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2012 Long Term Care User Manual - TMHP Flipbook PDF
Dear Long Term Care Provider, The 2012 Long Term Care User Manual for Paper Clai m Submitters is published by the Texas
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2012 Long Term Care User Manual for Paper Claim Submitters
Dear Long Term Care Provider, The 2012 Long Term Care User Manual for Paper Claim Submitters is published by the Texas Medicaid & Healthcare Partnership (TMHP) for providers that use the Long Term Care (LTC) Claim Form 1290 to submit paper claims. It includes detailed instructions for completing the Form 1290 plus other useful information. It is the intent of the Department of Aging and Disability Services (DADS) to eliminate paper claims effective March 1, 2012; therefore, this is the final issue of the LTC User Manual. DADS published Information Letter No. 11-87, Planned Change to Support Only Electronic Claims Submitted to TMHP for Payment of LTC Services, on September 19, 2011, and received no feedback that would preclude the move to electronic claims. Most providers generally submit claims electronically through a web-based TMHP application called TexMedConnect. TexMedConnect is a free, standalone, web-based application that can be accessed online at www.tmhp.com from any computer with internet access. To begin billing electronically, contact TMHP at 1-800-626-4117, Option 3, for assistance in obtaining access to TexMedConnect. Please continue to monitor regular LTC provider publications for updates on the transition to electronic claims. These include: the quarterly Long Term Care Provider Bulletin, online LTC News articles and, most importantly, future DADS Information Letters. All are available through the TMHP LTC homepage at www.tmhp.com/Pages/LTC/ltc_home.aspx. For questions about billing, electronic enrollment, or this user manual, call the TMHP Call Center/Help Desk at 1-800-626-4117. The Department of Aging and Disability Services appreciates your support as we transition to electronic claims. Sincerely,
Gordon Taylor, Chief Financial Officer Texas Department of Aging and Disability Services
Contents
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Chapter 1: Introduction to Claims Management System Claims Management System Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Provider Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . TexMedConnect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Advantages of Using TexMedConnect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . TexMedConnect Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Enrollment for Electronic Submission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1-1 1-2 1-4 1-4 1-5 1-5
Chapter 2: LTC Claim Form 1290 Type of Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper Claims Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Submission Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Form Retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Detailed Claims Filing Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Claims. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Using the LTC Bill Code Crosswalk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Required Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Section A—Header Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Section B—Complete for Nurse Aide Training (NAT) Only. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Section C—Line Item Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Line Item Adjustments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Form 1290. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2-1 2-1 2-2 2-2 2-3 2-3 2-3 2-3 2-3 2-4 2-5 2-8 2-9
Chapter 3: Remittance and Status (R&S) Report R&S Report Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-1 PDF R&S Report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-1 ANSI 835 R&S Report (only for providers billing ANSI claims) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-2 Claim Data Export . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-2 R&S Report Distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-2 R&S Report Section Descriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-3 Title Page. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-3 Non-Pending Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-3 Pending Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-6 Financial Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-7 EOB Codes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-8 R&S Report Examples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-8 Title Page R&S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-9 Non-Pending Claims R&S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-10 Non-Pending Claims R&S Continued . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-11 Financial Summary R&S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-12 EOB Page R&S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-13 Appendix A: Commonly Asked Questions Appendix B: LTC Bill Code Crosswalk How to Use the LTC Bill Code Crosswalk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-1 National HCPCS and CPT Code Sets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-1 Appendix C: Service Groups Appendix D: Service Codes Appendix E: Modifiers Modifier Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-1
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Appendix F: Tooth Identification (TID) TID Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . F-1 Appendix G: Explanation of Benefits. Appendix: Glossary
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CPT only copyright 2011 American Medical Association. All rights reserved.
Copyright Acknowledgements Use of the AMA’s copyrighted CPT® is allowed in this publication with the following disclosure: “Current Procedural Terminology (CPT) is copyright 2011 American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable Federal Acquisition Regulation System/ Defense Federal Acquisition Regulation Supplement (FARS/DFARS) apply.” The American Dental Association requires the following copyright notice in all publications containing Current Dental Terminology (CDT) codes: “Current Dental Terminology (including procedure codes, nomenclature, descriptors, and other data contained therein) is copyright © 2010 American Dental Association. All Rights Reserved. Applicable FARS/DFARS apply.” Microsoft Corporation requires the following notice in publications containing trademarked product names: “Microsoft® and Windows® are either registered trademarks or trademarks of Microsoft Corporation in the United States and/or other countries.”
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Chapter
Introduction to Claims Management System 1
In this chapter… Claims Management System Overview Provider Support Advantages of Using TexMedConnect TexMedConnect Requirements Enrollment for Electronic Submission
Claims Management System Overview The Claims Management System (CMS) provides a comprehensive, user-friendly claims processing system for the Long Term Care (LTC) provider community. This system supports electronic and paper submissions. Most providers can exchange information electronically through a web-based application called TexMedConnect or develop third-party software that meets CMS requirements. TexMedConnect is the web-based application used by Acute care and most LTC providers to connect to the Texas Medicaid & Healthcare Partnership (TMHP) Electronic Data Interchange (EDI) Gateway system. TexMedConnect enables agencies to bill more efficiently when providing services to Acute care and LTC individuals. CMS streamlines claims processing for most programs under the Texas Department of Aging and Disability Services (DADS). The goals of CMS are to: • Present an accurate way to reimburse provided services. • Eliminate duplicate functions. • Provide flexibility for future modifications. • Improve community relations with providers. • Lower administrative costs associated with processing claims. • Have a common payment and tracking system. While claims are processed and managed through a single system, specific program policies are accommodated. Providers of the following services use CMS for reimbursement: • Adult Foster Care (AFC) • Assisted Living/Residential Care Services (AL/RC) • Consumer Managed Personal Attendant Services (CMPAS) • Community-Based Alternatives (CBA) • Community Living Assistance and Support Services (CLASS) • Day Activity and Health Services (DAHS) • Deaf/Blind Multiple Disabilities Program (DBMD Waiver) • Extended Care Facility (also known as Swing Beds) • Emergency Response Service (ERS)
CPT only copyright 2011 American Medical Association. All rights reserved.
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Chapter 1
• Home-Delivered Meals (HDM) • Hospice • Intermediate Care Facilities (ICF) • Medically Dependent Children Program (MDCP) • Nurse Aide Training (NAT) • Nursing Facilities (NF) • Primary Home Care/Family Care/Community Attendant (PHC/FC/CA) • Program of All-Inclusive Care for the Elderly (PACE) • Rehabilitative Services/Specialized Services • Respite Care • Special Services to Persons with Disabilities (SSPD) • Special Services to Persons with Disabilities-24 hours (SSPD-24) • Transitional Assistance Services (TAS) These providers may submit claims using Form 1290, TexMedConnect, or third-party software. Upon receipt of a claim, CMS edits check the validity of the information on the claim and compliance with the business rules for the service/program billed. Claims that do not meet necessary requirements are rejected or denied. The Remittance and Status (R&S) Report notifies providers that a claim is paid, denied, or in process. If a claim is rejected, the claim is not shown on the R&S Report. The provider is notified through a claim response. Only electronic claims reject. CMS calculates the payment amount and applicable reductions for claims approved for payment. Reductions can be due to money owed to the state by the provider, retroactive adjustments, change in rates, individual and provider eligibility, or service authorization changes. CMS totals all payments, less the reductions, and if the payable amount is greater than zero, sends the information to DADS accounting for further processing.
Provider Support TMHP operates a Call Center/Help Desk that provides billing and payment support to providers billing through TMHP. The TMHP Call Center/Help Desk operates Monday through Friday, 7 a.m. to 7 p.m., Central Time (excluding TMHP-recognized holidays). Providers should have their nine-digit LTC Provider/Contract number ready when they call the TMHP Call Center/Help Desk. They will be prompted to enter the LTC Provider/Contract number using the telephone keypad. The TMHP Call Center/Help Desk system uses the LTC Provider/Contract number to automatically populate the call center representative’s screen with the provider’s specific information, such as name and telephone number. Providers should have their four-digit Vendor/Facility or Site ID number available for calls about Minimum Data Set (MDS), Medical Necessity and Level of Care Assessment (MN/LOC), Preadmission Screening and Resident Review (PASARR) instrument, and Forms 3071, 3074, 3618, and 3619. Providers must have a Medicaid or Social Security number and a medical chart or documentation for inquiries about a specific individual. Providers can contact the TMHP Call Center/Help Desk at: • Long Term Care (outside of Austin): 1-800-626-4117 or 1-800-727-5436 • Long Term Care (Austin local): (512) 335-4729
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Introduction to Claims Management System
Refer to the following table for a list of telephone options and definitions:
For questions about…
Choose…
• General inquiries
• Claim rejection and denials
• Using TexMedConnect
• Understanding R&S Reports
• Completing Claim Form 1290
• Resource Utilization Group (RUG) levels
• Claim adjustments • Claim status inquiries • Claim history
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Option 1: Customer service/ general inquiry
• LTC Medicaid Information (LTCMI) • Minimum Data Set • Medical Necessity and Level of Care Assessment • PASARR Instrument • Form 3618 or 3619 • Forms 3071 and 3074
• Medical necessity • TexMedConnect—Technical issues, obtaining access, user IDs, and passwords • Modem and telecommunication issues • American National Standards Institute (ANSI) ASC X12 specifications, testing, and transmission • Electronic submission of MDS • Electronic transmission of Forms 3618 and 3619 • Electronic transmission of Forms 3071 and 3074 • Electronic transmission of Medical Necessity and Level of Care Assessment
Option 2: To speak with a nurse • Processing provider agreements
Option 3: Technical support
• Verifying that system screens are functioning • Getting EDI assistance from software developers • EDI and connectivity • Minimum Data Set submission problems
Option 3: Technical support
• Technical issues • Transmitting forms • Interpreting Quality Indicator (QI) Reports
• Electronic transmission PASARR Instrument • Current Activity (formerlyWeekly Status Report) • New messages (banner) in audio format for paper submitters
Option 4: Headlines/topics for paper submitters
• Individual appeals
Option 5: Request fair hearing
• Appeal guidelines
• Individual fair hearing requests • Replay for menu options
Option 6: Replay options
The following is additional information about menu options. • Option 1. Provider claims, MDS, MN/LOC, PASARR, Form 3618, and Form 3619. This option gives providers: • Assistance on how to complete Form 1290.
CPT only copyright 2011 American Medical Association. All rights reserved.
1–3
Chapter 1
• The status of a claim or an MDS, MN/LOC, and PASARR. • Information about an individual’s eligibility. • Assistance with how to read an R&S Report. • Assistance with how to read the Current Activity (formerly Weekly Status Report). • Option 2. To speak with a nurse. This option allows providers to: • Speak with a nurse about a pending or denied MDS, MN/LOC Assessment, or PASARR Instrument. • Provide additional or missing information to a nurse for an MDS, MN/LOC Assessment, or PASARR instrument. • Option 3. Technical support. This option provides information about: • TexMedConnect, MDS, and ANSI specifications. • Submitter IDs and passwords. • How to obtain an application for TexMedConnect or the LTC Online Portal. • How to get set up to download the R&S Reports. • How to correct MDS error messages. • How to run MDS Validation and Quality Indicator reports. • Option 4. Audio messages for paper submitters. This option allows providers to listen to recorded messages about headlines/topics and news (banner) information. • Option 5. Fair Hearings. This option allows a fair hearing to be requested for denied medical necessity for a nursing facility resident. • Option 6. To replay menu options.
TexMedConnect TexMedConnect is a standalone, web-based application that can be accessed online at www.tmhp.com. Providers must have both a contract number and a National Provider Identifier (NPI) to use TexMedConnect.
Advantages of Using TexMedConnect The advantages of using TexMedConnect are: • TexMedConnect is free of charge. • It can be used by anyone with a computer and internet access. • Providers can receive payment within five to seven business days after the claim reaches approve-to-pay status. • The billing cycle is more closely related to business needs. • Time delays due to mailing are avoided. • Advantages of processing claims and adjustments electronically: • Users can submit a batch of claims or adjustments and receive a response (usually within 24 hours). • Users receive a response within one minute after submission of an interactive claim (interactive is not available for adjustments). • Users receive a response electronically when a claim or an adjustment has errors and needs to be corrected and resubmitted (avoid waiting for the next billing cycle to receive payment by correcting and resubmitting rejected claims). • Benefits of using the claim status inquiry function: • Electronically track accepted claims from the day of submission to the date of payment. • Electronically request individual payment history information. • Advantages of R&S Reports: • Electronically access claim information by individual, provider, or claim. 1–4
CPT only copyright 2011 American Medical Association. All rights reserved.
Introduction to Claims Management System
• Facilitate timely reconciliation of claim information. • Verify claim information for an individual for a requested period. 1
TexMedConnect Requirements • Internet service provider (ISP) • One of the following web browsers: • Microsoft® Internet Explorer® • Netscape® Navigator® • A broadband connection is recommended but not required.
Enrollment for Electronic Submission Providers interested in utilizing electronic submission should contact the TMHP Call Center/Help Desk at 1-800-626-4117, Option 3, or refer to “How do providers enroll in electronic billing?” in Appendix A, “Commonly Asked Questions”on page A-1 for procedures on how to enroll.
CPT only copyright 2011 American Medical Association. All rights reserved.
1–5
Chapter
LTC Claim Form 1290
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In this chapter… Type of Claims Paper Claims Process Submission Guidelines Detailed Claims Filing Instructions Using the LTC Bill Code Crosswalk
Type of Claims Note: Providers may submit the following types of claims on the Form 1290: • New • Dental • Nurse Aide Training (NAT) • Adjustments Form 1290 only allows billing for one individual per claim. For example, if providers bill for 25 individuals, 25 individual forms must be completed, one for each individual. A single claim form may contain up to 17 line items for one individual.
Paper Claims Process The following is a brief summary of the Texas Medicaid & Healthcare Partnership (TMHP) paper claims process: 1)
Receive claim
2)
Sort claim
3)
Image (take a picture of ) claim for tracking and archiving purposes
4)
Enter claims data into the Claims Management System (CMS)
Information is entered into CMS exactly as it appears on the claim form. No editing or correcting is performed. After the claim data is entered into CMS, the system checks the claim for validity and acceptance requirements. TMHP approves, denies, or suspends the claim according to business requirements. Once the claim is received by TMHP, the normal processing time averages seven to ten business days. The amount of time may be impacted by: • Suspension, awaiting manual or system review • Provider on hold • Ineligible data
CPT only copyright 2011 American Medical Association. All rights reserved.
2
Chapter 2
Submission Guidelines Submit claims for processing using one Form 1290 for each individual. Providers may submit more than one Form 1290 in the same mailing envelope. The claim forms should not be stapled together. No attachments should be submitted with the claim. TMHP sorts and images all claims submitted on Form 1290 before entering the claims into CMS. To ensure quality imaging, TMHP recommends using only black ink. Printing the completed claim using computer software or a typewriter is preferred. Providers will receive information about finalized claims on the Remittance and Status (R&S) Report. The R&S Report is provided electronically every week. Refer to Chapter 3, “Remittance and Status (R&S) Report” on page 3-1. Providers should use the following guidelines when completing the Form 1290: • Print legibly. • Do not write in cursive. • If data is typed, use a font large enough to distinguish between characters. • Complete all required fields. • Use the most current Long Term Care (LTC) Bill Code Crosswalk. • Review the form for accuracy before submitting. • Sign each form: • An original signature is required on each form. • Copied or stamped signatures are not accepted. Mail the Form 1290 to the following address: Texas Medicaid & Healthcare Partnership Attention: Long Term Care PO Box 200105 Austin, TX 78720-0105 Note: Delivery to TMHP could take five business days. Allow ten business days for the claim to appear in the system. Send overnight mail to: Texas Medicaid & Healthcare Partnership Attention: Long Term Care, MC-B02 12357-B Riata Trace Parkway Austin, TX 78727 Important: To avoid processing delays when sending overnight mail, the address on the envelope should include “Attention: Long Term Care, MC-B02.” Delivery to TMHP could take an additional day, depending on the time of day the claim is mailed. Allow three days for the overnighted claim to appear in the system. When calling to check the status of the claim, the overnight mail tracking number must be provided. For assistance completing the Form 1290, contact the TMHP Call Center/Help Desk at 1-800-626-4117 or (512) 335-4729 (Austin), and choose Option 1. Note: Providers initially receive an original camera-ready copy of the Form 1290. Save this form and make submissions using a photocopy of the original camera-ready form. Additional copies can be found on the Department of Aging and Disabilities Services (DADS) website at: www.dads.state.tx.us/forms/1290/ or by contacting the provider’s contract manager.
Form Retention The original Form 1290 must be submitted to TMHP. A copy should be retained according to LTC Program contract retention requirements.
2–2
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LTC Claim Form 1290
Detailed Claims Filing Instructions Claims Claims must contain the provider’s complete name, address, National Provider Identifier (NPI) or Atypical Provider Identifier (API), and nine-digit provider/contract number. All required items of the Form 1290 must be completed. The following instructions describe what information providers must enter in each item of the Form 1290. TMHP will not process a claim that is missing the required information.
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Important: The LTC Bill Code Crosswalk will be referenced throughout this manual for instructions on completing the Form 1290. The LTC Bill Code Crosswalk is a cross-referenced code set used to match the National Standard Codes (procedure and revenue codes) to the Texas LTC local codes, such as bill codes. When billing for LTC services, use information on the LTC Bill Code Crosswalk associated with the bill code that reflects the service billed. The LTC Bill Code Crosswalk includes codes necessary when billing services, such as revenue codes, procedure codes qualifiers, and Healthcare Common Procedure Coding System (HCPCS) codes. The LTC Bill Code Crosswalk is updated monthly as needed. The most current version of the LTC Bill Code Crosswalk must always be used and is available online at the following website address: www.dads.state.tx.us/providers/hipaa/billcodes/
Using the LTC Bill Code Crosswalk Follow these steps when using the LTC Bill Code Crosswalk: 1)
Identify the service group/service code (SG/SC) to be billed.
2)
Go to the LTC Bill Code Crosswalk table and find the same SG/SC.
3)
Continue on the same line to find the corresponding information to complete the applicable items on the Form 1290, such as bill codes, HCPCS codes, and revenue codes.
Required Information The following instructions describe the information that must be entered in each of the block numbers of the Form 1290.
Section A—Header Information Block 1—National Provider Identifier (NPI) This item is required. Enter the provider’s NPI number or API for atypical providers, the nine-digit contract number preceded by the letter D (e.g., D106321123). Block 2—Contract No. This item is required. Enter the provider’s contract number. Block 3—Provider Name This item is required. Enter the provider’s name as it appears on the contract. Block 4—Address This item is required. Enter the provider’s address as it appears on the contract. Block 5—Telephone No. Enter the provider’s telephone number as it appears on the contract. Block 6—Client/Medicaid No. This item is required for all claims except NAT claims. Enter the individual’s nine-digit client/Medicaid number.
CPT only copyright 2011 American Medical Association. All rights reserved.
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Chapter 2
Block 7—Patient Account No. Enter the provider's internal patient account number. Block 8—Client Last Name This item is required. Enter the individual’s last name. For NAT claims, enter the trainee’s last name. Block 9—Client First Name This item is required. Enter the individual’s first name. For NAT claims, enter the trainee’s first name. Block 10—Client Middle Initial Enter the individual’s middle initial. For NAT claims, enter the trainee’s middle initial. Block 11—Client Suffix Name Enter the individual’s suffix name (e.g., Jr., Sr.). Block 12—VA Indicator Complete item 12 when billing for a Veteran Affairs’ (VA) individual residing in a VA facility. This item is applicable only to SGs 1 and 8. Enter “VA” if the individual is residing in a VA facility. Block 13—Billed Applied Income/Copay Complete item 13 when billing for an individual that requires applied income (AI)/copay. Enter the dollar amount of the individual’s income contributed to the individual’s care or the individual’s assessed copay amount. Do not use items 14 through 18
Section B—Complete for Nurse Aide Training (NAT) Only Complete only for Section B or C. Do not complete both sections. Block 19—NAT SSN This item is required. Enter the trainee’s nine-digit Social Security number. Block 20—Service Group This item is required. Enter the service group. Refer to Appendix C, “Service Groups” on page C-1 for a list of service groups. Block 21—Bill Code This item is required. Enter the bill code, the five-character code for the specific service provided to the individual. Refer to the Bill Code column of the LTC Bill Code Crosswalk. Block 22—Patient Days % This item is required. One or all of the subtypes can be completed. The sum of all three types must equal 100.0 percent. This percentage should consist of a maximum of three leading digits before and one digit after the decimal point (e.g., 100.0). Medicaid. Enter the percentage of filled beds in the facility for Medicaid residents. This percentage should consist of a maximum of three leading digits before and one digit after the decimal point (e.g., 040.0). Medicare. Enter the percentage of filled beds in the facility for Medicare residents. This percentage should consist of a maximum of three leading digits before and one digit after the decimal point (e.g., 030.0). Private. Enter the percentage of filled beds in the facility for private-pay residents. This percentage should consist of a maximum of three leading digits before and one digit after the decimal point (e.g., 030.0). Block 23—Begin Date This item is required. Enter the eight-digit service begin date (mm/dd/yyyy) for the line item.
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LTC Claim Form 1290
Block 24—End Date This item is required. Enter the eight-digit service end date (mm/dd/yyyy) for the line item. Block 25—Training Hours This item is required. Enter the number of training hours completed. Include one digit after the decimal point (e.g., 79.5).
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Block 26—Number of Units This item is required. Enter the number of service units provided to the individual. Include one digit after the decimal point (e.g., 139.0). Block 27—Unit Rate This item is required. Enter the unit rate for the service provided. Include two digits after the decimal point (e.g., 33.00). Block 28—Line Item Total This item is required. Enter the line item total by calculating the information entered in items 26 and 27. The line item should include two digits after the decimal point (e.g., 432.00).
Section C—Line Item Information Block 29—Begin Date This item is required. Enter the eight-digit service begin date (mm/dd/yyyy) for the line item. Block 30—End Date This item is required. Enter the eight-digit service end date (mm/dd/yyyy) for the line item. Block 31—Rev Code (Revenue Code) This item is required for some services. Revenue codes are used to classify types of services. To determine if a revenue code is required for the service billed, refer to the Revenue Code column in the LTC Bill Code Crosswalk. Block 32—Proc Code Qual (Procedure Code Qualifier) This item is required when a procedure code is used. The procedure code qualifier describes the source of the procedure code entered in Block 32. To determine the procedure code qualifier to enter when billing for a particular service, refer to the Procedure Code Qualifier column in the LTC Bill Code Crosswalk. There are three types of procedure code qualifiers: • ER—Texas LTC Local Codes (usually referred to as a bill code) • HC—HCPCS and Current Procedural Terminology (CPT) codes • AD—American Dental Association codes Block 33—Proc/Item Code (Procedure/Item Code) This item is required for some services. The procedure/item code uniquely identifies a procedure, product, or the service provided to the individual. Services provided are described by codes. To determine the procedure/item codes to use when billing for a particular service, refer to the Bill Code, HCPCS, or CPT Code columns in the LTC Bill Code Crosswalk. There are four types of procedure codes: 1)
Bill codes (also referred to as Texas LTC local codes)
2)
HCPCS codes
3)
CPT codes
4)
AD codes (also referred to as Current Dental Terminology [CDT] codes)
Complete this block as follows: • If “ER” is entered in Block 31—Proc/Item Code Qual, enter a local/bill code. • If “HC” is entered in Block 31—Proc/Item Code Qual, enter a HCPCS or CPT code. • If “AD” is entered in Block 31—Proc/Item Code Qual, enter a dental (CDT) code. CPT only copyright 2011 American Medical Association. All rights reserved.
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Block 34—Modifiers Modifiers are two-digit codes used to further define a service or assist in determining what to pay during the claims adjudication process. There are four modifier fields on the Form 1290. Refer to the Modifier columns in the LTC Bill Code Crosswalk and the “Important Information About Modifiers 1 and 2” below, to determine if a modifier should be billed for a particular service. A copy of the Modifier table is available in Appendix E, “Modifiers” on page E-1. The Modifier table may be updated on occasion. The most current version of the Modifier table is available on the DADS website at www.dads.state.tx.us/providers/hipaa/billcodes/. Note: Modifiers 1 and 2 are used to provide contract-specific information, such as the service group (SG) or budget number, and are not included in the LTC Bill Code Crosswalk. To determine if a modifier should be included when billing for a particular service, refer to the following modifiers 1 and 2 examples. Important Information About Modifiers 1 and 2 Modifier 1 Modifier Field 1 is only used: • If shown on the LTC Bill Code Crosswalk. • If provider has a single contract with multiple SGs. Use modifier 1 to indicate the SG of the individual’s billed services. • If a hospice provider is billing for an Intermediate Care Facility for an individual with intellectual disabilities (ICF). Use modifier 1 to indicate the SG of the individual before entering hospice. Example: A provider has a single contract for both SG 3—Community-Based Alternatives (CBA), Assisted Living/ Residential Care (AL/RC), and SG 7—Community Care for the Aged and Disabled (CCAD RC) shown here.
Modifier
Service Group
U3
SG 3
U7
SG 7
Example: A Hospice provider billing for an individual in an SG 4 State Supported Living Center (e.g., modifier U4 in SG 04).
Modifier
Service Group
U4
SG 4
U5
SG 5
Modifier 2 Modifier Field 2 is used: • If shown on the LTC Bill Code Crosswalk. • To specify a budget when billing a service (if required by contract). Example: A provider has a single contract for two services.
Modifier
Budget
U1
Budget 1
U2
Budget 2
Modifier Field 3 is used only if shown on the crosswalk. Modifier Field 4 is used only if shown on the crosswalk.
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LTC Claim Form 1290
Block 35—POS Code (Place of Service) This code is not required. The place of service (POS) code identifies the location; such as a nursing facility, individual’s home, assisted living/residential care facility, or dentist’s office where the service was provided. The following is an example of a few of the POS codes: 2
Service
Place of Service
Place of Service Code
Personal Assistance Services (PAS)/Emergency Response Services (ERS)
Home
12
Dental Care
Office or other POS
11 or 99
Day Activity and Health Services (DAHS)
Other POS
99
Assisted Living/Residential Care
Assisted Living Facility
13
Block 36—TID (Tooth ID) Complete this block if billing for services for an individual receiving dental services/treatment by a licensed dentist. Enter up to a two-digit number (the tooth identification [TID] number) that identifies the tooth on which the service was performed. Refer to Appendix F, “Tooth Identification (TID)” on page F-1. Block 37—Rendering Provider Name This item is required if the service billed is a skilled/professional service and was provided by someone other than the provider agency; such as a dentist, therapist, or other licensed professional. The rendering provider name identifies the person that provided the service to the individual. This block does not apply to unskilled/ nonprofessional services delivered by the provider agency; such as meals, personal attendant services, day activities, and health services. Refer to the following table for examples of rendering provider names:
Skilled/Professional Service Provided
Name of Rendering Provider
Dental services
David Davis
Physical therapy
Patty Dee
Nursing services
Nadine Doe
Block 38—Number of Units This item is required. Enter the number of units of service provided to the individual. The units are based on the bill code, not the procedure code. Include one digit after the decimal point (e.g., 139.0). Note: If the unit rate for the services billed is hourly and is being billed for less than one hour of service, enter the unit in quarter-hour (15-minute) increments. For example, if 25 hours and 30 minutes of service were provided, enter 25.50 in the number of units field. Block 39—Unit Rate This item is required. Enter the unit rate for the service provided. Include two digits after the decimal point (e.g., 33.00). Block 40—Line Item Total This item is required. Enter the line item total by calculating the information entered in Block 38—Number of Units and Block 39—Unit Rate, and when applicable, Block 13—Billed Applied Income/Copayment. Block 41—Claim Total
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Chapter 2
This item is required. Enter the claim total. The claim total is the sum of all line items. Include two digits after the decimal point (e.g., 150.00). Block 42—Signature This item is required. Sign each form. Each Form 1290 must have an original signature. Block 43—Date Enter the date the claim is submitted.
Line Item Adjustments Line item adjustments are submitted to change a previously paid claim. Line items should contain the original claim’s information exactly as shown on the R&S Report. TMHP matches line item information to the original claim detail line item using data that includes, but is not limited to, service dates, units paid, and dollar amount paid codes (revenue, bill, and procedure/item). The line item adjustments may contain one or more negative line items. The negative line items cancel applicable line items listed on the original claim to be adjusted. To submit an adjustment, in Section C of the Form 1290, enter the line item to be adjusted as it appears on the original claim, except enter the units and line item totals in negative (-) amounts. More than one line item for a claim may be adjusted. Each line item adjusted must be credited back before any corrections are made. The credit appears on the adjusted line item as a negative number of units on the R&S Report. Not all negative line items (credited line items) have a corresponding positive line item (adjusted charge) adjustment associated with it.
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7. Patient Account No.
6. Client/Medicaid No.
20. Service Group 21. Bill Code Medicaid
Medicare
22. Patient Days %
13. Billed Applied Income/Copay
Private
23. Begin Date (mm/dd/yyyy)
10. Client Middle Initial 11. Client Suffix Name
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29. 30. Begin Date End Date (mm/dd/yyyy) (mm/dd/yyyy)
31. Rev Code
32. Proc Code Qual
33. Proc/Item Code
Texas Department of Aging and Disability Services
I certify that this information is true, accurate and complete to the best of my knowledge. I understand that claiming for services not actually provided constitutes fraud.
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16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
Line 1
2
3
34. Modifiers 4
36. TID
42. Signature
35. POS Code
43. Date
37. Rendering Provider Name
Claim Total:
38. Number of Units
41.
40. Line Time Total
28. Line Item Total
18. Billing Month/Year
39. Unit Rate
27. Unit Rate
17. Billed Amount
26. Number of Units
16. Fund Code
25. Training Hours
Form 1290 January 2010 5. Area Code and Telephone No.
This information is for expedited PAS use only. 15. Service Code
24. End Date (mm/dd/yyyy)
14. Service Group
9. Client First Name
4. Address
Section C – Line Item Information (Note: Negative Number of Units should appear as – 00.00. Show parts of units as decimal fractions.)
19. NAT SSN
Section B – Nurse Aide Training
12. VA Indicator
Long Term Care Claim
This information is for an individual requiring AI/Copay
8. Client Last Name
3. Provider’s Name
This information is for a VA individual residing in a VA facility
2. Contract No.
1. NPI No.
Section A – Header Information
LTC Claim Form 1290
Form 1290
2
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Chapter
Remittance and Status (R&S) Report
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In this chapter… R&S Report Overview R&S Report Distribution R&S Report Section Descriptions
R&S Report Overview Remittance and Status (R&S) Reports are valuable tools for tracking billing activities. A successful business typically has good accounting practices, such as the reconciliation of R&S Reports. Agencies that do not reconcile their R&S Reports may be billing incorrectly, which can result in audits and penalties. The R&S Report includes the following five sections:
Section
Description
Title Page
Provider address and R&S Report information pertinent to the reported week
Non-Pending Claims (R&S)
Claims and adjustment requests that have completed processing during the reported week and have finalized to either a paid or denied status
Pending Claims (Claim Activity Report)
Suspended claims and adjustments awaiting manual review/adjudication by an examiner or claims approved for payment but not yet paid. Pending claims may be for periods outside of the reported week
Financial Summary
Warrant summary information and other financial transactions such as administrative and deduction payment processing
Explanation of Benefits (EOB) Code and Description
EOB codes and descriptions found in the Non-Pending and Pending Claims sections. Instructions for submitting claim adjustments for previously paid and/or denied claims
The R&S Report includes information about paid claims, denied claims and the reason for denial, in-process claims and the reason for their status, warrants, and payment summary information. Claims received or processed with a status of paid, denied, or in-process during the previous week for the same provider number appear on the R&S Report. R&S Reports are available in two types of media: electronic and web-based portable document format (PDF) files. The TexMedConnect Online Help or the TMHP Call Center/Help Desk at 1-800-626-4117, should be consulted to access additional information about R&S Reports.
PDF R&S Report Description: The R&S Report is in a PDF format and provides financial reconciliation information. The information can be printed or downloaded, but not manipulated. A report is generated for each unique National Provider Identifier (NPI) or Contract Number. How to Access: Within TexMedConnect, users must click R and S on the navigation bar on the left side of the screen. Who has Access: Administrators and users with the “R&S Report Viewer” permission can access this option.
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Chapter 3
Availability: The report can be viewed online for up to three months. Three months after the posting date, the report will be removed from the website. Multiple users can access the report at any time.
ANSI 835 R&S Report (only for providers billing ANSI claims) Description: The ANSI 835 file is a Health Insurance Portability and Accountability Act (HIPAA)-compliant R&S Report format used by providers or third-party software and other “back-end” financial systems. The ANSI 835 file provides financial reconciliation information in a comma-delimited format. The information is downloaded in a flat file for use in software that can manipulate the data to meet a provider's needs (e.g., third-party billing software, Microsoft Access). How to Access: Within TexMedConnect, users must click ANSI 835 on the navigation bar on the left side of the screen. The provider's submitter ID must be entered so that the file can be placed on the File Transfer Protocol (FTP) server. The file must then be downloaded from the FTP server. The submitter ID is different from the TexMedConnect username and password that are used to access the website. Providers who do not already have a submitter ID must call the TMHP Electronic Data Interchange (EDI) Help Desk at 1-888-863-3638. Who has Access: Administrators and users with the “View 835 Report” permission can access this option. Availability: The report file is available until a user downloads it from the FTP server. Important: After the file has been downloaded by a user, it will not be available for other users.
Claim Data Export Description: A claim data export is a “customized” user search that allows providers to request up to three months of claim data for up to three years in the past. The results are returned in a user-friendly, formatted Microsoft Excel® file. The information is similar to the data in the PDF format above but in an Excel format. The primary use of this report is to give specific claim data for an NPI/Contract Number in an easily-readable format. How to Access: Within TexMedConnect, users must click Data Export Request on the navigation bar on the left side of the screen to perform the search. The provider's submitter ID must be entered so that the file can be placed on the FTP server. Once the request is submitted, an off-line batch process runs to retrieve the requested data and place the results on an FTP server. Users must then click Data Export Download on the navigation bar to download the file with the results of the search. The submitter ID is different from the TexMedConnect username and password that are used to access the website. Providers who do not already have a submitter ID must call the TMHP EDI Help Desk at 1-888-863-3638. Who has Access: Only Administrators can access this option. Availability: The report file is available until a user downloads it from the FTP server. Important: After the file has been downloaded by a user, it will not be available for other users.
R&S Report Distribution An R&S Report is available to providers each Monday with claim activity in the reporting week. Note: Copies of all R&S Reports must be retained for a minimum of five years.
R&S Report Section Descriptions Title Page The first page of the R&S Report, called the title page, contains provider and R&S information for the reported week. The title page includes the provider’s address (as listed in the Department of Aging and Disability Services [DADS] provider file) and the TMHP mailing address. Note: Address changes must be reported to the provider’s DADS contract manager or program consultant.
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Remittance and Status (R&S) Report
The following is a description of the information included in the title page: Title Page Information Agency Name
The name of the state agency
Remittance and Status No.
The unique number assigned to each Report
Report Sequence No.
The date the report was generated
Report From Date
The From date of service in MMDDYYYY (month, day, year) format
Report To Date
The To date of service in MMDDYYYY (month, day, year) format
Run Date
The date the report was generated by the Claims Management System (CMS)
Provider Number
The provider/contract number assigned to an agency by DADS. A provider with more than one provider/contract number will receive an R&S Report for each provider/contract number
PIN
Payee Identification Number. A unique number assigned by the Texas Comptroller’s Office to an individual or entity to enable them to receive state payments
Atypical Provider Identifier
Any provider delivering atypical services must obtain an Atypical Provider Identifier (API) to be included in lieu of the National Provider Identifier on all claim forms submitted. The API is the nine-digit contract number preceded by the letter “D” (e.g., D000001234).
National Provider Identifier
The standard unique health identifier for health care providers. On standard transactions it replaces the use of all legacy provider identifiers, such as the Medicaid LTC Provider Number
TMHP Address
The PO Box address for submitting paper claims and the TMHP physical address
Provider Name and Address
The name and address of the provider
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Non-Pending Claims Claims finalized to a paid or denied status during the reported week are included in the Non-Pending Claims section. The Non-Pending Claims section has three parts: General Information, Claim Header Information, and Claim Detail Information. Claims in the Non-Pending Claims section are sorted and shown in alphabetical order by the individual’s last name. The General Information component applies to the entire section and is located at the top of each page of the Non-Pending Claims section. General Information Page Number
The specific page of the report appears on the top left-hand corner of each page
Title of the Report
The title of the report appears at the top center of each page
Report Date
The date the R&S Report was generated appears at the top right-hand corner on the R&S Report
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Chapter 3
General Information PIN
Payee Identification Number. The provider’s PIN appears below the page number at the top left-hand corner
Non-Pending Claims
The label appears centered and below the title of the report and identifies the claims found in this section of the report
Provider Number
This is the provider/contract number associated with the agency whose claims are contained in this report
The second part of the Non-Pending Claims section is the claim header. It includes the following fields and information from left to right, top to bottom: Claims Header Information
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Client Name
The last name, first name, and middle initial (if applicable) of the individual who received LTC services
Client/Mcaid No.
The nine-digit number identifying the individual as being eligible for services
Trainee SSN
The Social Security number of the nurse aide trainee
Client/Control No.
The optional number used by the provider to identify the individual’s account number assigned by the provider’s accounting system
ICN
The internal control number assigned to a claim that has passed acceptance editing, sometimes referred to as the “claim number”
Svc Group
The number assigned to designate the LTC Program associated with the claim
Mcaid Days %
Percentage of patient Medicaid days
Mcare Days %
Percentage of patient Medicare days
Private Days %
Percentage of patient private days
Warr/DD No. 1
The first warrant or direct deposit number that the Comptroller issued
Warr/DD Date 1
The date the Comptroller issued the first warrant or direct deposit
Warr Status 1
The status of the first warrant or direct deposit, such as “on hold at the Comptroller or DADS”
DLN
The document locator number to identify each warrant request
Warr/DD No. 2
The second warrant or direct deposit number that the Comptroller issued
Warr/DD Date 2
The second warrant or direct deposit date that the Comptroller issued the warrant number
Warr Status 2
The second warrant status of the warrant or direct deposit, such as “on hold at the Comptroller or DADS”
Transmission ID
This field only applies to electronic claims submitted in a batch, and is used to identify the specific batch.
CPT only copyright 2011 American Medical Association. All rights reserved.
Remittance and Status (R&S) Report
Claims Header Information Warr/DD No. 3
The third warrant or direct deposit number that the Comptroller issued
Warr/DD Date 3
The third warrant or direct deposit date that the Comptroller issued the warrant number
Warr Status 3
The third warrant status of the warrant or direct deposit, such as “on hold at the Comptroller or DADS”
Tot Billed
The total dollar amount billed for the claim
Tot App Pay
The total dollar amount approved for payment for the claim
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The third part of the R&S Non-Pending section, referred to as the “Claim Detail,” has information from each claim’s detail. Positive and negative line items uniquely identify adjustment requests. Claim Detail Information #
The claim detail line item number
Adj
The adjustment indicator
Original ICN
The original Internal Control Number (ICN) of the claim line item of the adjustment requests
Srvc Dates
Begin and end dates for a billed service, also known as dates of service (DOS)
Bill Cd
The billing code
Proc/TID
The procedure code used to identify a procedure. The TID is the tooth identification number
Tng Hrs
The number of training hours used for a nurse aide trainee
Billed Units
The number of units billed
Allowed Units
The number of units allowed for the service billed
Allowed AI/Co-pay
The applied income or copayment on file in the system. The allowed amount is applied to the line item billed amount
Unit Rate
The approved-to-pay unit rate of the service
Paid Units
The number of units approved for payment
EOB 1
The explanation of benefits codes explain the reasons for payment, denial, or pending of the claim’s line item
Status
The claim status indicator: P—Paid PZ—Paid zero. The entire payment was applied to the balance owed the state (i.e., administrative payment) D—Denied (claim not paid) T—Transferred (no funds paid or recouped at this time)
Begin/End
The start and/or end dates of service for the service billed
Svc Cd
The service code authorized on the individual’s service authorization
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Chapter 3
Claim Detail Information Item Cd
The item code of the service billed
Lv Days
The number of days the client was on leave
Billed Amount
The dollar amount billed for a service
Allowed Amount
The dollar amount allowed for the service billed
Billed AI/Copay
Billed Applied Income represents the individual’s income that must be contributed toward the cost of the service billed by the provider. Copayment represents the amount the individual is responsible for contributing. Both amounts are applied to the line item billed amount
Budg No.
This identifies the budget number the claim is being charged against
Paid Amt
The dollar amount paid for a claim
EOB 2
The EOB codes explain the reasons for payment, denial, or pending of the claim’s line item
Pending Claims The Pending Claims section includes claims and adjustment requests that have been suspended or are approved for payment but for which warrant information was not available when the R&S Report was generated. The following status codes appear on a pending R&S Report: • A—Approved to pay (passed editing/no warrant issued yet) • S—Suspended (awaiting further information) • I—In process Claims in this section are still being processed in the system. This section informs providers of the status of claims that have not been finalized as paid or denied. The EOB message located on the R&S Report explains why the claim has not completed processing. Providers should not interpret the EOB message on a pending detail line of a claim as a final reason for payment or denial. Providers cannot adjust a pending claim (A, S, or I) until the claim has been finalized as paid and appears in the Non-Pending Claims section of the R&S Report. The format of the Pending Claims section resembles that of the Non-Pending Claims section except for the title “Pending Claims” that appears in the top center of the page. Some fields may be blank because the claim is still being processed through the system.
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Remittance and Status (R&S) Report
Financial Summary The Financial Summary section contains the following information: • Administrative and deduction payment processing information for the week being reported on the R&S Report • Total amount paid for this R&S Report (non-pending only) • Summary of all the warrants contained in the R&S Report The Financial Summary section contains four parts. The first part, referred to as “general information,” contains the same information described in the Non-Pending section of general information in this chapter.
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The second part of the Financial Summary section contains administrative and deduction payment processing information. For providers who receive recoupable administrative payments, or who are placed on deduction, the amount column reflects the total amount of the payment or deduction. The withheld column reflects paid claims to date applied toward repaying the payment or deduction. The balance column reflects any amount owed to repay the payment or deduction and includes the following fields on the form, from left to right: Financial Summary Type of Financial Action
Deductions and administrative payments are financial transactions that may appear under this heading. These types of transactions may or may not be associated with a specific claim
Administrative Payment(s)
A special payment to a provider agency authorized by DADS
Provider Total Deduction(s)
The directive by the state to withhold claim payment from a provider
Provider Monthly Deduction(s)
The directive by the state to withhold a specific monthly claim payment amount from a provider
Total Paid Amount For This R&S (Non-Pending Only)
The cumulative total of all the warrants included in the specific R&S Report number
Total Withheld to Date
The dollar amount withheld from a provider for an administrative payment or deduction
Total Withheld this R&S
The amount the provider owes to zero-out the balance
The third part of the Financial Summary section, titled “Total Paid Amount for this R&S Report, Non-Pending,” reflects total dollars that were paid on all the claims appearing on the Non-Pending R&S Report. This total does not reflect the amounts withheld on this R&S Report. The fourth part of the Financial Summary section, referred to as “Warrant Summary Information,” contains information that applies to the warrants included in the R&S Report. Up to nine warrants appear in this section. The form includes the following fields from left to right: Warrant Summary Information Warrant Information for This Report
The information on all warrants included in the specified R&S Report
Warrant/Direct Deposit Number
The check number of the warrant that is used to pay providers and vendors for services rendered
Warrant/Direct Deposit Date
The date the warrant was issued
Total Amount Paid
The total amount of the warrant
CPT only copyright 2011 American Medical Association. All rights reserved.
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Warrant Summary Information Warrant Status
The final status of the warrant: H—Comptroller hold M—Warrant mailed C—Warrant canceled D—Direct deposit A—Agency hold W—Warrant issued
EOB Codes All the EOB codes shown on the Non-Pending and Pending claims pages appear on the EOB code and description page. Codes for non-pending claims explain the payment or denial reason of a claim or line item on a claim. Codes for pending claims explain the reason a claim suspended or informs the provider of an approved claim for payment. However, the warrant information is not available when the R&S Report is generated. The EOBs for pending claims serve only to explain the status of the claims and should not be interpreted as a final reason of payment or denial. A list of EOB codes is located in Appendix G, “Explanation of Benefits” on page G-1. Electronic providers should refer to the national EOB codes for a complete set of codes and descriptions.
R&S Report Examples The following pages provide examples of R&S Reports.
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CPT only copyright 2011 American Medical Association. All rights reserved.
Mail Original Claim To: Texas Medicaid & Healthcare Partnership PO Box 200105 Austin, Texas 78720-0105 1-800-626-4117
Provider Number: 001234567 PIN: National Provider Number: 000000000000
Remittance and Status No.: 0200620 Report Sequence No. 0200620 Report From Date: 200613 Report To Date: 200620 Run Date: 200620
TEXAS DEPARTMENT OF AGING AND DISABLITITY SERVICES
Mail All Other Correspondence To: Texas Medicaid & Healthcare Partnership 12357B Riata Trace Parkway Austin, Texas 78727
Remittance and Status (R&S) Report
Title Page R&S
3
3–9
3–10
01 00 000000000000000 200501 G0930 0000 00003100 00003100 0000000000 0000002000 00002220 00003100 F0239 P 200531 19B 00 0000071269 0000068820 0000000000 0000000000 0000066820 F0238 --------------------------------------------------------------------------------------------------------------------------------------------
01 00 000000000000000 200501 G0929 0000 00003100 00003100 0000000000 0000029900 00002220 00003100 F0239 P 200531 19B 00 0000071269 0000068820 0000000000 0000000000 0000038920 F0238 -------------------------------------------------------------------------------------------------------------------------------------------Client Name: LAST FIRST MI Client/Mcaid No.: 333333333 Trainee SSN: 000000000 Client/Control No.: ICN: 123456712345678 Svc Group: 3 Mcaid Days %: 0000 Mcare Days %:0000 Private Days %:0000 Warr/DD No 1:1234567 Warr/DD Date 1:200613 Warr Stat 1:D DLN: 01234567891 Warr/DD No 2: Warr/DD Date 2: Warr Stat 2: Transmission ID: Warr/DD No 3: Warr/DD Date 3: Warr Stat 3: Tot Billed:000000071269 Tot App Pay: 000000066820 -------------------------------------------------------------------------------------------------------------------------------------------# Adj Original ICN Svc Dates Bill Cd Proc/TID Tng Hrs Billed Units Allowed Uts Allowed AI/Copay Unit Rate Paid Units EOB 1 Status Begin/End Svc Cd Item Cd Lv Days Billed Amount Allowed Amt Billed AI/Copay Budg No. Paid Amt EOB 2 --------------------------------------------------------------------------------------------------------------------------------------------
01 00 000000000000000 200501 G0932 0000 00003100 00003100 0000000000 0000048413 00002220 00003100 F0239 P 200531 19B 00 0000071269 0000068820 0000000000 0000000000 0000020407 F0238 -------------------------------------------------------------------------------------------------------------------------------------------Client Name: LAST FIRST MI Client/Mcaid No.: 222222222 Trainee SSN: 000000000 Client/Control No.: ICN: 123456123456789 Svc Group: 3 Mcaid Days %: 0000 Mcare Days %:0000 Private Days %:0000 Warr/DD No 1:1234567 Warr/DD Date 1:200613 Warr Stat 1:D DLN: 01234567891 Warr/DD No 2: Warr/DD Date 2: Warr Stat 2: Transmission ID: Warr/DD No 3: Warr/DD Date 3: Warr Stat 3: Tot Billed:000000071269 Tot App Pay: 000000038920 -------------------------------------------------------------------------------------------------------------------------------------------# Adj Original ICN Svc Dates Bill Cd Proc/TID Tng Hrs Billed Units Allowed Uts Allowed AI/Copay Unit Rate Paid Units EOB 1 Status Begin/End Svc Cd Item Cd Lv Days Billed Amount Allowed Amt Billed AI/Copay Budg No. Paid Amt EOB 2 --------------------------------------------------------------------------------------------------------------------------------------------
Page N-1 TMHP Remittance & Status Report Report Date: 200620 PIN: Non-Pending Claims Provider Number: 001234567 -------------------------------------------------------------------------------------------------------------------------------------------Client Name: LAST FIRST MI Client/Mcaid No.: 111111111 Trainee SSN: 000000000 Client/Control No.: ICN: 123456789123456 Svc Group: 3 Mcaid Days %: 0000 Mcare Days %:0000 Private Days %:0000 Warr/DD No 1:1234567 Warr/DD Date 1:200613 Warr Stat 1:D DLN: 01234567891 Warr/DD No 2: Warr/DD Date 2: Warr Stat 2: Transmission ID: Warr/DD No 3: Warr/DD Date 3: Warr Stat 3: Tot Billed:000000071269 Tot App Pay: 000000020407 -------------------------------------------------------------------------------------------------------------------------------------------# Adj Original ICN Svc Dates Bill Cd Proc/TID Tng Hrs Billed Units Allowed Units Allowed AI/Copay Unit Rate Paid Units EOB 1 Status Begin/End Svc Cd Item Cd Lv Days Billed Amount Allowed Amt Billed AI/Copay Budg No. Paid Amt EOB 2 --------------------------------------------------------------------------------------------------------------------------------------------
Chapter 3
Non-Pending Claims R&S
CPT only copyright 2011 American Medical Association. All rights reserved.
CPT only copyright 2011 American Medical Association. All rights reserved.
01 00 000000000000000 200514 G0929 0000 00003100 00003100 0000000000 0000013700 00002220 00003100 F0239 P 200514 19B 00 0000071269 0000068820 0000000000 0000000000 0000055120 F0238 -------------------------------------------------------------------------------------------------------------------------------------------Client Name: LAST FIRST MI Client/Mcaid No.: 777777777 Trainee SSN: 000000000 Client/Control No.: ICN: 123451234567891 Svc Group: 3 Mcaid Days %: 0000 Mcare Days %:0000 Private Days %:0000 Warr/DD No 1:1234567 Warr/DD Date 1:200613 Warr Stat 1:D DLN: 01234567891 Warr/DD No 2: Warr/DD Date 2: Warr Stat 2: Transmission ID: Warr/DD No 3: Warr/DD Date 3: Warr Stat 3: Tot Billed:000000071269 Tot App Pay: 000000066820 -------------------------------------------------------------------------------------------------------------------------------------------# Adj Original ICN Svc Dates Bill Cd Proc/TID Tng Hrs Billed Units Allowed Uts Allowed AI/Copay Unit Rate Paid Units EOB 1 Status Begin/End Svc Cd Item Cd Lv Days Billed Amount Allowed Amt Billed AI/Copay Budg No. Paid Amt EOB 2 --------------------------------------------------------------------------------------------------------------------------------------------
01 00 000000000000000 200516 G0929 0000 00001900 00001900 0000000000 0000008094 00002299 00001900 F0239 P 200518 19B 00 0000043681 0000043681 0000000000 0000000000 0000035587 F0238 02 00 000000000000000 200523 G0929 0000 00000700 00000700 0000000000 0000002982 00002299 00000700 F0239 P 200525 19B 00 0000016093 0000016093 0000000000 0000000000 0000013111 F0238 -------------------------------------------------------------------------------------------------------------------------------------------Client Name: LAST FIRST MI Client/Mcaid No.: 666666666 Trainee SSN: 000000000 Client/Control No.: ICN: 123456783456789 Svc Group: 3 Mcaid Days %: 0000 Mcare Days %:0000 Private Days %:0000 Warr/DD No 1:1234567 Warr/DD Date 1:200613 Warr Stat 1:D DLN: 01234567891 Warr/DD No 2: Warr/DD Date 2: Warr Stat 2: Transmission ID: Warr/DD No 3: Warr/DD Date 3: Warr Stat 3: Tot Billed:000000071269 Tot App Pay: 000000055120 -------------------------------------------------------------------------------------------------------------------------------------------# Adj Original ICN Svc Dates Bill Cd Proc/TID Tng Hrs Billed Units Allowed Uts Allowed AI/Copay Unit Rate Paid Units EOB 1 Status Begin/End Svc Cd Item Cd Lv Days Billed Amount Allowed Amt Billed AI/Copay Budg No. Paid Amt EOB 2 --------------------------------------------------------------------------------------------------------------------------------------------
01 00 000000000000000 200504 G0929 0000 00003100 00003100 0000000000 0000034954 00002220 00003100 F0239 P 200510 19B 00 0000071269 0000068820 0000000000 0000000000 0000033866 F0238 -------------------------------------------------------------------------------------------------------------------------------------------Client Name: LAST FIRST MI Client/Mcaid No.: 555555555 Trainee SSN: 000000000 Client/Control No.: ICN: 123456789345678 Svc Group: 3 Mcaid Days %: 0000 Mcare Days %:0000 Private Days %:0000 Warr/DD No 1:1234567 Warr/DD Date 1:200613 Warr Stat 1:D DLN: 01234567891 Warr/DD No 2: Warr/DD Date 2: Warr Stat 2: Transmission ID: Warr/DD No 3: Warr/DD Date 3: Warr Stat 3: Tot Billed:000000059774 Tot App Pay: 000000048698 -------------------------------------------------------------------------------------------------------------------------------------------# Adj Original ICN Svc Dates Bill Cd Proc/TID Tng Hrs Billed Units Allowed Uts Allowed AI/Copay Unit Rate Paid Units EOB 1 Status Begin/End Svc Cd Item Cd Lv Days Billed Amount Allowed Amt Billed AI/Copay Budg No. Paid Amt EOB 2 --------------------------------------------------------------------------------------------------------------------------------------------
Page N-2 TMHP Remittance & Status Report Report Date: 200620 PIN: Non-Pending Claims Provider Number: 001234567 Status Begin/End Svc Cd Item Cd Lv Days Billed Amount Allowed Amt Billed AI/Copay Budg No. Paid Amt EOB 2 --------------------------------------------------------------------------------------------------------------------------------------------
Remittance and Status (R&S) Report
Non-Pending Claims R&S Continued
3
3–11
3–12 Warrant/Direct Deposit Date 200613
0000000000.00 0000000000.00
0000003306.51
Warrant/Direct Deposit Number 1234567
Provider Total Deduction(s)
Provider Monthly Deduction(s)
Total Paid Amount For This R&S (Non-Pending Only)
Warrant Information for this Report
0000000000.00
0000000000.00
0000000000.00
0000000000.00
Administrative Payment(s)
Total Withheld To Date
Total Amount
Type of Financial Action
TMHP Remittance and Status Report Financial Summary
0000003306.51
Total Amount Paid
0000000000.00
0000000000.00
0000000000.00
D
Warrant Status
Total Withheld This R&S
Chapter 3
Financial Summary R&S
CPT only copyright 2011 American Medical Association. All rights reserved.
TMHP Remittance and Status Report EOB Codes and Descriptions
CPT only copyright 2011 American Medical Association. All rights reserved.
Claim line item paid amount differs from claim line item billed amount This line item is approved to pay S
F0239 F0238
Report Date: 200620 Provider Number: 001234567
To submit a paper adjustment request to a paid or denied claim or one of its line items, complete LTC Claim Form #1290 The claim form should be filled out containing the claim or lines to be adjusted. For more information, refer to the LTC Claims User Manual, Chapter 3, Paper Adjustment Requests.
PAPER SUBMISSION INSTRUCTIONS FOR ADJUSTMENT REQUESTS
To submit an electronic adjustment request to a paid or denied claim, or one of its line items, refer to the TexMedConnect help file, Adjustment Requests.
ELECTRONIC SUBMISSION INSTRUCTIONS FOR ADJUSTMENT REQUESTS
DESCRIPTION
EOB CODE
THE FOLLOWING IS A DESCRIPTION OF THE EXPLANATION (EOB) CODES USED ON THIS PAGE:
Page 1 PIN:
Remittance and Status (R&S) Report
EOB Page R&S
3
3–13
Appendix
A
Commonly Asked Questions
Contracts What is a contract number? It is the nine-digit contract number assigned by the Texas Department of Aging and Disability Services (DADS). Call the individual’s contract manager for questions about contract numbers. What is a National Provider Identifier (NPI) number? The NPI is the standard unique health identifier for health-care providers. On standard transactions, it will replace the use of all legacy provider identifiers, such as the Universal Provider Identifier Number (UPIN), Medicaid Provider Number, Medicare Provider Number, and Blue Cross and Blue Shield numbers. Where can I obtain an NPI number? Directions about how to apply for an NPI are available on the Centers for Medicare & Medicaid Services (CMS) website at https://nppes.cms.hhs.gov/NPPES. How do providers determine if a budget number is needed to submit a claim? The contract manager can provide this information. Block Grant services, such as family care, emergency response services (ERS), and meals, require budget numbers.
Medicaid Eligibility Where can the individual’s client/Medicaid number be located? Every individual is assigned a unique identification number upon qualifying for services. Providers should ask the individual for the number or contact the case manager to obtain the number. How often is the Medicaid Eligibility File updated? The Medicaid eligibility file is updated by DADS and sent to the Texas Medicaid & Healthcare Partnership (TMHP) every business day.
Billing/Payment If a provider has a billing problem, what is the first step in resolving the billing problem? The first step is to request a Medicaid Eligibility Service Authorization Verification (MESAV) inquiry by calling TMHP at 1-800-626-4117, Option 1. When should a provider contact TMHP? Providers should contact TMHP for the following reasons: • When the reason for a claim denial is unknown • To get an explanation of benefits (EOB) • To find out how to correct an error • To get assistance with using the Long Term Care (LTC) Bill Code Crosswalk When should providers call their caseworker about a billing problem? Community Services providers should call their caseworkers about a billing problem when: • The MESAV inquiry indicates there are not enough authorized units. • Services have not been added to the authorization. • There is a gap in the service authorization. • Changes need to be made to the service authorization.
CPT only copyright 2011 American Medical Association. All rights reserved.
A
Appendix A
Nursing Facility and Hospice providers should call their Medicaid for the Elderly and People with Disabilities (MEPD) advisor, financial worker, or the Integrated Eligibility Enrollment (IEE) Customer Care Center (2-1-1) about a problem when: • The MESAV inquiry indicates that the applied income is incorrect. • The MESAV inquiry indicates that the individual does not show financial eligibility for the services being requested. • The MESAV does not show the proper name, birth date, or address location. How do providers bill for nurses aid training (NAT)? Before a nursing facility (NF) can bill for NAT classes/testing, the NF must contact TMHP and confirm that a Service Code 6 (NAT) record and a rate record are included in their contract. This ensures NAT claims are not denied when submitted to TMHP for payment. If the service or rate records are not included in the provider’s contract, the agency must contact the NF Contract Services Specialist at (512) 438-2546 or (512) 438-2547 to add the missing records. What methods are available for providers to check claim status and verify whether reimbursement has been received for a previously filed claim? Providers should contact the TMHP Call Center/Help Desk at 1-800-626-4117, Option 1, to determine whether payment has been made. How do providers determine which service group/billing code to use? Refer to Appendix C, “Service Groups” on page C-1 for a list of service groups/billing codes. If the service group/billing code is unknown, the TMHP Call Center/Help Desk or the DADS contract manager can provide this information. How soon after a Remittance and Status (R&S) Report is downloaded can a provider expect payment? Warrants or direct deposits are issued by the State Comptroller’s Office. The issuance of warrants does not correspond with the R&S Report distribution. Claims finalized that show a paid status on the R&S Report either already have been issued a warrant or direct deposit, or will be issued a warrant or direct deposit. Why are modifiers 1 and 2 not included in the LTC Bill Code Crosswalk? Modifiers 1 and 2 are used to provide contract-specific information, such as service group and budget number. Refer to Chapter 2, “Section C—Line Item Information” on page 2-5 and “Block 34—Modifiers” on page 2-6 to determine if an entry is required in Modifier fields 1 and 2.
Applied Income How do providers verify the applied income or copayment amount for an individual? Contact the TMHP Call Center/Help Desk at 1-800-626-4117 or in Austin at (512) 335-4729, Option 1. How is the amount of applied income for a nursing facility resident calculated? Applied Income equals the total amount due to the provider for the service minus the amount to be paid by the DADS Program. Applied income is the amount to be paid by the resident. • Multiply the unit rate by the number of days in the month. This equals the monthly rate. • Subtract the applied income from the monthly rate and divide by the number of days in the month. This equals the adjusted daily rate. • Multiply the adjusted daily rate by the number of units to be billed. This equals the paid amount. • Multiply the unit rate by the number of units to be billed. This equals the billed amount.
Electronic Billing Is electronic billing mandatory? Electronic billing is mandatory only for Intermediate Care Facility (ICF) providers. Electronic billing is recommended for all other providers. How do providers enroll in electronic billing? Contact the TMHP Call Center/Help Desk at 1-800-626-4117, Option 3, to enroll for electronic billing.
A–2
CPT only copyright 2011 American Medical Association. All rights reserved.
Appendix
B
LTC Bill Code Crosswalk
How to Use the LTC Bill Code Crosswalk The most current version of the Long Term Care (LTC) Bill Code Crosswalk can be found on the DADS website at www.dads.state.tx.us/providers/hipaa/billcodes/. The LTC Bill Code Crosswalk table provides the service group, service code, and procedure codes providers must use when submitting claims. The provider’s contract and Medicaid Eligibility Service Authorization Verification (MESAV) inquiry information lists authorized service codes and service groups. The tips below should be helpful when using the LTC Bill Code Crosswalk table. Find the service group and service code on the crosswalk and follow the line across. If appropriate, find the bill code used to bill past services. Providers are to enter the bill code in the Procedure/Item Code field if there is a "ER" qualifier in the Procedure Code Qualifier field. Providers will find entries of "HC,""AD," or a blank in the Procedure Code Qualifier field and information in the Healthcare Common Procedure Coding System (HCPCS), Current Procedural Terminology (CPT), or Revenue Code field when the bill code is referenced to a national code. In some cases, providers will find entries in all three fields; the HCPCS, CPT, and Revenue Code fields. Associated HCPCS, CPT, and/or revenue code in the Procedure/Item Code field of the Form 1290 should be entered. Providers are to use modifiers in the designated fields when completing the detail line for that service. In some cases, Modifier fields 1 and 2 are necessary to provide contract-specific information and are not included in the crosswalk, such as modifiers for service group and budget number. In this case, providers must refer to Chapter 2, “Section C—Line Item Information” on page 2-5 to determine whether a modifier entry is required in the Modifier fields 1 and 2. Unless otherwise noted on the LTC Bill Code Crosswalk, providers should use the "ER" qualifier and the local/bill code for dates of service prior to the Begin Date of the HCPCS/CPT code listed on the crosswalk. The crosswalk contains a field labeled End Date. An entry in this field means that services provided after the end date will not be paid. The crosswalk is updated monthly as needed. The most current version of the crosswalk can be found at the following website: www.dads.state.tx.us/providers/hipaa/billcodes/.
National HCPCS and CPT Code Sets The standard medical data code sets from the HCPCS and CPT are the national cross-referenced code sets used to match or map to the Texas LTC local bill codes. In an effort to standardize transmission of code sets, the Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires the elimination and replacement of all medical service local code sets. However, HIPAA allows for nonmedical, nonhealth care, and atypical services to be exempt from this standard code set requirement. Each state can continue to use its local code designator for atypical services only, such as home modifications. The HCPCS and CPT code sets used in the Bill Code Crosswalk table are downloadable from www.cms.hhs.gov and the Texas Medicaid & Healthcare Partnership (TMHP) procedure code file listed on the TMHP Electronic Data Interchange (EDI) Gateway. The code sets are also available in hard copy from TMHP. Due to copyright limitations, CPT and Current Dental Terminology (CDT-4) code descriptions cannot be published in this manual. Please consult reference manuals published or authorized by the American Medical Association (AMA) or the American Dental Association (ADA) for complete code descriptions.
CPT only copyright 2011 American Medical Association. All rights reserved.
B
Appendix
C
Service Groups
The following table contains service groups and descriptions:
Service Group
Description
1
Nursing facility
2
Community Living Assistance and Support Services (CLASS)
3
Community-Based Alternatives (CBA)
4
State Supported Living Center
5
ICF-MR community/state
6
ICF-MR non-state
7
Community Care for Aged and Disabled (CCAD)
8
Hospice
9
LTC Support Services
10
Swing beds
11
Program of All-Inclusive Care for the Elderly (PACE)
12
Home and Community-Based Services (HCS)
13
HCS-O (Home and Community-Based Services-Omnibus Budget Reconciliation Act [OBRA]) – no longer applicable (ended 09/01/2003)
14
Local Authorities
15
Texas Home Living Waiver (TxHmL)
16
Deaf Blind Multi-Handicap (DBMD)
17
Consolidated Waiver Program (CWP) - no longer applicable (ended 12/31/2011)
18
Medically Dependent Children Program (MDCP)
19
Managed Care Program (STAR+PLUS)
20
Guardianship Program
CPT only copyright 2011 American Medical Association. All rights reserved.
C
Appendix
D
Service Codes
The following table contains service codes and descriptions:
Service Code
Service Code Description
1
Daily care
1T
Daily care—transitional add-on
3
Extended care facility
3A
Skilled nursing facility (SNF)—part A full Medicare
4
Ventilator(s)
5
Dental
5A
Dental—waiver programs
5AV
Dental treatment—consumer directed services (CDS)
5AW
Integrated health management (ICM)/medical assistance only (MAO)—dental waiver programs
5AY
ICM—dental waiver programs
5B
Dental sedation
6
Nurse aide training
7
Occupational therapy (OT)/assessment
7A
OT—Nursing facility specialized services
7B
CPWC assessments by OT
7V
Occupational therapy—CDS
7VW
CDS/ICM/MAO—occupational therapy
7VY
CDS/ICM/supplemental security income (SSI)—occupational therapy
7W
ICM/MAO—occupational therapy
7Y
ICM—occupational therapy
8
Physical therapy (PT)/assessment
8A
PT—nursing facility specialized services
8B
CPWC assessments by PT
8V
Physical therapy—CDS
CPT only copyright 2011 American Medical Association. All rights reserved.
D
Appendix D
D–2
Service Code
Service Code Description
8VW
CDS/ICM/MAO—physical therapy
8VY
CDS/ICM/SSI—physical therapy
8W
ICM/MAO—physical therapy
8Y
ICM—physical therapy
9
Speech/language/pathology therapy (ST)/assessment
9A
ST—nursing facility specialized services
9V
Speech/language/pathology therapy—CDS
9VW
CDS/ICM/MAO—speech therapy
9VY
CDS/ICM/SSI—speech therapy
9W
ICM/MAO—speech/language/pathology therapy
9Y
ICM—speech/language/pathology therapy
10
Habilitation
10A
Habilitation—delegated nursing
10B
Habilitation—supportive employ/prevocational
10C
Habilitation—day habilitation
10CV
Day habilitation—CDS
10V
CDS—residential habilitation
11
Respite—in-home
11A
Respite—out-of-home
11AV
CDS Respite—out-of-home
11B
Respite—foster care
11BV
CDS—respite adult foster care
11BVW
CDS/ICM/MAO—respite adult foster care
11BVY
CDS/ICM—respite adult foster care
11BW
ICM/MAO—respite foster care
11BY
ICM—respite foster care
11C
Respite—assisted living apartment
11CV
CDS—respite—assisted living apartment
11CVW
CDS/ICM/MAO—respite assisted living apartment
CPT only copyright 2011 American Medical Association. All rights reserved.
Service Codes
Service Code
Service Code Description
11CVY
CDS/ICM—respite assisted living apartment
11CW
ICM/MAO—respite assisted living apartment
11CY
ICM—respite—assisted living apartment
11D
Respite—assisted living residential care apartment
11DV
CDS—respite—assisted living residential care apartments
11DVW
CDS/ICM/MAO—respite assisted living residential care apartment
11DVY
CDS/ICM—respite assisted living residential care apartment
11DW
ICM/MAO— respite assisted living residential care apartment
11DY
ICM respite—assisted living residential care apartment
11E
Respite—assisted living residential care nonapartment
11EV
CDS—respite—assisted living nonapartment
11EVW
CDS/ICM/MAO—respite assisted living residential care nonapartment
11EVY
CDS/ICM—respite assisted living residential care nonapartment
11EW
ICM/MAO—respite assisted living residential care nonapartment
11EY
ICM—respite assisted living residential care nonapartment
11F
Respite—nursing facility
11FA
Respite—nursing facility with 24-hour vent
11FB
Respite—nursing facility with less than 24-hour vent
11FC
Respite—nursing facility with pediatric trach
11FV
CDS—respite—nursing facility
11FVW
CDS/ICM/MAO—respite—nursing facility
11FVY
CDS/ICM—respite—nursing facility
11FW
ICM/MAO—respite—nursing facility
11FY
ICM—respite—nursing facility
11G
Respite—camp
11GV
CDS—respite camp
11H
Respite—day care/licensed child care facility
11HV
CDS—respite—child support services
11J
Respite—licensed special care facility
CPT only copyright 2011 American Medical Association. All rights reserved.
D
D–3
Appendix D
D–4
Service Code
Service Code Description
11K
Respite—intermediate care facility for persons with intellectual disabilities (ICF-MR)
11KV
CDS—respite—ICF-MR
11L
Respite—hospital
11LV
CDS—respite—hospital
11M
Respite—HCSS (registered nurse [RN]/licensed practical/vocational nurse [LVN])
11MS
Specialized respite—HCSS (RN/LVN)
11N
Respite—LVN
11NS
Specialized respite—LVN
11NSV
CDS specialized respite—LVN
11NV
CDS respite—LVN
11O
Daily respite
11OV
Daily respite—CDS
11P
Respite—RN
11PS
Specialized respite—RN
11PSV
CDS specialized respite—RN
11SSV
CDS specialized adjunct—LVN
11TSV
CDS specialized adjunct—RN
11TV
CDS adjunct—RN
11PV
CDS—respite—in-home
11PVW
CDS/ICM/MAO—respite—RN
11PVY
CDS/ICM—respite—in-home
11Q
Respite—personal assistance services (PAS) delegated
11R
Adjunct—PAS HCSS
11RS
Specialized respite—RN
11S
Adjunct—LVN
11SS
Specialized adjunct—HCSS LVN
11T
Adjunct—RN
11TS
Specialized adjunct—RN
CPT only copyright 2011 American Medical Association. All rights reserved.
Service Codes
Service Code
Service Code Description
11U
Adjunct—PAS HCSS
11UV
CDS—adjunct—PAS HCSS
11V
Adjunct—PAS delegated
11W
ICM/MAO—respite—in-home
11X
Hourly respite
11XV
Hourly respite—CDS
11Y
ICM—respite—in-home
11ZV
Medically dependent children program (MDCP)—CDS respite-in-home
12
Case management
12A
Targeted case management comprehensive
12B
Case management—self directed
12C
Targeted case management follow-up
13
Nursing services
13A
Nursing services—LVN
13AV
CDS nursing services—LVN
13AW
ICM/MAO—nursing services—LVN
13AY
ICM—nursing services—LVN
13B
Nursing services—RN
13BV
CDS nursing services—RN
13BW
ICM/MAO—nursing services—RN
13BY
ICM—nursing services—RN
13C
RN—add-on
13CV
CDS—specialized nursing—RN
13CVW
ICM/MAO CDS—specialized nursing—RN
13CVY
ICM/SSI CDS—specialized nursing—RN
13CW
ICM/MAO—specialized nursing—RN
13CY
ICM/SSI—specialized nursing—RN
13D
Specialized nursing—LVN
13DV
CDS—specialized nursing—LVN
CPT only copyright 2011 American Medical Association. All rights reserved.
D
D–5
Appendix D
D–6
Service Code
Service Code Description
13DVW
ICM/MAO CDS—specialized nursing—LVN
13DVY
ICM/SSI CDS—specialized nursing—LVN
13DW
ICM/MAO—specialized nursing—LVN
13DY
ICM/SSI—specialized nursing—LVN
13V
Nursing—CDS
13VW
CDS/ICM/MAO—nursing services
13VY
CDS/ICM/SSI—nursing services
13W
ICM/MAO—nursing services
13Y
ICM—nursing services
14
Psychological services
15
Adaptive aids/durable medical equipment (DME)
15A
Customized power wheelchair (CPWC)
15B
CPWC modifications
15C
CPWC adjustments
15V
Adaptive aids—CDS
15W
ICM/MAO—adaptive aids—DME
15Y
ICM—adaptive aids—DME
16
Home modifications
16V
Minor home modifications—CDS
16W
ICM/MAO—home modifications
16Y
ICM—home modifications
17
PAS
17A
PAS delegated
17B
PAS protective supervision
17C
PAS family care
17CS
PAS—family care service responsibility option
17CV
CDS—PAS family care
17D
Community attendant (CAS)
17DS
CAS—service responsibility option
CPT only copyright 2011 American Medical Association. All rights reserved.
Service Codes
Service Code
Service Code Description
17DV
CDS—CAS
17E
PAS chore
17S
PAS—service responsibility option
17SY
ICM—PAS—SRO
17V
CDS—PAS
17VW
CDS/ICM/MAO—PAS
17VY
CDS/ICM—PAS
17W
ICM/MAO—PAS
17Y
ICM—PAS
18
Adult foster care
18W
ICM/MAO—adult foster care
18Y
ICM—adult foster care
19
Assisted living—apartment
19A
Assisted living—residential care apartment
19AW
ICM/MAO—assisted living—residential care apartment
19AY
ICM—assisted living—residential care apartment
19B
Assisted living—residential care nonapartment
19BW
ICM/MAO—assisted living—residential care nonapartment
19BY
ICM—assisted living—residential care nonapartment
19C
Assisted living—personal care 3
19CW
ICM/MAO—assisted living—personal care
19CY
ICM—assisted living—personal care
19D
Assisted living—emergency care
19E
Assisted living—habilitation 24-hour
19F
Assisted living—habilitation less than 24-hour
19G
Assisted living—family surrogate services
19H
Assisted living—bed hold
19I
Residential care bed hold—nonapartment Title XX
19J
Residential care bed hold—apartment Title XX
CPT only copyright 2011 American Medical Association. All rights reserved.
D
D–7
Appendix D
D–8
Service Code
Service Code Description
19K
Residential care—apartment Title XX
19L
Residential care—nonapartment Title XX
19M
Residential care—emergency care
19N
Residential care—room and board—nonapartment
19O
Residential care—room and board—apartment
19W
ICM/MAO—assisted living—apartment
19Y
ICM—assisted living—apartment
20
Emergency response services (ERS)
20W
ICM/MAO—emergency response services
20Y
ICM—emergency response services
21
Prescriptions
22
Medical supplies
22W
ICM/MAO—medical supplies
22Y
ICM—medical supplies
23
Medicare
24
Tracheostomy cleaning (NF only)
25
Meals
25W
ICM/MAO—home delivered meals
25Y
ICM—home delivered meals
26
In-home family support program (IHFSP)
26A
IHFSP—service subsidy
26B
IHFSP—spenddown
27
Consumer managed personal attendant services (CMPAS)
27A
CMPAS-individual directed services
28
Spec services to persons with disabilities (SSPD)
28A
SSPD—case management
29
Day activity and health services (DAHS)
29A
DAHS—Title XX
29Y
ICM—DAHS
CPT only copyright 2011 American Medical Association. All rights reserved.
Service Codes
Service Code
Service Code Description
30
Physician directed care
31
Nursing facility room and board
32
Medicare pharmacy coinsurance
33
Medicare respite coinsurance
34
Dietary
34V
Dietary—CDS
35
Audiology
35B
Auditory integration/enhancement training
35V
Audiology—CDS
36
Social work
37
Supported employment
37V
Supported employment—CDS
38
Residential support
39
Program for all inclusive care for the elderly (PACE)—dual-eligible
39A
PACE—Medicaid only
39B
PACE—qualified Medicare beneficiary (QMB)
40
Assessment (full, partial, and annual)
40A
Pre-assessment
40AW
ICM/MAO pre-assessment
40AY
ICM pre-assessment
41
Requisition fees—adaptive aids
41A
Requisition fees—medical supplies
41AW
ICM/MAO—requisition fees—medical supplies
41AY
ICM—requisition fees—medical supplies
41B
Requisition fees—minor home modifications
41BW
ICM/MAO—requisition fees—minor home modifications
41BY
ICM—requisition fees—minor home modifications
41C
Specifications—adaptive aids
41CW
ICM/MAO—specification—adaptive aids
CPT only copyright 2011 American Medical Association. All rights reserved.
D
D–9
Appendix D
D–10
Service Code
Service Code Description
41CY
ICM—specification—adaptive aids
41D
Specifications—home modifications
41DW
ICM/MAO—specifications—home modifications
41DY
IMCM—specifications—home modifications
41E
Requisition fees—dental
41EW
ICM/MAO—requisition fees—dental waivers
41EY
ICM—requisition fees—dental waivers
41F
Requisition fee for specialized therapies
41W
ICM/MAO—requisition fees—adaptive aids
41Y
ICM—requisition fees—adaptive aids
42
Specialized therapies
43
Behavior communication specialist
43A
Behavioral support
43AV
Behavioral support—CDS
44
Orientation and mobility
45
Intervenor
45A
Intervenor I
45AV
CDS intervenor I
45B
Intervenor II
45BV
CDS intervenor II
45C
Intervenor III
45CV
CDS intervenor III
45V
CDS—intervenor
46
Mental health and mental retardation (MHMR) night residential support services
47
MHMR supervised living services
48
Transportation
49
Child support services
50
Personal needs allowance
51
Independent advocacy
CPT only copyright 2011 American Medical Association. All rights reserved.
Service Codes
Service Code
Service Code Description
52
Community support services
52V
Community support—CDS
53
Transitional assistance services (TAS)
53A
TAS fees
53AW
ICM/MAO—transition assistance services fees
53AY
ICM—transition assistance services fees
53W
ICM/MAO—transition assistance services
53Y
ICM—transition assistance services
54
Employment assistance
54V
Employment assistance—CDS
55
Support family services (SFS)
55A
Continued family support
56
Medicare choice
57CV
CDS FC support consultation
57DV
CDS CAS support consultation
57V
Support consultation—CDS
57VW
CDS/ICM/MAO support consultation
57VY
CDS/ICM support consultation
58
Supported home living
58V
Supported home living—CDS
60
Unlimited prescriptions
63V
CDS monthly administration fee
63VW
CDS/ICM/MAO—monthly administration fee
63VY
CDS/ICM—monthly administration fee
65
Overnight support services
65V
CDS overnight support services
99
Expedited services
CPT only copyright 2011 American Medical Association. All rights reserved.
D
D–11
Appendix
E
E
Modifiers
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 solution chosen for the Department of Aging and Disability Services (DADS) Claims Management System is to recreate the state-defined local codes from the HIPAA-compliant information being sent by the provider and supplemental information found in various subsystems, such as provider and individual. The HIPAA-compliant information may include a revenue code, a Healthcare Common Procedure Coding System (HCPCS) code, HCPCS modifiers, and others, depending on the service. In certain instances, to accurately recreate the bill codes for payment, the use of modifiers is required to define or clarify service group, budget number, service provider type, occupancy, dwelling type, and so on. The following table depicts the modifiers to be used, modifier description, and modifier field placement. It is not possible to show definitively when a modifier will be used, because the circumstances requiring the use of a modifier vary and because the dependencies cannot always be accurately described in a chart. For example, modifier U1 in Field 1 will only be used if the provider contract includes two service groups to designate the service group (program) of the individual who received the services. The most recent version of the Modifier table is located on the DADS–HIPAA website at: www.dads.state.tx.us/providers/hipaa/billcodes/.
Modifier Table Modifier Field No.
Modifier
Modifier Description
1
U1
Service group 1
1
U2
Service group 2
1
U3
Service group 3
1
U4
Service group 4
1
U5
Service group 5
1
U6
Service group 6
1
U7
Service group 7
1
U9
Service group 9
1
UA
Service group 11
1
UB
Service group 16
1
UC
Service group 17
1
UD
Service group 18
2
TG
Complex/high-tech level of care
2
U1
Budget number 1
2
U2
Budget number 2
2
U3
Level/priority 1
CPT only copyright 2011 American Medical Association. All rights reserved.
Appendix E
E–2
Modifier Field No.
Modifier
Modifier Description
2
U4
Level 2
2
U5
Level 3
2
U6
Level 4
2
U7
Level 5
2
U8
Level 6
2
U9
Level 7
2
UA
Level 8
2
UD
TAS—Agency fees
3
AJ
Clinical social worker
3
GN
Services provided by a speech language pathologist
3
GO
Services provided by an occupational therapist
3
GP
Services provided by a physical therapist
3
TD
Registered nurse (RN)
3
TE
Licensed practical/vocational nurse (LPN/LVN)
3
U1
Assisted living/single occupancy
3
U2
Residential care/double occupancy
3
U3
Training
3
U4
Pre-vocational services
3
U5
Activities of daily living
3
U7
Full
3
U8
Partial
4
U1
Apartment
4
U2
Nonapartment
4
U4
Participating provider
4
U5
Non-participating provider
4
UB
CDS—Individual
4
UD
CDS—Agency
CPT only copyright 2011 American Medical Association. All rights reserved.
Appendix
Tooth Identification (TID)
F
The following TID Chart shows the valid TID numbers that can be entered on the claim. Choose the tooth on the graphic that matches the tooth on which the service was performed. The number next to the picture of the tooth is the valid TID that should be entered on the claim. Note: Some dental procedure codes require a TID. Use code 99 for other.
TID Chart
CPT only copyright 2011 American Medical Association. All rights reserved.
F
Appendix
G
Explanation of Benefits
The following table contains explanation of benefits (EOB) codes and descriptions:
EOB Code
Description
F0001
Claim header record ID is an invalid value.
F0002
Test/production flag is missing or invalid.
F0003
Program type is a required field.
F0004
Claim type code is missing.
F0005
Claim header source identifier must be present.
F0006
Claim header source identifier is an invalid value.
F0007
Claim header signature indicator is missing or invalid.
F0008
Claim header endorsement number is an invalid value.
F0009
Detail count must be present.
F0010
Detail count is an invalid value.
F0011
Total claim positive indicator must be present.
F0012
Previous claims indicate more than five consecutive days billed.
F0013
The claim total amount billed is not in a valid format.
F0014
The provider number submitted is not in a valid format.
F0016
Last name must be present in order to process a claim.
F0018
The client/Medicaid number is missing or invalid.
F0021
Medicaid patient days percent positive/negative indicator must be present.
F0022
Medicaid patient days percent positive/negative indicator is not a valid entry.
F0025
Medicaid patient days percent is missing.
F0026
Medicare patient days percent positive/negative indicator must be present.
F0028
Medicare patient days percent positive/negative indicator is not a valid entry.
F0031
The private patient days percent entry is invalid.
F0032
Medicare patient days percent is missing.
F0033
Private patient days percent positive/negative indicator must be present.
CPT only copyright 2011 American Medical Association. All rights reserved.
G
Appendix G
G–2
EOB Code
Description
F0035
Private patient days percent positive/negative indicator is not a valid entry.
F0037
Private patient days percent is missing.
F0040
Trainee social security number is missing or invalid.
F0041
Service group is missing, invalid, inactive, or cannot be determined.
F0042
The payee identification number submitted is invalid.
F0044
Payee identification number must be submitted on claim.
F0045
Claim header adjustment segment indicator is an invalid value.
F0046
Claim header special pay segment indicator is an invalid value.
F0048
Adjustment claims require an original ICN.
F0050
Special pay segment ID is invalid.
F0051
Fund code is a required field.
F0052
PAC code is missing.
F0053
Special pay object code is missing.
F0054
Special pay reason code is missing.
F0055
Special pay type indicator is missing.
F0056
Special pay service code is missing or invalid.
F0057
Special pay agency must be present in order to process a claim.
F0058
Special pay region/division code is missing.
F0059
Special pay appropriation code is missing.
F0060
Special pay begin service date is missing or invalid.
F0061
Special pay end service date is missing or invalid.
F0063
Claim detail segment ID is an invalid value.
F0064
Detail number must be present.
F0065
Claim detail adjustment line reference number is an invalid value.
F0067
Detail number is greater than detail count in header.
F0068
Detail number is an invalid value.
F0069
Detail numbers are not consecutive.
F0070
Line item is missing a service begin date.
F0071
Services cannot be before January 1, 1971.
CPT only copyright 2011 American Medical Association. All rights reserved.
Explanation of Benefits
EOB Code
Description
F0072
The service end date is missing.
F0073
The service begin date must be on or before the service end date.
F0075
The service begin date is not for the same month and year as the service end date.
F0077
Billing code was not submitted or cannot be determined.
F0078
Claim detail training hours positive/negative indicator must be present.
F0080
Training hours must be in a valid format.
F0081
Applied income positive/negative indicator must be present.
F0083
Applied income is not in a valid format.
F0087
Copayment amount is not in a valid format.
F0089
Copayment percent positive/negative indicator must be present.
F0091
Copayment percentage is not in a valid format.
F0092
Units billed positive/negative indicator must be present.
F0094
Number of units billed is missing.
F0095
Units rate positive/negative indicator must be present.
F0097
Unit rate is missing or invalid.
F0098
Claim detail line item total positive/negative indicator must be present.
F0100
Line item total billed must be in a valid format.
F0101
Claim header adjustment segment is missing.
F0102
A claim header adjustment segment exists, claim header adjustment indicator is “N.”
F0106
Claim leave days must be in a valid format.
F0107
The original line item in history is not in an adjustable status.
F0108
The original line item in history is not in an adjustable status.
F0110
Matching history detail not found or not in adjustable status.
F0111
Positive line item contains a negative units billed.
F0112
Claim header contains no details.
F0113
Number of details in claim does not match header count.
F0114
Unable to determine service code from supplied information, verify bill code.
F0115
Unable to determine budget key from supplied information.
G
CPT only copyright 2011 American Medical Association. All rights reserved.
G–3
Appendix G
G–4
EOB Code
Description
F0116
The units billed must be greater than zero.
F0117
Unit rate must be greater than zero.
F0118
Incorrect number of billed units for this service.
F0119
Claims for month following submission must be submitted within last week of month prior to service.
F0121
Late billing—claim must be filed 95 days from the end of the month of service.
F0123
Original ICN is not on file.
F0125
Units billed exceed possible number of units for dates of service.
F0126
Claim line items cannot span current fiscal years.
F0128
Provider is not enrolled to provide CMS services, or invalid provider number entered.
F0131
Provider has been placed on hold.
F0132
Provider is not authorized to perform this service for these service dates, verify billing code.
F0134
Provider authorized to provide services only to clients residing within provider region.
F0138
A valid service authorization for this client for this service on these dates is not available.
F0139
Client/Medicaid number does not match information on file.
F0141
Client ID is a previous reference which is not valid for service dates.
F0142
Client Medicaid eligibility is not currently active or is on hold for dates of service.
F0143
Client last name not on file.
F0145
Client last name matched with former name on file.
F0147
Client’s LOS type and level do not match service group and billing code requirements.
F0148
Provider not authorized to provide services billed for client.
F0150
Client not living in approved nursing facility on service dates.
F0151
Cannot bill for more than five consecutive days for this service.
F0152
Records show that client has received this service for more than five consecutive days.
F0153
Client is eligible for Medicare enrollment. Please bill Medicare first.
F0155
Unable to determine appropriate fund code for service billed, verify Medicaid eligibility.
F0163
Item code billed is not authorized for the service provided.
F0165
This service has already been paid. Please do not file for duplicate services.
F0167
A claim for this procedure for this tooth has already been paid.
CPT only copyright 2011 American Medical Association. All rights reserved.
Explanation of Benefits
EOB Code
Description
F0168
Claim denied because trainee has already completed full training course.
F0169
Claim denied because trainee has not completed the full training course.
F0170
Trainee has already passed a skills test.
F0171
Trainee has not previously passed a skills test.
F0172
Trainee has previously passed a written or oral examination.
F0173
Trainee has previously passed a written or oral examination.
F0174
Claim is for a service group that is mutually exclusive with service group for previous claim.
F0175
Claim is for a service that is mutually exclusive with a service for previous claim with the same service date.
F0177
The budget number is not valid for provider.
F0179
Claim cannot be paid because client is a Managed Care client.
F0184
Provider has submitted a claim for the current month of service for the service code submitted on the claim.
F0185
Claim cannot process due to balance owed by provider to the state.
F0187
No units available from client service authorization.
F0189
Amount of claim exceeds available budget.
F0191
Units billed exceeds allowable units for this client.
F0193
All positive line items must be referenced to a negative line item.
F0194
Adjustment request received past the filing deadline.
F0195
Header adjustment: total paid amount submitted does not match paid amount on history.
F0196
The sum of the Medicaid patient days % and/or Medicare patient days % and/or private patient days % does not equal 100.
F0198
Cannot bill for future service dates or current date.
F0200
Procedure code is missing.
F0201
An item code is required for this service.
F0202
This service requires a tooth ID.
F0203
The client’s eligibility requires a budget number to be submitted.
F0204
The budget number is invalid.
F0205
Medicaid patient days % is greater than 100.0.
CPT only copyright 2011 American Medical Association. All rights reserved.
G
G–5
Appendix G
G–6
EOB Code
Description
F0206
Medicare patient days % is greater than 100.0.
F0207
Private patient days % is greater than 100.0.
F0208
Leave days may not exceed the units billed.
F0214
Provider number is missing or invalid.
F0215
Unable to determine rate key for detail or contract, verify billing code, if correct contact TMHP Help Desk.
F0216
The payee identification number on the claim is not associated with the client/Medicaid number.
F0220
Client/Medicaid number is missing.
F0222
Copayment amount exceeds claim line item amount.
F0223
Amount reduced, billed amount is greater than maximum allowed.
F0224
Applied income amount exceeds claim line item amount.
F0225
Units billed exceeds allowable units for this client.
F0228
Units on claim exceed available budget.
F0229
Rate not found.
F0230
County rate not found.
F0231
Procedure rate not found.
F0232
Amount changed due to difference in copayment.
F0233
Claim has more than 28 details.
F0234
Service is duplicate of another line item on same claim for same or overlapping service dates.
F0235
Positive line item contains a negative units billed.
F0236
Unable to determine appropriate state accounting codes for this claim. TMHP is researching this problem.
F0237
Authorizing agency has changed or is not consistent for dates of service.
F0238
This line item is approved to pay.
F0239
Claim line item paid amount differs from claim line item billed amount.
F0240
Provider has an outstanding sanction.
F0241
Applied income or copay must exist for the dates of service.
F0242
A change to the client’s service authorization has generated a recoupment for services, dates, or units no longer allowed.
CPT only copyright 2011 American Medical Association. All rights reserved.
Explanation of Benefits
EOB Code
Description
F0243
A change in the rate for this service has generated repayment for this line item.
F0244
A change to the providers contract has generated a recoupment for services on dates no longer allowed.
F0245
A change to the clients applied income or copayment has generated a recoupment for services previously billed.
F0246
A change to the units authorized for this client has been submitted by a state auditor.
F0247
The billed tooth ID has been previously billed.
F0248
A repayment for this line item was created to adjust a previous payment due to new updates to claim reference data.
F0249
Unable to determine region/division code for client.
F0250
Late billing—Claim must be filed 12 months from the end of the month of service or 12 months from the end of the eligibility add date.
F0251
NAT claims may only contain one detail line item.
F0252
Incorrect number of training hours for this training course billing code.
F0253
A completed NAT training course has been billed for earlier dates.
F0254
Only one incomplete training course per trainee is allowed for NAT.
F0255
Failed skills test previously paid for this trainee.
F0256
This NAT service has been paid the maximum number of times.
F0257
An incomplete NAT training course has been billed for later dates.
F0258
Amount of claim exceeds available budget.
F0259
Failed oral test previously paid for this trainee.
F0260
Failed written test previously paid for this trainee.
F0261
Incorrect number of training hours for this training course billing code.
F0263
Records show that client has received this service for more than 14 consecutive days.
F0264
Claim is for a billing code that is mutually exclusive with billing code for previous claim.
F0265
This claim is approved to pay.
F0266
Unable to determine appropriate state accounting codes for this claim. TMHP is researching this problem.
F0267
Unable to determine budget number from supplied information.
F0268
A valid service authorization for client for these service dates not available or claim dates cannot overlap more than one service authorization.
F0269
Claim detail is an exact dup of history claim detail.
G
CPT only copyright 2011 American Medical Association. All rights reserved.
G–7
Appendix G
G–8
EOB Code
Description
F0270
Cannot bill a positive line item for a separated alias client ID.
F0271
Client has received this service for more than five units per bill code per month.
F0272
The billed unit rate exceeds the current maximum.
F0273
The billed units count exceeds the current maximum.
F0274
The billed applied income/billed copay amount is in an incorrect format.
F0275
Claim must be filed via a HIPAA-compliant transaction set.
F0276
Procedure qualifier is missing, invalid, or not payable under the CMS LTC Program.
F0277
National Code is missing, invalid, not billable with procedure code qual.
F0278
Claim must be filed with the appropriate HCPCS/CPT or revenue code.
F0279
NPI/API is required.
F0280
NPI/API cannot be associated to Contract Number.
F0281
Contract Number for NPI cannot be determined.
F0282
NPI/API is invalid.
F0283
Referral Number is not numeric.
FO284
Daily units exceed the number of days billed.
F0999
Corresponding negative line item or header denied.
P0001
Researching provider information.
P0002
Searching history for duplicate or mutually exclusive claims.
P0003
Verifying budget information.
P0004
Researching service limitations.
P0005
Verifying billing code.
P0006
Verifying tooth ID.
P0007
Verifying service group.
P0008
Verifying availability of units.
P0009
Searching history for completion of required training/tests.
P0010
Researching client eligibility.
P0011
Researching service authorization.
P0012
Researching provider eligibility.
P0014
Verifying units billed.
CPT only copyright 2011 American Medical Association. All rights reserved.
Explanation of Benefits
EOB Code
Description
P0015
Verifying dates of service.
P0016
Verifying claim submission deadline.
P0017
Verifying fund code.
P0018
Verifying procedure code.
P0019
Verifying item code.
P0021
Researching patient days percent.
P0023
Researching payee identification number.
G
CPT only copyright 2011 American Medical Association. All rights reserved.
G–9
Glossary
Glossary
The following table contains a collection of useful terms and definitions:
Terms
Definition
Adjustment Request
A change to a previously paid claim. Negative detail lines are considered adjustments.
AFC
Adult Foster Care. Services provided in a 24-hour living arrangement with supervision in an adult foster home for individuals who, because of physical, mental, or emotional limitations, are unable to continue functioning independently in their own homes.
ANSI
American National Standards Institute.
API
Atypical Provider Identifier. Any provider delivering atypical services must obtain an API to be included in lieu of the NPI on all claim forms submitted. The API consists of the nine-digit contract number preceded by the letter “D” (e.g., D000001234).
Applied Income
The portion of an individual’s income that must be contributed toward the cost of long-term care.
ASCII
American Standard Code for Information Interchange.
ASCII File
A file containing only letters, numbers, and symbols. An ASCII file is a text file that contains no formatting information except for line feeds and returns.
Atypical
Services that are deemed nonmedical in nature or those services determined by DADS to not have an appropriate national procedure or revenue code. These services will continue to use local bill codes.
Billing Code
The specific service that is submitted on a claim, also referred to as a local code. See also Procedure Code.
Billing Cycle
The period of time between submitting a claim and receiving payment.
Budget Number
A two-digit number indicating the budget to bill against. The second modifier field on paper and electronic claims are used to denote which budget is used (U1=Budget Number 1; U2=Budget Number 2). This item is needed for block grant services. Contact the DADS Contract Manager to determine if a budget number is necessary.
CAS
Claim Adjustment and Service Adjustment. The segment of the R&S Report that provides reasons, amounts, and quantities of any adjustments that the payor made to either the original submitted charge or the units related to the claim or service.
CBA
Community-Based Alternatives Program. A Medicaid waiver program that provides home and community-based services to aged and disabled adults as an alternative to residing in a nursing facility.
CPT only copyright 2011 American Medical Association. All rights reserved.
Glossary
Glossary–2
Terms
Definition
Claim
A request for payment of services from a provider for a single individual that consists of one or more types of services performed for the individual and may span multiple months but cannot span fiscal years.
Claim Type
A code that identifies the category in which a claim falls. Claim Types: 837D, 837I, 837P, NAT, and paper.
CLASS
Community Living Assistance and Support Services Program. A Medicaid waiver program that provides home and community-based services to individuals with related conditions as an alternative to residing in an ICF.
CMPAS
Consumer Managed Personal Attendant Services. Financial intermediary services provided to eligible individuals who supervise or have someone who can supervise their attendant. Individuals are responsible for interviewing, selecting, training, supervising, and releasing their attendants.
CMS
Claims Management System. The system that adjudicates provider claims.
Contract Number
See Provider/Contract Number
Copayment
The assessed dollar amount or percentage that the individual is responsible for contributing toward the cost of care. This amount is applied to the total amount billed for a service.
CPA
Comptroller of Public Accounts.
CPT
Current Procedural Terminology.
CSI
Claims Status Inquiry. A transaction (276) requesting information on the status of a claim previously submitted to the Claims Management System for processing.
DADS
Department of Aging and Disability Services.
DAHS
Day Activity and Health Services. Facilities providing daytime services to individuals residing in the community. Services are designed to address the individual’s physical, mental, medical, and social needs. Services include the provision of nursing and personal care, physical rehabilitation, noon meal and snacks, transportation, social, educational, and recreational activities.
DBMD
Deaf-Blind with Multiple Disabilities Program. A Medicaid waiver program that provides home and community-based services to people who are deaf and blind with multiple disabilities as a cost-effective alternative to residing in an ICF.
Default
A value automatically assigned or an option chosen when no value is specified by the user or assigned by a program statement.
Denied Claim
A claim denied for payment.
Direct Deposit
An electronic transfer of funds from the State Comptroller to reimburse providers and vendors for services provided.
DLN (Claims)
Document Locator Number. Unique number assigned by TMHP to identify each warrant request.
CPT only copyright 2011 American Medical Association. All rights reserved.
Glossary
Terms
Definition
DLN (Forms)
Document Locator Number. Unique number assigned by TMHP to forms submitted through the LTC Online Portal.
DME
Durable Medical Equipment. Equipment (adaptive aids) that withstands repeated use and is primarily and customarily used for medical purposes. Equipment/appliances must be medically necessary in each case; for example, wheelchairs, walkers, canes, crutches, trapeze bars, hospital beds, and bedpans.
ECF
Extended Care Facility.
EDI
Electronic Data Interchange.
Edits
Claims processing checkpoints that verify field validity and compliance with LTC business rules.
EDS
Emergency Dental Services provided to residents residing in nursing facilities.
EOB
Explanation of Benefits. An explanation of the payment or denial of a provider’s claim. The EOB code, which appears on the provider’s R&S Report, also explains the status of pending claims.
ERS
Emergency Response Services. Services provided through an electronic monitoring system and used by functionally impaired adults who live alone or who are socially isolated in the community.
File Acknowledgment
A system-generated response to a third-party software submitter. The acknowledgment indicates the success or failure of a file transmission to the Claims Management System.
Finalized Claim
A claim that has completed processing through the Claims Management System and has a paid or denied status.
Financial Summary
A section within the R&S Report that provides summary information for expedited payments, administrative payments, provider total deductions, provider monthly deductions, and warrant or direct deposits.
HCPCS
Healthcare Common Procedure Coding System.
HDM
Home-Delivered Meals. Nutritious meal(s) delivered to a qualified individual’s home or residence.
HSP
Hospice. Medical, social, and support services for terminally ill individuals, with no known curative treatment options, who have a prognosis of less than six months to live.
ICF
Intermediate Care Facility. Institutional care and treatment for individuals with Intellectual or Developmental Disabilities with an onset date before 18 years of age.
ICN
Internal Control Number. A Claims Management System-assigned number to uniquely identify an accepted claim.
Individual
An individual determined by DADS as eligible for LTC services. The individual may also be referred to as a “consumer.” In the case of a nursing facility, the individual may be referred to as a “resident.”
CPT only copyright 2011 American Medical Association. All rights reserved.
Glossary
Glossary–3
Glossary
Glossary–4
Terms
Definition
Individual Number
The number that DADS uses to track an individual. If the individual becomes eligible for Medicaid, the number becomes their case/Medicaid number. See also, “Medical Care Identification.”
Interactive Transaction
Real-time processing of a transaction taking place while the submitter remains directly or indirectly connected to the processing computer.
Level of Service
The level of effort necessary for a provider to provide service to an individual. The level of service is a factor in determining the payment rate for services to the individual. Level of service includes level of care, level of need, and priority status.
Line Item
A claim line of services performed for an individual within a specified time period. Several line items, each for different services or time periods, may appear on a claim. Also known as a “detail line.”
LOC
Level of Care. Determines an individual’s eligibility for a specific program or service.
LON
Level of Need. The level of effort necessary for a facility to provide service to an individual receiving ICF services. The level of need is a factor in determining the payment rate for services to that individual.
LTC
Long Term Care. Programs provided for aged and disabled individuals through DADS.
LTCMI
Long Term Care Medicaid Information. The LTCMI is completed by nursing facility providers on the TMHP LTC Online Portal as a final step in completion of the MDS assessment for Medicaid payment.
LTC Bill Code Crosswalk
A cross-referenced code set used to match national standard procedure codes (procedure and revenue codes) to the local codes, such as bill codes. Providers must use the information on the LTC Bill Code Crosswalk associated with the bill code that reflects the service provided when submitting claims for LTC services. The LTC Bill Code Crosswalk includes codes necessary when billing for service; for example, revenue codes, procedure code qualifiers, and HCPCS.
MDCP
Medically Dependent Children Program. A Medicaid waiver program that provides a variety of services to support families caring for children who are medically dependent, and to encourage deinstitutionalization of children in nursing facilities.
Medical Care Identification
Provides proof of eligibility for regular Medicaid benefits and an assigned Medicaid number specific to the eligible individual.
MESAV
Medicaid Eligibility Service Authorization Verification. MESAV refers to the information given to an authorized provider when inquiring about a specific individual for a specific date range. This information can include Medicaid eligibility, medical necessity, applied income/copayment, level of service, and service authorization.
MN/LOC
Medical Necessity and Level of Care Assessment. MN/LOC is submitted by community service providers for TMHP to determine medical necessity for individuals in the community.
Modifiers
A two-digit code used to further define a service and assist in determining what to pay during the claims adjudication process.
CPT only copyright 2011 American Medical Association. All rights reserved.
Glossary
Terms
Definition
NAT
Nurse Aide Training. The provision of training and competency evaluation.
NEWS
An electronic message from DADS or TMHP that contains new or updated information about the Claims Management System. These pages can be downloaded from the TMHP EDI Gateway.
NF
Nursing Facilities. Facilities licensed and Medicaid-certified. Eligible residents receive nursing care and appropriate rehabilitative/restorative services under the Title XIX (Medicaid) Long Term Care Program.
NPI
The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered health-care providers.
PAC
Program Activity Code.
PACE
Program of All-Inclusive Care for the Elderly. The provision of communitybased services to frail elderly people who qualify for nursing facility placement. PACE uses a comprehensive care approach providing an array of services for a capitated monthly fee that is below the cost of comparable institutional care.
PAS
Personal Assistance Services. Nontechnical attendant care services provided to eligible persons functionally limited in performing activities of daily living. PAS are provided through the Primary Home Care Program.
Patient Control Number
A user-defined number submitted on the claim to identify individuals. Note: Do not confuse this number with the individual’s case/Medicaid number.
Per Authorization Unit Type
Units approved to equal the cost of the authorized service. This authorization type is associated with the unit rate of one dollar. For example, if a wheelchair costs $500.00, the dollar rate would be 500 units.
PIN
Payee Identification Number. Also referred to as the Comptroller Vendor ID No., Comptroller Payee ID No., and Texas ID No. The 14-digit number assigned by the State Comptroller’s Office to an individual or entity so that the individual or entity can receive funds issued by the State Comptroller’s Office. For Claims Management System purposes, the preferred term is Payee Identification Number (PIN).
POS
Place of Service. Identifies the location, (such as a nursing facility, individual’s home, assisted living/residential care facility, or dentist’s office), where the service, (such as daily care, PAS, ERS, assisted living/ residential care, and dental services) was provided.
Procedure Code
A code that uniquely identifies a procedure, product, or service provided to the individual. Services provided are described by codes. The following are types of procedure codes: • Bill codes (also called local codes)
Glossary
• HCPCS codes • CPT codes • American Dental Association (ADA) codes (also called Current Dental Terminology [CDT] codes)
CPT only copyright 2011 American Medical Association. All rights reserved.
Glossary–5
Glossary
Terms
Definition
Procedure Code Qualifier
Describes the source of the procedure code entered on the paper or electronic claim. There are three types of procedure code qualifiers: • ER—Texas LTC local codes (usually referred to as a bill code) • HC—HCPCS or CPT • AD—American Dental Association codes (or CDT codes)
Glossary–6
Provider
A person, group, or agency that has a contract to provide LTC service(s) to individuals. Examples include: licensed nursing facilities, day activity and health service facilities, home and community support agencies, and others.
Provider/Contract Number
The contract number DADS assigns to the LTC provider when the contract is signed. For Claims Management System purposes, the preferred term is Provider Number.
Provider Support
TMHP Call Center/Help Desk that assists providers with questions about TexMedConnect, the status of claims (electronic and paper), and the process to enroll in electronic claims submission. The TMHP Call Center/ Help Desk answers questions about an individual’s Medicaid eligibility, the consumer’s service authorization, and the provider’s eligibility as they apply to a claim.
R&S Reports
Remittance and Status Reports. A paper report that informs a provider about pending, paid, denied, or adjusted claims.
RC
Residential Care services. The provision of services to eligible individuals who require access to care on a 24-hour basis but do not require daily nursing intervention.
Record
A record is equivalent to a row on a table. For example, a record denotes one individual and all information pertaining to that individual.
Rendering Provider
The person providing a skilled service to an individual.
Rendering Provider Name
The name of the (skilled) person who provided the service to the individual. This item is required if the service (being billed) is a skilled/ professional service and was provided by someone other than the provider agency, for example, a dentist, therapist, or other licensed professional. This dentist, et al., is contracted by an agency to provide service. This does not apply to unskilled/nonprofessional services delivered by the provider agency, such as meals, attendant services, day activities, and health services.
Respite Care
The provision of short-term care or supervision services for qualified individuals to give their caregivers temporary relief.
Revenue Code (Rev Code)
A four-digit standard national code depicting the revenue center for the specific services being billed. Revenue codes are used to classify types of services. In some cases, the revenue code must be used in tandem with HCPCS.
RS
Rehabilitative Services Program. The program that reimburses nursing facilities or therapy providers for physical, occupational, and speech therapy to Medicaid nursing facility consumers. The program requires preauthorization of services.
CPT only copyright 2011 American Medical Association. All rights reserved.
Glossary
Terms
Definition
RUG
Resource Utilization Group. RUG is used to classify relative direct care resource requirements for NF residents and to establish the cost limit for community services consumers in the CBA and MDCP waiver programs and PACE.
Service Authorization
An authorization for an individual to receive a service in a specified period of time from an authorized provider.
Service Code
A code used to denote a specific service or category of service.
Service Group
The LTC Program that provides services to an eligible individual.
SS
Specialized Services. Reimburses nursing facilities or therapy providers for physical, occupational, or speech therapy, and rehabilitation programs provided to Medicaid NF residents identified in the PreAdmission Screening and Annual Resident Review (PASARR) process as having mental illness, intellectual disabilities, or a related condition.
SSPD/SSPD—24
Special Services to Persons with Disabilities or Special Services to Persons with Disabilities—24 hours. The provision of services to assist individuals to live in the community. Services include the provision of 24-hour attendant care services, interpreter services, and adult daycare.
State Supported Living Center
Service Group 4. Formerly ICF State School.
Suspended Claim
A claim that has failed a claims processing edit and is pending further information for resolution.
Swing Beds
Certified nursing facility beds located in a hospital for temporary stays of 30 days or less.
TexMedConnect
A web-based application accessed through www.tmhp.com. TexMedConnect is NPI-compliant and supports Provider Claims Submissions, MESAV Inquiries, Claim Status Inquiries, Electronic Remittance & Status (ER&S) Reports, and adjustment request submissions.
Third-Party Billing Agency
A company authorized by a provider agency to submit claims and perform MESAV inquiries on behalf of the agency.
Third-Party Software
A claims processing application developed by parties other than TMHP according to the Claims Management System standard transaction forms.
Title XVIII Medicare
The provisions of Title 42, United States Code Annotated, Section 1395, including any amendments thereto of the Social Security Act, authorizing health insurance and supplementary medical insurance for the aged and disabled (Medicare).
Title XIX Medicaid
The provisions of Title 42, United States Code Annotated, Sections 13961396g, including any amendments thereto of the Social Security Act, authorizing grants to states for medical assistance programs (Medicaid).
Title XX Federal Grant
Grant benefit for provision of Social Services.
TMHP
Texas Medicaid & Healthcare Partnership.
CPT only copyright 2011 American Medical Association. All rights reserved.
Glossary
Glossary–7
Glossary
Glossary–8
Terms
Definition
TMHP EDI Gateway
The TMHP EDI Gateway contains and provides download capabilities for user guides and updates, the ANSI ASC X12 Provider Specifications manual, banner pages (NEWS), bulletins, and updated reference file information such as explanation of benefits (EOB) codes, service groups, and billing codes.
Transaction
The exchange of information between two parties to carry out financial or administrative activities related to health care.
Unit
The authorized amount of service/units provided to the individual. The units are based on the bill code, not the procedure code.
Unit Rate
The dollar amount applied to each unit being billed for the billing code. The number of units multiplied by the applicable unit rate equals the payment amount.
Unit Type
For LTC, the unit type denotes the class of units for a specific service. Four unit types exist: daily, weekly, monthly, and per authorization. For example, when billing for an individual in a nursing facility, the unit type is daily and the maximum number of units equals the number of days in a given month.
Vendor/Facility Site ID Number
Four-digit number DADS assigns for providers to use to submit forms through the LTC Online Portal.
Waiver Programs
Federally funded programs that provide an array of supportive, community-based services not usually available under Texas Medicaid. The “waiving” of certain Medicaid rules and regulations by the U.S. Centers for Medicare & Medicaid Services allows for these innovative services.
Warrants
Checks or direct deposits issued by the State Comptroller’s Office to providers and vendors for services rendered.
CPT only copyright 2011 American Medical Association. All rights reserved.