedures Manual (TMPPM) CSHCN Services Program Provider Manual Texas Medicaid Quick Reference Guide CMS-1500 Online Claims Submission Manual Medicaid Automated Inquiry System (AIS) User Guide CSHCN Services Program Automated Inquiry System (AIS) User Guide TexMedConnect instructions for Acute Care and Long Term Care Forms Provider forms are separated into their associated program and can be located by clicking the appropriate program name in the yellow tool bar and then clicking Forms in the menu. Provider Forms: Medicaid forms CSHCN Services Program forms Enrollment forms Health Information Technology, Fee Schedules, Provider Education: Fee schedules Acute care reference codes Long Term Care (LTC) Programs reference codes Learning Management System with Computer Based Training v CPT only copyright 2013 American Medical Association. All rights reserved. 51

54 Functions on the TMHP Website On the TMHP website, you can: Enroll as a provider. Update a National Provider Identifier (NPI) or change the taxonomy code associated with an NPI. Use TexMedConnect to submit a claim electronically, which reduces errors and speeds up the reimbursement of funds. Register for a workshop and view upcoming events. Submit a request for an authorization. View the status of a submitted prior authorization request. Immediately verify the eligibility of a client. Find a Medicaid specialist in network. 52 CPT only copyright 2013 American Medical Association. All rights reserved. v

55 Locating and Searching the Provider Manual 1. Go to the TMHP website at and click providers in the top menu bar. Medicaid: Beyond the Basics Participant Guide 2. Click Reference Material in the left-side navigation pane. 3. The TMPPM is the default page. From here, you can: a. Click PDF in the Complete Book row to view the TMPPM in portable document format (PDF). b. Click PDF in the Individual chapters row to view a particular chapter of the TMPPM in PDF format. or c. Click HTML to view the complete TMPPM in hypertext markup language (HTML) on the web. v CPT only copyright 2013 American Medical Association. All rights reserved. 53

56 4. For our example, we will choose the Book PDF option. Click PDF in the book row. 5. Once the document opens in Adobe Acrobat Reader, press the Ctrl and F keys simultaneously to begin searching through the document for a word or phrase. 6. When the two keys are depressed, a window in the menu bar will become active. Type the word or phrase you would like to find in this field. When finished, press the enter key to begin the search. Adobe Reader will automatically take you to each instance of the word even if it s a partial word in a longer string. For instance, if you typed resident, Adobe would show you all instances of the word including deviations such as president. To alleviate this, perform an advanced search. Advanced Search 1. Next to the Find window, you ll notice a drop-down arrow. Click the arrow to see your options. Choose Open Full Acrobat Search. 54 CPT only copyright 2013 American Medical Association. All rights reserved. v

57 2. The Full Acrobat Search will display. Type the word or phrase that you are looking for and click Search or press the Enter key. a. Whole words only Searches for whole word matches so that similar words with partial matches do not appear in search results. a. Case-Sensitive For a Case-Sensitive search select this check box. For example, if you search for Enter with the Case-Sensitive check box selected, the search will not list occurrences of the word enter. b. Include Bookmarks Searches the text of any bookmarks, as viewed in the Bookmarks panel. c. Include Comments Searches the text of any comments added to the PDF, as viewed in the Comments panel. 3. The Search PDF pane displays the search results and the first occurrence of the word or phrase is highlighted in the document. 4. To view a specific occurrence of the word or phrase in the document, click its link in the Results list. Acrobat highlights the selected occurrence of the word or phrase in the document. 5. Click the icon to collapse the search menu or click New Search to start a new search. v CPT only copyright 2013 American Medical Association. All rights reserved. 55

58 Provider Bulletins and Banner Messages Note: The 2014 Healthcare Common Procedure Coding System (HCPCS) Special Bulletin is published as needed and is available on the Texas Medicaid Bulletin page at Pages/Medicaid/ medicaid_pubs_ bulletin.aspx. 1. Go to the TMHP website at and click providers in the top menu bar. 2. Click Reference Material in the left-side navigation pane. 3. To view provider bulletins, click Texas Medicaid Bulletin or to view banner messages, click Banner Messages. 4. Once the document opens in Adobe Reader, press the Ctrl and F keys simultaneously to being searching through the document for a word or phrase. 5. When the two keys are depressed, a window in the menu bar will become active. Type the word or phrase you would like to find into this field. When finished, press the enter key to begin the search. Adobe Reader will automatically display each instance of the word, even if it s a partial word in a longer string. 56 CPT only copyright 2013 American Medical Association. All rights reserved. v

59 Online Provider Lookup Medicaid: Beyond the Basics Participant Guide The Online Provider Lookup (OPL) on the TMHP website at is a great resource for both clients and providers, in finding a provider participating in the Medicaid program in a selected area. In order to provide a positive experience with Texas Medicaid and the Children with Special Health Care Needs (CSHCN) Services Program, we must ensure that accurate provider information is available to everyone who needs it. After March 24, 2011, affected providers that have not verified their demographic information within the last six months will be unable to use any applications from their accounts on the TMHP secure portal, including TexMedConnect Acute Care. These restrictions will be removed as soon as a provider verifies and, if necessary, updates their key demographic information on PIMS and any bad address information. Additionally, non-administrative users will not be able to perform work functions on NPIs that are listed on the Review Required page. Non-administrative users will be advised to notify users with administrative rights so that they can verify demographic information and remove the block. Non-administrative users can determine the identity of the administrative users for each NPI by clicking Provider Administrator Lookup on the My Account page. Using the Online Provider Lookup (OPL) Tool to Find a Provider 1. Go to the TMHP website at and click providers in the top menu bar. v CPT only copyright 2013 American Medical Association. All rights reserved. 57

60 2. Click Looking for a provider? in left-side navigation pane. 3. Enter your Provider Search Criteria. Health Plan TPI NPI/API Taxonomy Benefit Code Note: Fields marked with a red asterisk are required. Last Name/Facility Name HMO Plan Name Provider Type ZIP Code 4. Click more information for instructions on how to complete the adjacent field. 58 CPT only copyright 2013 American Medical Association. All rights reserved. v

61 5. Click Search to obtain a list of providers that meet the search criteria entered or click Clear Form to remove the information and start over. Medicaid: Beyond the Basics Participant Guide 6. A list of providers that meet the search criteria will display. Click the provider s name to display detailed information for that provider. Click Back To Results to return to the provider list. Click Print to display a printer-friendly page for printing. Click View Map to display a map of the provider s location. Click more information for a description of the Primary Care Provider symbol. v CPT only copyright 2013 American Medical Association. All rights reserved. 59

62 Using the Advanced Search in OPL Clicking 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 additional search options such as: Accepting new patients Provider specialty Provider subspecialty Extended hours Medicaid waiver program Other services offered Languages spoken Patient age Patient gender County served by the provider Note: To locate a specialist select Specialist from the drop-down box under the Provider Type field. Next, click the arrow next to the Provider Specialty field to choose a list of provider specialties. 60 CPT only copyright 2013 American Medical Association. All rights reserved. v

63 Note: The criteria entered in the Provider Type field changes the information displayed under Provider Specialty. v CPT only copyright 2013 American Medical Association. All rights reserved. 61

64 Updating Address Information 1. The provider must click the link on the My Account page to change/verify their address information. 2. The provider must click the Edit button to activate a section for editing. The provider can: Update address information. Update telephone numbers and their address. Add or remove counties served. Update business hours. Indicate whether or not they are accepting patients for each plan in which they participate. Indicate languages spoken in their office. Indicate if they offer additional services. Limit the gender or age of clients served. 3. Save and Cancel buttons appear when an area is active for editing. The provider must save the information or cancel their changes before editing any other sections. Once the information is updated by the provider, it should appear with the new information in the Online Provider Lookup immediately. The more complete a provider s 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 update the 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 ( ). Additional information about the Texas VDP can be found online at 62 CPT only copyright 2013 American Medical Association. All rights reserved. v

65 Online Fee Lookup Medicaid: Beyond the Basics Participant Guide To access the online fee lookup: 1. Go to the TMHP website at and click providers. 2. Click Fee Schedules in the left-side navigation pane. 3. The Fee Schedules/Home screen will display. From here you can: View the static fee schedule; Perform a fee search; or Perform a batch search. v CPT only copyright 2013 American Medical Association. All rights reserved. 63

66 Static Fee Schedules (OFL) The files on the Static Fee Schedule page contain the Texas Medicaid fee schedules for the selected federal fiscal quarter. These fee schedules provide a view of the fees that were in effect within the first seven days of the selected quarter. If you are a Texas Medicaid provider with an active account on the TMHP website at you can limit the fee schedules that appear to those that apply to your provider identifier. If you are not a Texas Medicaid provider with an active account on the TMHP website at and know which fee schedule you want to see, you can open the corresponding Excel or PDF file. If you do not know which fee schedules apply to you, you may use the search feature. To do this you must: 1. Select a provider type and provider specialty from the drop-down menus. 2. Click Search. The screen will display only the applicable fee schedules. You may also view past fee schedules by clicking Archives on the bottom of the screen. 64 CPT only copyright 2013 American Medical Association. All rights reserved. v

67 Fee Search (OFL) To search for a single or multiple codes click Fee Search in the left-side navigation pane. Using the OFL, you can search for fees using following options: A single procedure code A list of up to 50 procedure codes A range of procedure codes All procedure codes pertaining to a specific provider type and specialty Note: Providers who log in using their TPI, NPI, or API have the option to perform a contracted rate search. The contracted rate search function allows providers to view contract fees that are specific to them. You may access this function by clicking Contracted Rate Search below the Submit button. If you are not logged in, you may do so by clicking TMHP in the upperright corner of the screen. When you search using one of the following options, you will receive a Batch Request ID: A list of more than 10 procedure codes A range of codes All procedure codes pertaining to a specific provider type and specialty Record the Batch Request ID. This Batch ID will allow you to access your search results with 36 hours of your request. v CPT only copyright 2013 American Medical Association. All rights reserved. 65

68 Batch Search (OFL) To access your search results, you can click Batch Search on the left-side navigation pane. Enter your batch ID, and click Search. For more detailed instructions you may access the OFL Computer-Based Training on the TMHP Learning Management System (LMS) at 66 CPT only copyright 2013 American Medical Association. All rights reserved. v

69 ICD-10 Implementation The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and ICD-10-PCS (inpatient procedure code) code sets will replace ICD-9-CM codes that are used to report medical diagnoses and inpatient procedures through Health Insurance Portability and Accountability Act (HIPAA) standard transactions. ICD-10 code set implementation will affect diagnosis and inpatient procedure coding for all entities that use standard transactions that are identified in HIPAA. Health-care providers, payers, clearinghouses, and billing services must be prepared to comply with the ICD-10 code set implementation. Preparation for the ICD-10 code set implementation will help alleviate future operational and budgetary issues. Providers should consider the following actions when preparing for ICD-10 code set implementation: Testing claims six to ten months before ICD-10 code set implementation Assessing revenue risk and developing a strategy to handle delayed reimbursement Training and educating billing staff on the new coding Developing a transition plan that includes tactics, timing and resource and budget allocations Considering full remediation or General Equivalency Mapping (GEM) instead of a crosswalk ICD-10 code set Evaluating super bills for ICD-10 code set updates Meeting with billing system vendors to confirm software changes for the documentation and claims processing specifications that will be required to submit claims with ICD-10 code sets Conducting test transactions using ICD-10 code sets with vendors and payers Considering changes in the documentation requirements for ICD-10 code sets for the most common client conditions Changing reports that contain ICD-9-CM codes to ICD-10 code sets Monitoring any Texas Medicaid policy and billing changes that will be required by ICD-10 code sets Evaluating and reconfiguring current benefit plan structures to identify changes to coinsurance, copayments, deductibles, and other plan elements that are more specific to the precise ICD-10 code sets Providers should also monitor the ICD-10 Implementation page on the TMHP website at for updated information as it becomes available. Additional information is available on the CMS website at NCCI Compliance The Patient Protection and Affordable Care Act (PPACA) mandates that all claims submitted on or after October 1, 2010, must be filed in accordance with the National Correct Coding Initiative (NCCI) guidelines. NCCI was developed by CMS to promote the correct coding of health-care services by providers. NCCI consists of pairs of procedure codes that should not be reported together. For more information, refer to v CPT only copyright 2013 American Medical Association. All rights reserved. 67

70 Checking for Updates: ICD, HCPCS Procedure Codes, and NCCI guidelines Here s how to check for the most recent updates to the International Classification of Diseases (ICD), Healthcare Common Procedure Coding System (HCPCS) Procedure Codes, and NCCI guidelines on the TMHP website: 1. Go to the TMHP website at and click providers in the top menu bar. 2. Click Code Updates in the left-side navigation pane. 68 CPT only copyright 2013 American Medical Association. All rights reserved. v

71 3. Click HCPCS Updates, ICD Updates, or NCCI Compliance. Note: The current ICD-9 (Ninth Revision) CM codes will be in effect until ICD-10 implementation. At that time the Code Updates Screen will change reflecting information for ICD-10 (Tenth Revision). Here are the steps to follow to access the NCCI information using the TMHP Website to link to the CMS website: 1. From the Code Updates screen click on NCCI Compliance on left-hand side menu. 2. Next, click on right-hand side link under the heading Help Links Centers for Medicare & Medicaid Services (CMS) NCCI web page. 3. Scroll down to the heading: Medicaid NCCI Edit Files. v CPT only copyright 2013 American Medical Association. All rights reserved. 69

72 Steps to Resolve Your Medicaid Questions Step 1 - Provider Manual: A provider s first resource for Medicaid information. Available on the TMHP website. Step 2 - Banner Messages: An additional source of information available in the office and at Step 3 - R&S Report: A provider s first resource for checking claim status. The report provides detailed information on pending, paid, denied, and incomplete claims. Step 4 - TMHP Website at providers can find the latest information on TMHP news and bulletins. Providers can also verify client eligibility, submit claims, check claim status, view R&S Reports, and view many other helpful links. Step 5 - TMHP Telephone Numbers: TMHP: ; Telephone Appeals: ; THSteps Dental Inquiries: ; THSteps Medical Inquiries: ; TMHP EDI Help Desk: , Option 3 Step 6 - Automated Inquiry System (AIS): A provider s resource for checking client eligibility, claim status, and benefit limitations. Available 23 hours a day, with daily downtime from 3:00 a.m. to 4:00 a.m. Call , and select an option from the menu. Step 7 - TMHP Contact Center: A provider s resource for general Medicaid program information. Available from 7:00 a.m. to 7:00 p.m. (CT). Call Ensure that you note a Ticket Number for the TMHP agent when calling, in order to provide appropriate citation. Step 8 - Provider Relations Representative: A provider s personal resource for issue escalation as well as educational and trouble-shooting visits. Visit the TMHP website and click Provider, then Provider Support Services, then Provider Relations Reps to contact Provider Relations. Section 6401 of The Affordable Care Act (ACA) of 2012 Providers are now subject to the ACA screening requirements, which screens them according to their risk category. Providers must re-enroll at least every five years, but durable medical equipment (DME) providers must re-enroll at least every three years. HHSC may require certain providers to re-enroll more frequently. All newly enrolling and re-enrolling institutional providers will be subject to an application fee. Enrollment is required for individual providers whose only relationship with Medicaid is ordering and referring services for Medicaid clients. For more information about the ACA, please refer to the ACA page on the TMHP website at Topics/ACA.aspx. 70 CPT only copyright 2013 American Medical Association. All rights reserved. v

73 Texas Women s Health Program (TWHP) Overview The goal of TWHP is to expand access to family planning services. TWHP clients receive a limited family planning benefit that supports this goal. Most providers who render services to TWHP clients are required to complete an annual TWHP certification and family planning attestation prior to serving TWHP clients. Benefits TWHP benefits include: One family planning exam each year, which may include a clinical breast exam, screening for cervical cancer, diabetes, sexually transmitted infections, high blood pressure, and other health issues. Follow-up office or other outpatient family planning visits that are related to the client s chosen method of birth control. Birth control, except for emergency contraception. Counseling on family planning methods, including natural family planning and excluding emergency contraception. Sterilization and sterilization-related procedures. Treatment for certain sexually transmitted infections. If a TWHP provider identifies a health problem, such as diabetes or cancer, the provider must refer the client for treatment services, and the client may have to pay for those additional services. TWHP only reimburses for the services that are listed above. Client Eligibility TWHP provides annual family planning exams, family planning services, and contraception to women who: Are 18 through 44 years of age. Are U.S. citizens or eligible immigrants. Reside in Texas. Have a household income at or below 185 percent of the federal poverty level (FPL). Do not currently receive Medicaid benefits (including Medicaid for pregnant women), CHIP, or Medicare Part A or B. Are not pregnant. Are not sterile, infertile, or unable to get pregnant because of medical reasons. Do not have other insurance that covers family planning services. For details on TWHP, see the TWHP webpage on the TMHP website at TWHP/TWHP_Home.aspx. v CPT only copyright 2013 American Medical Association. All rights reserved. 71

74 Provider Education TMHP Computer-Based Training TMHP offers a variety of training for providers online using computer-based training (CBT) modules on the TMHP Learning Management System (LMS). Texas Medicaid providers can access this on-demand training from any location with Internet access, anytime, at their convenience. TMHP CBT modules offer a flexible training experience by allowing providers to play, pause, rewind, and even search for specific words or phrases within a CBT module. How to Access Training. 1. Go to and enter your User Name and Password and click Login. (First-time users can follow the easy, on-screen instructions to create a user account.) 2. Hover over Provider Education in the menu bar and click Computer-Based. 72 CPT only copyright 2013 American Medical Association. All rights reserved. v

75 3. Scroll down the list and find the CBT you want to view. Click View Now. Medicaid: Beyond the Basics Participant Guide TMHP Computer-Based Training Titles CSHCN Services Program Basics Claim Forms Claim Appeals Client Eligibility Crossover Claims DSHS Family Planning Program (DFPP) and Medicaid Title XIX Durable Medical Equipment (DME) Physician Services Prior Authorization Provider Enrollment on the Portal Remittance and Status Reports TexMedConnect for Acute Care Providers TexMedConnect for Long Term Care Providers Third Party Liability Long Term Care (LTC) Community Services Waiver Programs Long Term Care (LTC) Nursing Facility/Hospice Medicaid Basics: Part 1 and Part 2 THSteps Dental Services THSteps Medical Services Medical Transportation Program (MTP) Nursing, Therapies, and Personal Care Online Fee Lookup THSteps Provider Education THSteps has an award-winning, online continuing education (CE) program for providers who render services to children enrolled in Medicaid. The courses cover preventive health, mental health, oral health, and case management services. To access THSteps training information, visit the website at v CPT only copyright 2013 American Medical Association. All rights reserved. 73