2011 long term care user manual - tmhp ltc ug.pdf · the 2011 long term care user manual for paper...

2011 Long Term CareUser Manual

PLACE POSTAGE

HERE

for Paper Claim Submitters

Dear Long Term Care Provider,

The 2011 Long Term Care User Manual for Paper Claim Submitters is published for Long Term Care (LTC) providers who use the LTC Claim Form 1290 to submit paper claims. It provides detailed instructions that must be used as a resource for completing the Form 1290. This manual is published online for LTC providers by the Texas Medicaid & Healthcare Partnership (TMHP).

TMHP is the claims administrator for the Texas Health and Human Services Commission (HHSC), including the Department of Aging and Disability Services (DADS). Under the state claims administrator contract, TMHP operates the Claims Management System (CMS). CMS is used for LTC claims processing in partnership with DADS. CMS is a comprehensive, user-friendly claims processing system for the LTC provider community that supports both electronic and paper submissions.

Providers are encouraged to take advantage of electronic claim billing. The web-based application for electronic filing can provide faster claim processing and payment.

For questions about billing, electronic enrollment, or the user manual, call the TMHP Call Center/Help Desk at 1-800-626-4117.

The Texas Department of Aging and Disability Services and the Texas Medicaid & Healthcare Partnership appreciate your continued support.

Sincerely,

Gordon Taylor, Chief Financial OfficerTexas Department of Aging and Disability Services

1Contents

Chapter 1: Introduction to Claims Management SystemClaims Management System Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-1

Provider Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-2TexMedConnect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-4Advantages of Using TexMedConnect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-4

TexMedConnect Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-5Enrollment for Electronic Submission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-5

Chapter 2: LTC Claim Form 1290Type of Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-1Paper Claims Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-1Submission Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-2

Form Retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-2Detailed Claims Filing Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-3

Claims. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-3Using the LTC Bill Code Crosswalk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-3Required Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-3

Section A—Header Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-3Section B—Complete for Nurse Aide Training (NAT) Only. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-4Section C—Line Item Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-5

Line Item Adjustments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-8Form 1290. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-9

Chapter 3: Remittance and Status (R&S) ReportR&S Report Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-1

PDF R&S Report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-1ANSI 835 R&S Report (only for providers billing ANSI claims) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-2Claim Data Export . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-2

R&S Report Distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-2R&S Report Section Descriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-3

Title Page. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-3Non-Pending Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-3Pending Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-6Financial Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-7EOB Codes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-8R&S Report Examples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-8

Title Page R&S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-9Non-Pending Claims R&S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-10Non-Pending Claims R&S Continued . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-11Financial Summary R&S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-12EOB Page R&S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-13

Appendix A: Commonly Asked Questions

Appendix B: LTC Bill Code CrosswalkHow to Use the LTC Bill Code Crosswalk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-1National HCPCS and CPT Code Sets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-1

Appendix C: Service Groups

Appendix D: Service Codes

Appendix E: ModifiersModifier Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-1

CPT only copyright 2010 American Medical Association. All rights reserved.

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Appendix F: Tooth Identification (TID)TID Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . F-1

Appendix G: Explanation of Benefits

Appendix: Glossary


Copyright Acknowledgements

Use of the AMA’s copyrighted CPT® is allowed in this publication with the following disclosure:

“Current Procedural Terminology (CPT) is copyright 2010 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 © 2009 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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C h a p t e r

1
1Introduction to Claims Management SystemIn this chapter…
Claims Management System Overview

Provider Support

Advantages of Using TexMedConnect

TexMedConnect Requirements

Enrollment for Electronic Submission

Claims Management System OverviewThe 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 Windows®-based software application called TexMedConnect or develop third-party software that meets CMS requirements. TexMedConnect is the software 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)

• Consolidated Waiver Program (CWP)

• Day Activity and Health Services (DAHS)

• Deaf/Blind Multiple Disabilities Program (DBMD Waiver)

• Extended Care Facility (also known as Swing Beds)


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Chapter 1

• Emergency Response Service (ERS)

• Home-Delivered Meals (HDM)

• Hospice

• Intermediate Care Facilities for Persons with Intellectual Disabilities (ICF-MR)

• 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. Providers who use a rotary telephone can remain on the line for assistance. The TMHP Call Center/Help Desk system uses the LTC Provider/Contract number to automatically populate the call center represen-tative’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 3618, 3619, 3071, and 3074.

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): 1-512-335-4729


Introduction to Claims Management System

1

Refer to the following table for a list of telephone options and definitions:

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.

For questions about… Choose…

• General inquiries

• Using TexMedConnect

• Completing Claim Form 1290

• Claim adjustments

• Claim status inquiries

• Claim history

• Claim rejection and denials

• Understanding R&S Reports

• Resource Utilization Group (RUG) levels

• LTC Medicaid Information (LTCMI)

• Minimum Data Set

• Medical Necessity and Level of Care Assessment

• PASARR Instrument

• Form 3618 or 3619

• Forms 3071 and 3074

Option 1: Customer service/general inquiry

• Medical necessity Option 2: To speak with a nurse

• TexMedConnect—Technical issues, obtaining access, user IDs, and passwords

• Modem and telecommuni-cation issues

• American National Standards Institute (ANSI) ASC X12 specifi-cations, testing, and transmission

• Processing provider agreements

• Verifying that system screens are functioning

• Getting EDI assistance from software developers

• EDI and connectivity

Option 3: Technical support

• 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

• Electronic transmission PASARR Instrument

• Current Activity (formerly-Weekly Status Report)

• Minimum Data Set submission problems

• Technical issues

• Transmitting forms

• Interpreting Quality Indicator (QI) Reports

Option 3: Technical support

• New messages (banner) in audio format for paper submitters Option 4: Headlines/topics for paper submitters

• Individual appeals

• Individual fair hearing requests

• Appeal guidelines Option 5: Request fair hearing

• Replay for menu options Option 6: Replay options

CPT only copyright 2010 American Medical Association. All rights reserved. 1–3

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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.

TexMedConnectTexMedConnect 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 TexMedConnectThe 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.


http://www.tmhp.com

Introduction to Claims Management System

1

• Facilitate timely reconciliation of claim information.• Verify claim information for an individual for a requested period.

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.


C h a p t e r

2
2LTC Claim Form 1290In this chapter…
Type of Claims

Paper Claims Process

Submission Guidelines

Detailed Claims Filing Instructions

Using the LTC Bill Code Crosswalk

Type of ClaimsNote: 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 ProcessThe following is a brief summary of the 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 require-ments. 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


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Chapter 2

Submission GuidelinesSubmit 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 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 PartnershipAttention: Long Term Care

PO Box 200105Austin, 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 PartnershipAttention: Long Term Care, MC-B02

12357-B Riata Trace ParkwayAustin, 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 1-512-335-4729 (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 RetentionThe original Form 1290 must be submitted to TMHP. A copy should be retained according to LTC Program contract retention requirements.


http://www.dads.state.tx.us/forms/1290/

LTC Claim Form 1290

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Detailed Claims Filing Instructions

ClaimsClaims 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.

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 quali-fiers, 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 CrosswalkFollow 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 InformationThe 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.


http://www.dads.state.tx.us/providers/hipaa/billcodes/

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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 appli-cable 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.


LTC Claim Form 1290

2

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).

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:

• ZZ—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 “ZZ” 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.


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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-MR). 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.

Example: A Hospice provider billing for a SG 4 MHMR individual (e.g., modifier U4 in SG 04).

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 Field 3 is used only if shown on the crosswalk.

Modifier Field 4 is used only if shown on the crosswalk.

Modifier Service Group

U3 SG 3

U7 SG 7

Modifier Service Group

U4 SG 4

U5 SG 5

Modifier Budget

U1 Budget 1

U2 Budget 2


http://www.dads.state.tx.us/providers/hipaa/billcodes/

LTC Claim Form 1290

2

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:

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:

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

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).

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

Skilled/Professional Service Provided Name of Rendering Provider

Dental services David Davis

Physical therapy Patty Dee

Nursing services Nadine Doe


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Chapter 2

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 AdjustmentsLine 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 appli-cable 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.


LTC Claim Form 1290

2

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C h a p t e r

3
3Remittance and Status (R&S) ReportIn this chapter…
R&S Report Overview

R&S Report Distribution

R&S Report Section Descriptions

R&S Report OverviewRemittance 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:

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 ReportDescription: The R&S Report is in a PDF format and provides financial reconciliation information. The infor-mation 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.

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/adjudi-cation 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 previ-ously paid and/or denied claims


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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 ExportDescription: 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 DistributionAn 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 PageThe 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.


Remittance and Status (R&S) Report

3

The following is a description of the information included in the title page:

Non-Pending ClaimsClaims 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.

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

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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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:

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

Claims Header Information

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 accep-tance 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.

General Information



3

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.

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

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—PaidPZ—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

Claims Header Information


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Pending ClaimsThe 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.

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

Claim Detail Information



3

Financial SummaryThe 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.

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:

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:

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

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


3–8

Chapter 3

EOB CodesAll 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 inter-preted 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 ExamplesThe following pages provide examples of R&S Reports.

Warrant Status The final status of the warrant:H—Comptroller holdM—Warrant mailedC—Warrant canceledD—Direct depositA—Agency holdW—Warrant issued

Warrant Summary Information



3

Title Page R&S

TEXAS DEPARTMENT OF AGING AND DISABLITITY SERVICES

Remittance and Status No.: 020

0620

Report Sequence No. 020

0620

Report From Date: 20

0613

Report To Date: 20

0620

Run Date: 20

0620

Provider Number: 001234567

PIN:

National Provider Number: 000000000000

Mail Original Claim To: Mail All Other Correspondence To:

Texas Medicaid & Healthcare Partnership Texas Medicaid & Healthcare Partnership

PO Box 200105 12357B Riata Trace Parkway

Austin, Texas 78720-0105 Austin, Texas 78727

1-800-626-4117


3–10

Chapter 3

Non-Pending Claims R&S

Page N-1 TMHP Remittance & Status Report Report Date: 20

0620

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 1:20

0613 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

--------------------------------------------------------------------------------------------------------------------------------------------

01 00 000000000000000 20

0501 G0932 0000 00003100 00003100 0000000000 0000048413 00002220 00003100 F0239

P 20

0531 19B 00 0000071269 0000068820 0000000000 0000000000 0000020407 F0238

--------------------------------------------------------------------------------------------------------------------------------------------




0613 Warr Stat 1:D DLN: 01234567891



--------------------------------------------------------------------------------------------------------------------------------------------

# Adj Original ICN Svc Dates Bill Cd Proc/TID Tng Hrs Billed Units Allowed Uts Allowed AI/Copay Unit Rate Paid Units EOB 1


--------------------------------------------------------------------------------------------------------------------------------------------

01 00 000000000000000 20

0501 G0929 0000 00003100 00003100 0000000000 0000029900 00002220 00003100 F0239

P 20

0531 19B 00 0000071269 0000068820 0000000000 0000000000 0000038920 F0238

--------------------------------------------------------------------------------------------------------------------------------------------




0613 Warr Stat 1:D DLN: 01234567891



--------------------------------------------------------------------------------------------------------------------------------------------



--------------------------------------------------------------------------------------------------------------------------------------------

01 00 000000000000000 20

0501 G0930 0000 00003100 00003100 0000000000 0000002000 00002220 00003100 F0239

P 20

0531 19B 00 0000071269 0000068820 0000000000 0000000000 0000066820 F0238

--------------------------------------------------------------------------------------------------------------------------------------------



3

Non-Pending Claims R&S Continued

Page N-2 TMHP Remittance & Status Report Report Date: 20

0620

PIN: Non-Pending Claims Provider Number: 001234567


--------------------------------------------------------------------------------------------------------------------------------------------

01 00 000000000000000 20

0504 G0929 0000 00003100 00003100 0000000000 0000034954 00002220 00003100 F0239

P 20

0510 19B 00 0000071269 0000068820 0000000000 0000000000 0000033866 F0238

--------------------------------------------------------------------------------------------------------------------------------------------




0613 Warr Stat 1:D DLN: 01234567891



--------------------------------------------------------------------------------------------------------------------------------------------



--------------------------------------------------------------------------------------------------------------------------------------------

01 00 000000000000000 20

0516 G0929 0000 00001900 00001900 0000000000 0000008094 00002299 00001900 F0239

P 20

0518 19B 00 0000043681 0000043681 0000000000 0000000000 0000035587 F0238

02 00 000000000000000 20

0523 G0929 0000 00000700 00000700 0000000000 0000002982 00002299 00000700 F0239

P 20

0525 19B 00 0000016093 0000016093 0000000000 0000000000 0000013111 F0238

--------------------------------------------------------------------------------------------------------------------------------------------




0613 Warr Stat 1:D DLN: 01234567891



--------------------------------------------------------------------------------------------------------------------------------------------



--------------------------------------------------------------------------------------------------------------------------------------------

01 00 000000000000000 20

0514 G0929 0000 00003100 00003100 0000000000 0000013700 00002220 00003100 F0239

P 20

0514 19B 00 0000071269 0000068820 0000000000 0000000000 0000055120 F0238

--------------------------------------------------------------------------------------------------------------------------------------------




0613 Warr Stat 1:D DLN: 01234567891



--------------------------------------------------------------------------------------------------------------------------------------------



--------------------------------------------------------------------------------------------------------------------------------------------


3–12

Chapter 3

Financial Summary R&S

TMHP Remittance and Status Report

Financial Summary

Type of Financial Action Total Amount Total Withheld To Date Total Withheld This R&S

Administrative Payment(s) 0000000000.00 0000000000.00 0000000000.00

Provider Total Deduction(s) 0000000000.00 0000000000.00 0000000000.00

Provider Monthly Deduction(s) 0000000000.00 0000000000.00 0000000000.00

Total Paid Amount For This R&S 0000003306.51

(Non-Pending Only)

Warrant Information for this Report Warrant/Direct Deposit Number Warrant/Direct Deposit Date Total Amount Paid Warrant Status

1234567 20

0613 0000003306.51 D



3

EOB Page R&S

Page 1 TMHP Remittance and Status Report Report Date: 20

0620

PIN: EOB Codes and Descriptions Provider Number: 001234567

THE FOLLOWING IS A DESCRIPTION OF THE EXPLANATION (EOB) CODES USED ON THIS PAGE:

EOB CODE DESCRIPTION

F0239 Claim line item paid amount differs from claim line item billed amount

F0238 This line item is approved to pay

ELECTRONIC 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.

PAPER SUBMISSION INSTRUCTIONS FOR ADJUSTMENT REQUESTS

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.


A p p e n d i x

A
ACommonly Asked QuestionsContractsWhat 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 EligibilityWhere 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/PaymentIf 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.


https://nppes.cms.hhs.gov/NPPES

A–2

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 client 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 1-512-438-2546 or 1-512-438-2547 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 IncomeHow 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 1-512-335-4729, 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

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