Chapter Claims Filing Reimbursement, Authorizations, and 4 2007/04_Reimbursement-Auth... · Complete the EFT form, include a deposit slip or canceled check, ... on the claim form

C h a p t e r

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4Reimbursement, Authorizations, and Claims Filing
4.1 Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-34.1.1 Electronic Funds Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-3

4.1.1.1 Using Electronic Funds Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-34.1.1.2 Advantages of EFT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-34.1.1.3 Enrollment Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-4

4.1.2 Texas Medicaid Reimbursement Methodology . . . . . . . . . . . . . . . . . . . . . . . . . 4-44.1.3 Manual Pricing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-54.1.4 Maximum Allowable Fee Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-54.1.5 Physician Services in Hospital Outpatient Setting . . . . . . . . . . . . . . . . . . . . . . . 4-5

4.2 TMHP-CSHCN Services Program Authorization and Prior Authorization Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-5

4.2.1 Definition of Authorization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-64.2.1.1 Services Requiring Authorization by TMHP . . . . . . . . . . . . . . . . . . . . . . . . 4-6

4.2.2 Definition of Prior Authorization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-64.2.2.1 Services Requiring Prior Authorization . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-74.2.2.2 Specialty Team/Center Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-8

4.3 TMHP Claims Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-84.3.1 TMHP Processing Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-84.3.2 Claims Filing Deadlines and Exceptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-9

4.4 Third-Party Resource (TPR) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-104.4.1 Health Maintenance Organization (HMO). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-114.4.2 CSHCN Services Program Eligibility Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-124.4.3 Claims Filing Involving a TPR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-124.4.4 Verbal Denials by a TPR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-124.4.5 Filing Deadlines Involving a TPR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-124.4.6 Blue Cross Blue Shield Nonparticipating Physicians. . . . . . . . . . . . . . . . . . . . . 4-134.4.7 Refunds to TMHP Resulting From Other Insurance. . . . . . . . . . . . . . . . . . . . . . 4-144.4.8 Accident-Related Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-14

4.4.8.1 Accident Resources and Refunds Involving Claims for Accidents . . . . . . . 4-14

4.5 Correction and Resubmission (Appeal) Time Limits . . . . . . . . . . . . . . . . . . . . . . . . . . 4-154.5.1 Claims with Incomplete Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-154.5.2 Authorization and/or Filing Deadline Calendar for 2006 . . . . . . . . . . . . . . . . . . 4-164.5.3 Authorization and/or Filing Deadline Calendar for 2007 . . . . . . . . . . . . . . . . . . 4-17

4.6 Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-184.6.1 Diagnosis Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-184.6.2 Procedure Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-18

4.6.2.1 Healthcare Common Procedure Coding System (HCPCS) . . . . . . . . . . . . 4-184.6.2.2 Level I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-184.6.2.3 Level II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-184.6.2.4 Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-194.6.2.5 Place of Service (POS) Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-19

4.7 Claims Filing Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-194.7.1 Provider Types and Selection of Claim Forms . . . . . . . . . . . . . . . . . . . . . . . . . 4-20

4.7.1.1 CMS-1500 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-20

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4.7.1.2 HCFA-1450 (UB-92) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-204.7.1.3 Dental Claim Filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-204.7.1.4 Electronic Claims Submission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-204.7.1.5 CMS-1500 Online Claims Submission . . . . . . . . . . . . . . . . . . . . . . . . . . 4-214.7.1.6 Dates on Claims. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-214.7.1.7 Span Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-214.7.1.8 Hospital Billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-21


Reimbursement, Authorizations, and Claims Filing

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4.1 ReimbursementCSHCN Services Program reimbursements are available to all providers either by check or electronic funds transfer (EFT). Through EFT, TMHP deposits reimbursements directly into a provider’s bank account.

The CSHCN Services Program reimburses hospitals, physicians, and other suppliers of service. Each section of this manual gives more detail concerning the methods used to reimburse each provider specialty for claims processed by TMHP. The following information is provided as an overview of the CSHCN Services Program reimbursement methodology.

The 78th Texas Legislature, Regular Session, House Bill 1 was the General Appropriations Bill for the 2004–2005 biennium. This bill appropriated money for the support of the judicial, executive, and legis-lative branches of the state government for the period beginning September 1, 2003, and ending August 31, 2005, authorizing and prescribing conditions, limitations, rules, and procedures for allocating and expending the appropriated funds. Specifically, Article II of this bill appropriated money for the support, maintenance, or improvement of designated health and human service agencies.

The 78th Texas Legislature, Regular Session, House Bill 2292 implemented changes in health and human service policy necessary to ensure that Texas continues to serve citizens who are most in need of health and human service assistance and enacted measures that were necessary to deal with a budget crisis. Effective September 1, 2003, by action of the 78th Texas Legislature, for the 2004–2005 biennium, reimbursement for many provider services was reduced by 2.5 percent.

Effective September 1, 2005, by action of the 79th Texas Legislature, for the 2006–2007 biennium, the 2.5 percent reduction continues to apply to many provider services. The reductions apply to Medicaid, Medicaid Managed Care, Family Planning, and the CSHCN Services Program. Some services are excluded from the reimbursement reductions. The exclusions applicable to the CSHCN Services Program are:

• Durable medical equipment (DME) and DME supplies

• Outpatient and inpatient hospital claims

• Hemophilia claims, drug copays, and transportation of remains

4.1.1 Electronic Funds TransferEFT is a method for directly depositing funds into a designated bank account. When providers enroll, TMHP deposits funds from their approved claims directly into their designated bank account. Transac-tions transmitted through EFT contain descriptive information to help providers reconcile their bank accounts.

4.1.1.1 Using Electronic Funds Transfer

As a result of the 76th legislature, House Bill 2085 recommends that all Texas Medicaid service providers receive payment by EFT. All providers are strongly encouraged to participate in EFT. EFT does not require special software, and providers can enroll immediately. To enroll in EFT, complete the “Electronic Funds Transfer (EFT) Information and Authorization Agreement,” located in Appendix B on page B-53. Complete the EFT form, include a deposit slip or canceled check, and mail the items to:

Texas Medicaid & Healthcare PartnershipAttn: Provider Enrollment

PO Box 200795Austin, TX 78720–0765

4.1.1.2 Advantages of EFT

The advantages of EFT are:

• Stop payments are no longer necessary because no paper is involved in the transaction process.

• Payment theft is less likely to occur because the process is handled electronically rather than by paper.

• Deposited funds are available for withdrawal within just a few days after completion of the TMHP financial cycle.

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• Upon deposit, the bank considers the transaction immediately collected. No float is attached to EFT deposits for CSHCN Services Program funds.

• TMHP includes provider and Remittance and Status (R&S) report numbers with each transaction submitted. If the bank’s processing software captures and displays the information, both numbers would appear on the banking statement.

4.1.1.3 Enrollment Procedures

Electronic Funds Transfer can be requested by faxing the following information to 1-512-514-4214:

• EFT Enrollment Form

• Organization name

• Contact name

• Address

• Contact telephone number

• Contact fax number

To enroll for EFT, providers must submit a completed enrollment form to TMHP. A voided check or copy of a deposit slip must be attached to the enrollment form. One form must be filled out for each billing provider identifier, including an original signature of the provider.

TMHP issues a prenotification transaction during the next cycle directly to the provider’s bank account. This transaction serves as a checkpoint to verify EFT is working correctly.

If the bank returns the prenotification without errors, the provider begins to receive EFT transactions with the third cycle following the enrollment form processing. The provider continues to receive paper checks until they begin to receive EFT transactions.

If the provider changes bank accounts, the provider must submit a new EFT Agreement to Provider Enrollment. The prenotification process is repeated and, once completed, the EFT transaction is deposited to the new bank account.

4.1.2 Texas Medicaid Reimbursement Methodology The CSHCN Services Program reimburses physicians based on the Texas Medicaid Reimbursement Methodology (TMRM). This methodology is used to reimburse the following services and tests:

• Physician services

• Services incidental to physician’s services

• Diagnostic tests (other than clinical laboratory)

• Radiology services

TMRM is based on Medicare’s resource-based relative value scale (RBRVS) with Medicaid modifica-tions. Some of the differences include:

• Access-based fee adjustments for specific services.

• A flat fee structure applicable on a statewide basis (there are no geographic or specialty differences in this system).

Providers may determine the CSHCN Services Program payment for a service in one of the following ways:

• Identify the total relative value units (RVUs) (as published in the November 1991 Federal Register) and multiply this number by the TMRM conversion factor ($27.276). For anesthesia conversion factors, refer to Section 17.3.3.4, “Reimbursement,” on page 17-9.

• Contact the TMHP-CSHCN Contact Center at 1-800-568-2413. Callers must provide the provider identifier, date of service, type of service, and the procedure code.

Reimbursement information for provider types and services paid by the Department of State Health Services (DSHS) is available in the CSHCN Provider Manual Part II, which may be obtained at www.dshs.state.tx.us/cshcn or by contacting the CSHCN Services Program at 1-800-252-8023 or 1-512-458-7111, Ext. 3099.



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4.1.3 Manual PricingWhen services are billed that do not have an established TMRM fee or a maximum fee schedule, TMHP-CSHCN Services Program medical staff determines the reimbursement amount by comparing the services to other services requiring a similar amount of skill and resources.

4.1.4 Maximum Allowable Fee SchedulePhysicians/supplier services that are not reimbursed according to TMRM or reasonable charge may be reimbursed according to a maximum fee schedule. Maximum fee schedules are determined by state and/or federal regulations.

4.1.5 Physician Services in Hospital Outpatient SettingSection 104 of Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) requires the CSHCN Services Program and Medicaid to limit reimbursement of physician services furnished in a hospital outpatient setting that are also ordinarily furnished in a physician’s office. The limit for each service is determined by establishing a charge base for each professional service and multiplying the charge base by 0.60. The charge base for a service is the TMRM fee for similar routine services furnished by family physicians in the office.

This provision applies to those procedures performed in the outpatient department of the hospital, such as clinics and emergency situations. When the eligible client is seen in the outpatient department of the hospital in an emergency situation, the condition that created the emergency must be documented on the claim form.

The following services are excluded from this limitation:

• Surgical services that are covered by ambulatory surgical center services

• Anesthesiology and radiology services

• Emergency services provided in a hospital emergency room after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain), such that the absence of immediate medical attention may be reasonably expected to result in one of the following outcomes:

• Serious jeopardy to the patient’s health

• Serious impairment to bodily functions

• Serious dysfunction of any body organ or part

4.2 TMHP-CSHCN Services Program Authorization and Prior Authorization RequirementsAuthorization is a condition for reimbursement. It is not a guarantee of payment. Each provider must be enrolled and eligible, and must verify client eligibility. Any services provided while the client is not eligible, or services provided beyond the limitations of the CSHCN Services Program, are not reimbursed.

TMHP sends notification to the client when an authorization approval, denial, or reduction in requested services letter is sent to his or her provider. Refer to the specific provider sections in this manual for more details on the services that require authorization or prior authorization. Fax transmittal confirma-tions and postal registered mail receipts are not accepted as proof of timely authorization submission.

Authorization and prior authorization requirements may also apply for services reimbursed by DSHS.

Section 2.1.2, “Claims Processed by DSHS-CSHCN Services Program,” on page 2-3 provides a listing of services reimbursed by DSHS.


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4.2.1 Definition of AuthorizationAn authorization is a request submitted to the program, or its designated payment contractor, to provide a service the program ultimately considers for reimbursement. The request must be submitted on a program-approved form and must contain all information necessary for the program to make a determi-nation about coverage. The request may be submitted before the service is provided, but must not be received by the program more than 95 days following the date the service is provided. If the service has already been provided, the authorization form may be attached to the claim, as long as they are received for processing within the authorization (95-day) deadline. Only complete authorization requests may be accepted by the program. No extensions beyond the 95-day initial deadline are given for providers to correct incomplete authorization requests. This 95-day deadline applies to all services requiring autho-rization (not prior authorization), including extensions and emergency situations.

Incomplete authorization requests, or claims for services requiring authorization, but submitted without an attached authorization form and all required documentation, are denied and are reconsidered only when resubmitted and received by the program within the initial 95-day authorization deadline. Requests to extend the deadline beyond 95-days from the date of service are not considered.

Providers must mail or fax written authorization requests, along with all other applicable documentation, to the following address:

Texas Medicaid & Healthcare PartnershipAttn: CSHCN Authorizations, MC-A11

12357-B Riata Trace Parkway, Suite 150Austin, TX 78727

Fax: 1-512-514-4222

4.2.1.1 Services Requiring Authorization by TMHP

Authorization must be requested for the following services:

• Blood pressure devices, in specific instances (see “Blood Pressure Devices,” on page 9-12)

• Botulinum Toxin (Type A and B) requires authorization when provided for diagnoses other than those listed in Chapter 16, “Botulinum Toxin (Type A and Type B),” on page 17-35

• Diapers, liners, pull-ups, and underpads (or any combination of these supplies) require authorization for quantities that exceed 300 per month

• Durable medical equipment (DME) (with the exception of custom, manual, or powered wheelchairs, custom seating systems, and pediatric hospital cribs and tops, which require prior authorization)

• Ambulatory surgeries performed at a freestanding facility or as outpatient hospital day surgeries (not including procedures listed under Section 4.2.2.1, “Services Requiring Prior Authorization,” on page 4-7)

• Hemophilia supplies and blood factor products

• Home health (skilled nursing only) up to 200 hours per calendar year

• Nebulizers in specific instances (see Section 19.4.1, “Nebulizers,” on page 19-4)

• Orthotics and prosthetics

• Outpatient dental surgical procedures

• Outpatient physical, occupational, and speech language pathology therapies

• Prescription shoes

• Therapeutic apheresis

Additional information about authorization requirements is found in the chapters that follow.

4.2.2 Definition of Prior AuthorizationA prior authorization is a request submitted to the program, or its designated payment contractor, to provide a service the program ultimately considers for reimbursement. The request must be submitted on a program-approved form and must contain all information necessary for the program to make a determination regarding coverage. Prior authorization must be obtained before the delivery of the service. However, when the service is provided after hours or on a holiday or weekend, services may be prior authorized when authorization is requested on the next working day. A complete form must be



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received according to these deadlines for prior authorization to be considered. The program does not grant extensions to these deadlines to allow providers to correct and resubmit incomplete prior autho-rization requests.

Holidays that may extend the deadlines in 2007 are:

• January 1, 2007, New Year’s Day

• January 15, 2007, Martin Luther King, Jr. Day

• February 19, 2007, President’s Day

• May 28, 2007, Memorial Day

• July 4, 2007, Independence Day

• September 3, 2007, Labor Day

• October 8, 2006, Columbus Day

• November 22 and 23, 2007, Thanksgiving Holidays

• December 24, 25, and 26, 2007, Christmas Holidays

Incomplete prior authorization requests are denied and are reconsidered only when completed and received before the service is provided.

Note: Prior authorization for inpatient admissions occurring on a Friday, a weekend or holiday may be authorized the next business day following the weekend or holiday when an emergency exists or when the required medical services cannot be delayed due to the timing of the admission. See Section 12.4.1.1, “Initial Inpatient Requests,” on page 12-10 for additional information.

Exception: The prior authorization requirement may be waived if the client’s eligibility had not been determined when the request was received by TMHP. Claims for these services must be received within 95 days of the eligibility add date.

Providers must mail or fax written authorization requests, along with all other applicable documentation, to the following address:

Texas Medicaid & Healthcare PartnershipAttn: CSHCN Authorizations, MC-A11

12357-B Riata Trace Parkway, Suite 150Austin, TX 78727

Fax: 1-512-514-4222

4.2.2.1 Services Requiring Prior Authorization

Prior authorization must be obtained before performing the following services:

• Anterior temporal lobectomies

• Bone marrow/stem cell transplants (initial and one subsequent transplant)

• Cleft/craniofacial surgical procedures

• Cranial molding devices (Dynamic Orthotic Cranioplasty [DOC™] only)

• Custom (manual or powered) wheelchair purchases and custom seating systems

• Home health (skilled nursing) services over 200 hours per calendar year

• Inpatient admissions

• Inpatient admissions extensions

• Inpatient rehabilitation admissions

• More than two nutritional assessments per calendar year

• More than four nutritional counseling sessions per calendar year

• Orthodontia

• Pediatric hospital cribs and tops

• Reduction mammoplasties

• Renal transplants

• Rhizotomies


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• Select dental procedures, including inpatient admissions for dental surgical procedures (see Chapter 8, “Dental”). Providers must obtain prior authorization to perform more than two non-intravenous (IV) conscious sedation services for the same client in a 12 month period

• Ultrasonic nebulizers, in specific instances (see Section 19.4.1, “Nebulizers,” on page 19-4)

• Vaccines/toxoids (when the vaccine is not provided by Texas Vaccines for Children Program)

Note: All inpatient admission/stays, including extensions of any previously authorized inpatient stays, must be prior authorized using the “Prior Authorization Request for Inpatient Hospital Admission” form located in Appendix B on page B-23. All inpatient rehabilitation admissions must be prior authorized using the “Prior Authorization Request for Inpatient Rehabilitation Admission” form located in Appendix B on page B-24. The request may be submitted by the hospital, provided that all required infor-mation indicating inpatient admission is on the request form. Both the facility and the physician/supplier must be enrolled in the CSHCN Services Program for either inpatient or outpatient claims to be considered for payment.

Tip: Photocopy these forms and retain the originals for future use.

Additional information about prior authorization requirements is found in the chapters that follow.

4.2.2.2 Specialty Team/Center Services

In addition to requiring prior authorization, the following services require that physicians and/or facilities be enrolled as specialty team/center providers:

• For stem cell transplant services, the facility must be specialty center-enrolled.

• For cleft/craniofacial surgical procedures, only the physician, dentist, and other professional providers constitute the enrolled specialty team.

If the specialty team/center requirements are not met, all services related to the procedure are denied.

Note: Anesthesiologists and assistant surgeons are not required to be specialty team/center-enrolled. However, when a procedure or admission is denied by the CSHCN Services Program because the primary surgeon or hospital is not appropriately specialty team/center-enrolled, the assistant surgeon(s) claims also are denied. An anesthesiologist may be paid if all enrollment and filing deadlines are met.

For information about specialty team/center provider enrollment, see Section 3.1.8, “Specialty Team/Center Enrollment,” on page 3-3. For more information about authorization and requirements, see Section 17.4, “Authorization and Team/Center Requirements,” on page 17-72.

4.3 TMHP Claims Information

4.3.1 TMHP Processing ProceduresThe provider who performed the service must file an assigned claim and agree to accept the allowable charge as full payment.

Regulations prohibit providers from charging clients or TMHP a fee for completing or filing claim forms. The cost of claims filing is considered a part of the usual and customary charges for services provided to all CSHCN Services Program clients.

Claims filed to the CSHCN Services Program with TMHP are subject to the following procedures:

• TMHP verifies that all required information is present on the claim form.

• The claim is processed using clerical and/or automated procedures. Claims requiring special consid-eration are reviewed by medical professionals.

• All claims from the same provider that are ready for disposition at the end of each week are paid by a single check sent to the provider with an explanation of each payment or denial. This explanation is called the R&S report. If no payment is made to the provider, an R&S report identifying denied or pending claims is sent to the provider. If there is no claim action during that time period, the provider does not receive an R&S report that week.



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4.3.2 Claims Filing Deadlines and ExceptionsFor claims payment to be considered, providers must adhere to the following time limits. Claims received after the following time limits are not payable because the CSHCN Services Program does not provide coverage for late claims:

• When a filing deadline falls on a weekend or holiday, the filing deadline is extended to the next business day following the weekend or holiday. See Section 4.2.2, “Definition of Prior Authorization,” on page 4-6 for a list of recognized holidays in 2007.

• Inpatient claims filed by a hospital must be submitted to TMHP within 95 days from the discharge date. Hospitals may submit interim claims prior to discharge. These claims must be submitted to TMHP within 95 days from the last date of service on the claim.

• Outpatient hospital services must be submitted to TMHP within 95 days from the date of service.

• All other claims must be submitted to TMHP within 95 days from each date of service.

• Claims for services not processed by TMHP that are submitted to TMHP in error, must be received by the DSHS-CSHCN Services Program central office within 95 days of the date on the TMHP R&S report. Refer to Section 1.2.1, “Central Office,” on page 1-3 to obtain the mailing address.

When a service is a benefit of Medicare, Medicaid, and the CSHCN Services Program, and the client is covered by all programs, the claim must be filed with Medicare first, then with Medicaid. If a Medicaid claim is denied or recouped for client ineligibility, the claim must be submitted to the CSHCN Services Program within 95 days from the date of Medicaid disposition. A copy of the disposition must be submitted with the claim.

• When a service is billed to another insurance resource, the filing deadline is 95 days from the date of disposition by the other resource.

• When a service is billed to a third-party resource that has not responded, the filing deadline is 365 days from the date of service. After 110 days have elapsed without a response from the third-party resource, the claim may be submitted to TMHP.

The DSHS manager having responsibility for oversight of the CSHCN Services Program, or his or her designee, considers a provider’s request for an exception to the 95-day claims filing deadline and the 120-day correction and resubmission deadline, if the delay is due to one of the following reasons:

• Damage to or destruction of the provider’s business office or records by a catastrophic event or natural disaster; including, but not limited to fire, flood, or earthquake that substantially interferes with normal business operations of the provider. The request for an exception to the filing deadline must include:

• An affidavit or statement from a person with personal knowledge of the facts detailing the requested exception.

• The cause for the delay.

• Verification that the delay was not caused by neglect, indifference, or lack of diligence of the provider or the provider’s employee or agent.

• Any additional information requested by the program, including independent evidence of insurable loss; medical, accident or death records; a police or fire department report substanti-ating the damage or destruction.

• Damage or destruction of the provider’s business office or records caused by intentional acts of an employee or agent of the provider, only if the employment or agency relationship was terminated and the provider filed criminal charges against the former employee or agent. The request for an exception to the filing deadline must include:




• Any additional information requested by the program, including a police or fire report substanti-ating the damage or destruction caused by the former employee or agent’s criminal activity.


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• Delay or error or constraint imposed by the program in the eligibility determination of a client and/or in claims processing, or delay due to erroneous written information from the program or its designee, or another state agency. The request for an exception to the filing deadline must include:




• Any additional information requested by the program, including written documentation from the program, its designee, or another state agency containing the erroneous information or expla-nation of the delay, error, and/or constraint.

• Delay due to problems with the provider’s electronic claims system or other documented and verifiable problems with claims submission. The request for an exception to the filing deadline must include:




• Any additional information requested by the program, including a written repair statement or invoice; a computer or modem-generated error report indicating attempts to transmit the data failed for reasons outside the control of the provider, or an explanation for the system implemen-tation or other claim submission programs; a detailed, written statement by the person making the repairs or installing the system concerning the relationship and impact of the computer problem or system implementation to delayed claims submission; and the reason alternative billing procedures were not initiated after the problems became known.

The DSHS manager of the unit having responsibility for oversight of the CSHCN Services Program, or his or her designee(s), considers a provider’s request for an exception to claims receipt deadlines due to delays caused by entities other than the provider and the program only if the following criteria are met:

• All claims that are to be considered for the same exception accompany the request (only the claims that are attached are considered).

• The exception request is received by the program within 18 months from the date of service.

• The exception request includes an affidavit or statement from a representative of an original payer, a third-party payer, and/or a person who has personal knowledge of the facts, stating the requested exception, documenting the cause for the delay, and providing verification that the delay was caused by another entity and not the neglect, indifference, or lack of diligence of the provider or the provider’s employee(s) or agent(s).

Send requests for exceptions to claim filing deadlines to:

CSHCN Services ProgramDepartment of State Health Services

Purchased Health Services Unit, MC-19381100 West 49th StreetAustin, TX 78756–3179

Fax: 1-800-441-5133

Note: Correspondence greater than ten pages must be mailed.

4.4 Third-Party Resource (TPR)Federal and state laws require that the CSHCN Services Program use program funds for the payment of most medical services only after all reasonable measures were taken to use a client’s third-party resources.

A TPR is a source of payment (other than payment from the CSHCN Services Program) for medical services. TPR includes payment from any of the following sources:

• Private health insurance



4

• Dental insurance plan

• Health maintenance organization (HMO)

• Home, automobile, or other liability insurance

• Preferred provider organization (PPO)

• Cause of action (lawsuit)

• Medicare

• Health care plans of the United States Department of Defense or the United States Department of Veterans Affairs (also known as TRICARE, CHAMPUS, or CHAMPVA)

• Employee welfare plan

• Union health plan

• Children’s Health Insurance Program (CHIP)

• Prescription drug card

• Vision insurance plan

Even though Medicaid is considered a nonTPR source when the client is eligible for both the CSHCN Services Program and Texas Medicaid Program, Medicaid must be billed before billing the CSHCN Services Program.

If Medicaid denied or recoups a claim for client ineligibility, a copy of the Medicaid R&S report must be submitted with the claim and received at TMHP within 95 days from the date of disposition.

A provider who furnishes services and is participating in the CSHCN Services Program must not refuse to furnish services to an eligible client because of a third party’s potential liability for payment of the services.

Eligible clients must not be held responsible for billed charges in excess of the TPR payment for services covered under the CSHCN Services Program. When the TPR pays less than the program allowable amount for covered services, the provider may submit a claim to TMHP for any additional allowable amount. The program does not reimburse providers for copays or provider discounts deducted from TPR payments.

When the client has other third-party coverage, the CSHCN Services Program may pay the deductible/coinsurance for the client as long as the combination of insurance and program payment does not exceed CSHCN Services Program’s fee schedule in use at the time of service.

Exception: By law, the CSHCN Services Program cannot reimburse for CHIP deductibles or coinsurance.

4.4.1 Health Maintenance Organization (HMO)Important: The CSHCN Services Program does not reimburse providers for client copays.

The CSHCN Services Program considers payment for services specifically excluded or limited by HMOs, but covered by the CSHCN Services Program. An explanation of benefits (EOB) is required from the HMO. Payment of those services must not exceed the CSHCN Services Program’s maximum allowable fees for those services.

The CSHCN Services Program does not provide assistance for:

• Supplement of payment made by HMOs to their providers, unlike other insurance.

• Services that are available through an HMO and were not provided by an HMO approved provider.

• Authorization and payment for services available through an HMO.

• Copayments to providers for services available through an HMO.

Providers may collect copays for CSHCN Services Program clients with private insurance. TMHP-CSHCN Services Program reimburses clients for medication copays only. Clients should contact TMHP-CSHCN at 1-877-888-2350 for additional information.


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4.4.2 CSHCN Services Program Eligibility FormInsurance coverage is indicated by the word Insurance below the date of birth in the CSHCN Services Program Eligibility form’s case number block. Refer to Section 2.3.1, “CSHCN Services Program Eligi-bility Form Sample,” on page 2-9 for a sample copy of the form. The information is obtained at the time of the application and must be verified at the time services are rendered.

4.4.3 Claims Filing Involving a TPRWhen a CSHCN Services Program client has other health insurance, that resource must be billed before billing the program. All claims for clients with other insurance coverage must reference the following information whether or not a copy of the EOB from the insurance company is attached:

• Name of the other insurance resource

• Address of the other insurance resource

• Policy (identification) number and group number

• Policyholder

• Effective date, if available

• Date of disposition by other insurance resource

• Payment or specific denial information

See the “Claims Information” section at the end of each chapter of this manual for more information.

4.4.4 Verbal Denials by a TPROccasionally, providers may call the other insurance resource and receive a verbal denial. In these situations, the provider must indicate the following information in Block 11 of the CMS-1500 claim form:

• Date of the telephone call

• Name and telephone number of the insurance company

• Name of the person with whom they spoke

• Policyholder and group information

• Specific reason for the denial (include client’s type of coverage to enhance the accuracy of claims processing; for example, a policy that covers only inpatient services or only physician services)

If a TPR has not responded or delays payment/denial of a provider’s claim for more than 110 days after the date the claim was billed, the CSHCN Services Program considers the claim for payment. The following information is required:

• The name and address of the TPR

• The date the TPR was billed (used to calculate the filing deadline)

• A statement signed and dated by the provider that no disposition was received from the TPR within 110 days from the date the claim was filed

When a claim is denied by TMHP because of the client’s other coverage, information identifying the TPR appears on the provider’s R&S report. The claim must not be refiled with TMHP until a disposition from the TPR is received or until 110 days have elapsed since the billing of the claim to the TPR with no disposition received. A statement from the client or family member indicating that they no longer have this resource is not sufficient documentation to reprocess the claim.

When a provider is advised by a TPR that benefits were paid to the client, the provider must include that information on the claim with the date and amount of payment made to the client, if available. If a denial was sent to the client, refer to the information in Section 4.4.4, “Verbal Denials by a TPR,” on page 4-12. This information enables TMHP to consider the claim for payment.

4.4.5 Filing Deadlines Involving a TPRAny health insurance, including CHIP or Medicaid, that provides coverage to a CSHCN Services Program eligible client must be utilized before the program can consider the services for reimbursement. Claims must be received by the program or the payment contractor within 95 days of the date of the disposition



4

by the other TPR. If the claim is denied, the provider may submit a claim for consideration to the program. The letter of denial must accompany the claim, or the provider must include the following infor-mation with the claim for consideration:

• Date the claim was filed with the insurance company

• Reason for the denial

• Name and telephone number of the insurance company

• Policy (identification) number

• Name of the policy holder and identification numbers for each policy covering the client

• Name of the insurance company contact who provided the denial information

• Date of the contact with the insurance company

Claims involving a TPR have the following deadlines applied:

• Claims with a valid disposition must be submitted to TMHP within 95 days from the disposition (payment or denial).

• As a courtesy to the provider, if more than 110 days elapsed from the date a claim was filed to the TPR and no response was received, the claim may be submitted to TMHP for consideration of payment. The following information is required:

• The name and address of the TPR

• The date the TPR was billed (used to calculate the filing deadline)

• A statement signed and dated by the provider that no disposition was received from the TPR within 110 days from the date the claim was filed

• In addition to the above, there is a 365-day filing deadline from the date of service. This means that a fully documented claim must be received by TMHP within 365 days of the date of service. However, when a TPR recoups a payment made in error on a claim, and that claim was never submitted to TMHP, the provider must send the claim for special handling to the attention of the Third-Party Resources Unit at TMHP within 95 days of the TPR action, if the 365-day filing period was exceeded.

Texas Medicaid & Healthcare PartnershipThird-Party Resources Unit

PO Box 202948Austin, TX 78720-2948

Claims denied by the TPR on the basis of late filing are not considered for payment by the CSHCN Services Program.

TMHP does not have the authority to waive state or federal mandates, such as filing deadlines.

Note: Providers may request an administrative review of any claim denied by the CSHCN Services Program payment contractor. Refer to Section 6.3, “Administrative Review,” on page 6-5, for more information.

4.4.6 Blue Cross Blue Shield Nonparticipating PhysiciansBlue Cross Blue Shield (BCBS) currently has procedures in place to pay assigned claims directly to nonparticipating providers. A nonparticipating provider is eligible to receive direct reimbursement from BCBS, when assignment is accepted. However, only payment dispositions are sent to the provider. An explanation of benefits regarding denials is sent only to the client.

Be aware that by accepting assignment on a claim when the client also has the CSHCN Services Program coverage, providers are agreeing to accept payment made by insurance carriers and the CSHCN Services Program, when appropriate, as payment in full. The CSHCN Services Program client must not be held liable for any balance related to CSHCN Services Program-covered services.

Physicians who treat CSHCN Services Program clients with BCBS private insurance and who are nonpar-ticipating with BCBS must follow the instructions and procedures as follows:

• Do not provide the CSHCN Services Program client with a bill or anything the client could use as a bill. An informational statement may be given. To avoid confusion, write “Information only” clearly on the copy of the statement.

• Bill BCBS directly, accepting assignment. When payment from BCBS is received, the claim may be filed with TMHP to seek additional payment up to the CSHCN Services Program allowable amount.


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• If no BCBS disposition is received within 110 days from the date the claim was billed to BCBS, file the claim to TMHP-CSHCN Services Program and furnish the following information:

• Indicate “Nonparticipating BCBS.”

• Provide the date BCBS was billed.

• Include a statement signed and dated by the provider that no disposition was received from the TPR within 110 days from the date the claim was billed.

A claim must be filed with TMHP-CSHCN Services Program within 365 days of the date of service.

4.4.7 Refunds to TMHP Resulting From Other InsuranceIf the CSHCN Services Program makes payment for a claim and payment is received from another resource for the same services, TMHP-CSHCN Services Program requires a refund. These refunds must not be held until the end of an accounting year. Providers must accept assignment; therefore, they must accept the CSHCN Services Program payment as payment in full for covered services and must not use payment by another TPR to make up the difference between the amount billed and the CSHCN Services Program’s payment. The provider must refund TMHP the lesser of the amount paid by the TPR or the amount paid by the CSHCN Services Program.

Providers must use the following guidelines to determine the amount to be refunded to TMHP:

• When the CSHCN Services Program pays more than the other resource pays, the amount of the other payment is due as a refund to TMHP. For example:

• When the CSHCN Services Program pays less than the other resource, the amount paid by the program is due as a refund. For example:

4.4.8 Accident-Related ClaimsTMHP monitors all accident claims to determine whether another resource may be liable for the medical expenses of the CSHCN Services Program clients. Providers are requested to ask clients whether the medical services are necessary because of accident-related injuries. If the claim is the result of an accident, providers must enter the appropriate code and date in Block 10 of the CMS-1500 claim form, or Blocks 32ab–35ab on the HCFA-1450 (UB-92) claim form.

If payment is available from a known third party, such as personal injury protection (PIP) automobile insurance, that responsible party must be billed before the CSHCN Services Program. If the third-party payment is substantially delayed due to contested liability or unresolved legal action, a claim may be submitted to TMHP for consideration of payment. TMHP processes the liability-related claim and pursues reimbursement directly from the potentially liable party on a post-payment basis.

The following information must be included on these claims:

• Name and address of the TPR

• Description of the accident including location, date, time, and alleged cause

• Reason for delayed payment by the TPR

4.4.8.1 Accident Resources and Refunds Involving Claims for Accidents

Acting on behalf of the CSHCN Services Program, TMHP has the authority to recover payments from any settlement, court judgment, or other resources awarded to a CSHCN Services Program client. In most cases, TMHP works directly with the attorneys, courts, and insurance companies to seek

Total billed $300

CSHCN Services Program payment $200

Other resource payment $150

Amount to be refunded to TMHP $150

Total billed $300

CSHCN Services Program payment $200

Other resource payment $250

Amount to be refunded to TMHP $200



4

reimbursement for program payments. If a provider receives a portion of a settlement for which the program has made payment, the provider must make a refund to TMHP. Any provider filing a lien for the entire billed amount must contact the Third-Party Resources Unit at TMHP to coordinate program post-payment activities. Providers may contact the TMHP Third-Party Resources Unit by calling 1-800-846-7307.

A provider who receives an attorney’s request for an itemized statement, claim copies, or both, should contact the TMHP Third-Party Resources Unit, if the CSHCN Services Program was billed for any services relating to the request. The provider must furnish TMHP with the client’s name and CSHCN Services Program ID number, dates of service involved, and the name and address of the attorney or casualty insurance company. This information enables TMHP to pursue reimbursement from any settlement.

4.5 Correction and Resubmission (Appeal) Time LimitsAll correction and resubmission (appeals) of denied claims and requests for adjustments on paid claims must be received by TMHP within 120 days from the date of disposition of the claim (the date of the R&S report on which the claim appears).

4.5.1 Claims with Incomplete InformationClaims lacking the information necessary for processing are listed on the R&S report with an EOB code requesting the missing information. Providers must resubmit a signed, completed/corrected claim with a copy of the R&S report on which the claim appears to TMHP within 120 days from the date on the R&S report to be considered for payment. Hospitals are not required to resubmit itemized inpatient charges if those charges were included with the original submission.


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American M

edical Association. All rights reserved.

Chapter 4

4.5.2 Authorization and/or Filing Deadline Calendar for 2006

2/11 (345)2/11 (345)2/11 (345)2/12 (346)2/13 (347)2/14 (348)2/15 (349)2/18 (352)2/18 (352)2/18 (352)2/19 (353)2/20 (354)2/21 (355)2/22 (356)2/27 (361)2/27 (361)2/27 (361)2/27 (361)2/27 (361)2/28 (362)2/29 (363)1/02 (002)1/02 (002)1/02 (002)1/02 (002)1/03 (003)1/04 (004)1/05 (005)1/08 (008)1/08 (008)1/08 (008)1/09 (009)1/10 (010)1/11 (011)1/12 (012)1/16 (016)1/16 (016)1/16 (016)1/16 (016)1/17 (017)1/18 (018)1/19 (019)1/22 (022)1/22 (022)1/22 (022)1/23 (023)1/24 (024)1/25 (025)1/26 (026)1/29 (029)1/29 (029)1/29 (029)1/30 (030)1/31 (031)2/01 (032)2/02 (033)2/05 (036)2/05 (036)2/05 (036)2/06 (037)2/07 (038)2/08 (039)2/09 (040)2/12 (043)2/12 (043)2/12 (043)2/13 (044)2/14 (045)2/15 (046)2/16 (047)2/20 (051)2/20 (051)2/20 (051)2/20 (051)

10/24 (297) 01/29 (029) 02/21 (052)10/25 (298) 01/29 (029) 02/22 (053)10/26 (299) 01/29 (029) 02/23 (054)10/27 (300) 01/30 (030) 02/26 (057)10/28 (301) 01/31 (031) 02/26 (057)10/29 (302) 02/01 (032) 02/26 (057)10/30 (303) 02/02 (033) 02/27 (058)10/31 (304) 02/05 (036) 02/28 (059)11/01 (305) 02/05 (036) 03/01 (060)11/02 (306) 02/05 (036) 03/02 (061)11/03 (307) 02/06 (037) 03/05 (064)11/04 (308) 02/07 (038) 03/05 (064)11/05 (309) 02/08 (039) 03/05 (064)11/06 (310) 02/09 (040) 03/06 (065)11/07 (311) 02/12 (043) 03/07 (066)11/08 (312) 02/12 (043) 03/08 (067)11/09 (313) 02/12 (043) 03/09 (068)11/10 (314) 02/13 (044) 03/12 (071)11/11 (315) 02/14 (045) 03/12 (071)11/12 (316) 02/15 (046) 03/12 (071)11/13 (317) 02/16 (047) 03/13 (072)11/14 (318) 02/20 (051) 03/14 (073)11/15 (319) 02/20 (051) 03/15 (074)11/16 (320) 02/20 (051) 03/16 (075)11/17 (321) 02/20 (051) 03/19 (078)11/18 (322) 02/21 (052) 03/19 (078)11/19 (323) 02/22 (053) 03/19 (078)11/20 (324) 02/23 (054) 03/20 (079)11/21 (325) 02/26 (057) 03/21 (080)11/22 (326) 02/26 (057) 03/22 (081)11/23 (327) 02/26 (057) 03/23 (082)11/24 (328) 02/27 (058) 03/26 (085)11/25 (329) 02/28 (059) 03/26 (085)11/26 (330) 03/01 (060) 03/26 (085)11/27 (331) 03/02 (061) 03/27 (086)11/28 (332) 03/05 (064) 03/28 (087)11/29 (333) 03/05 (064) 03/29 (088)11/30 (334) 03/05 (064) 03/30 (089)12/01 (335) 03/06 (065) 04/02 (092)12/02 (336) 03/07 (066) 04/02 (092)12/03 (337) 03/08 (067) 04/02 (092)12/04 (338) 03/09 (068) 04/03 (093)12/05 (339) 03/12 (071) 04/04 (094)12/06 (340) 03/12 (071) 04/05 (095)12/07 (341) 03/12 (071) 04/06 (096)12/08 (342) 03/13 (072) 04/09 (099)12/09 (343) 03/14 (073) 04/09 (099)12/10 (344) 03/15 (074) 04/09 (099)12/11 (345) 03/16 (075) 04/10 (100)12/12 (346) 03/19 (078) 04/11 (101)12/13 (347) 03/19 (078) 04/12 (102)12/14 (348) 03/19 (078) 04/13 (103)12/15 (349) 03/20 (079) 04/16 (106)12/16 (350) 03/21 (080) 04/16 (106)12/17 (351) 03/22 (081) 04/16 (106)12/18 (352) 03/23 (082) 04/17 (107)12/19 (353) 03/26 (085) 04/18 (108)12/20 (354) 03/26 (085) 04/19 (109)12/21 (355) 03/26 (085) 04/20 (110)12/22 (356) 03/27 (086) 04/23 (113)12/23 (357) 03/28 (087) 04/23 (113)12/24 (358) 03/29 (088) 04/23 (113)12/25 (359) 03/30 (089) 04/24 (114)12/26 (360) 04/02 (092) 04/25 (115)12/27 (361) 04/02 (092) 04/26 (116)12/28 (362) 04/02 (092) 04/27 (117)12/29 (363) 04/03 (093) 04/30 (120)12/30 (364) 04/04 (094) 04/30 (120)12/31 (365) 04/05 (095) 04/30 (120)01/01 (001) 04/06 (096) 05/01 (121)

Date of Service or Disposition 95 Days 120 Days120 Days

01/01 (001) 04/06 (096) 05/01 (121)01/02 (002) 04/07 (097) 05/02 (122)01/03 (003) 04/10 (100) 05/03 (123)01/04 (004) 04/10 (100) 05/04 (124)01/05 (005) 04/10 (100) 05/05 (125)01/06 (006) 04/11 (101) 05/08 (128)01/07 (007) 04/12 (102) 05/08 (128)01/08 (008) 04/13 (103) 05/08 (128)01/09 (009) 04/14 (104) 05/09 (129)01/10 (010) 04/17 (107) 05/10 (130)01/11 (011) 04/17 (107) 05/11 (131)01/12 (012) 04/17 (107) 05/12 (132)01/13 (013) 04/18 (108) 05/15 (135)01/14 (014) 04/19 (109) 05/15 (135)01/15 (015) 04/20 (110) 05/15 (135)01/16 (016) 04/21 (111) 05/16 (136)01/17 (017) 04/24 (114) 05/17 (137)01/18 (018) 04/24 (114) 05/18 (138)01/19 (019) 04/24 (114) 05/19 (139)01/20 (020) 04/25 (115) 05/22 (142)01/21 (021) 04/26 (116) 05/22 (142)01/22 (022) 04/27 (117) 05/22 (142)01/23 (023) 04/28 (118) 05/23 (143)01/24 (024) 05/01 (121) 05/24 (144)01/25 (025) 05/01 (121) 05/25 (145)01/26 (026) 05/01 (121) 05/26 (146)01/27 (027) 05/02 (122) 05/30 (150)01/28 (028) 05/03 (123) 05/30 (150)01/29 (029) 05/04 (124) 05/30 (150)01/30 (030) 05/05 (125) 05/30 (150)01/31 (031) 05/08 (128) 05/31 (151)02/01 (032) 05/08 (128) 06/01 (152)02/02 (033) 05/08 (128) 06/02 (153)02/03 (034) 05/09 (129) 06/05 (156)02/04 (035) 05/10 (130) 06/05 (156)02/05 (036) 05/11 (131) 06/05 (156)02/06 (037) 05/12 (132) 06/06 (157)02/07 (038) 05/15 (135) 06/07 (158)02/08 (039) 05/15 (135) 06/08 (159)02/09 (040) 05/15 (135) 06/09 (160)02/10 (041) 05/16 (136) 06/12 (163)02/11 (042) 05/17 (137) 06/12 (163)02/12 (043) 05/18 (138) 06/12 (163)02/13 (044) 05/19 (139) 06/13 (164)02/14 (045) 05/22 (142) 06/14 (165)02/15 (046) 05/22 (142) 06/15 (166)02/16 (047) 05/22 (142) 06/16 (167)02/17 (048) 05/23 (143) 06/19 (170)02/18 (049) 05/24 (144) 06/19 (170)02/19 (050) 05/25 (145) 06/19 (170)02/20 (051) 05/26 (146) 06/20 (171)02/21 (052) 05/30 (150) 06/21 (172)02/22 (053) 05/30 (150) 06/22 (173)02/23 (054) 05/30 (150) 06/23 (174)02/24 (055) 05/30 (150) 06/26 (177)02/25 (056) 05/31 (151) 06/26 (177)02/26 (057) 06/01 (152) 06/26 (177)02/27 (058) 06/02 (153) 06/27 (178)02/28 (059) 06/05 (156) 06/28 (179)03/01 (060) 06/05 (156) 06/29 (180)03/02 (061) 06/05 (156) 06/30 (181)03/03 (062) 06/06 (157) 07/04 (185)03/04 (063) 06/07 (158) 07/04 (185)03/05 (064) 06/08 (159) 07/04 (185)03/06 (065) 06/09 (160) 07/04 (185)03/07 (066) 06/12 (163) 07/05 (186)03/08 (067) 06/12 (163) 07/06 (187)03/09 (068) 06/12 (163) 07/07 (188)03/10 (069) 06/13 (164) 07/10 (191)03/11 (070) 06/14 (165) 07/10 (191)03/12 (071) 06/15 (166) 07/10 (191)03/13 (072) 06/16 (167) 07/11 (192)03/14 (073) 06/19 (170) 07/12 (193)03/15 (074) 06/19 (170) 07/13 (194)

03/16 (075) 06/19 (170) 07/14 (195)03/17 (076) 06/20 (171) 07/17 (198)03/18 (077) 06/21 (172) 07/17 (198)03/19 (078) 06/22 (173) 07/17 (198)03/20 (079) 06/23 (174) 07/18 (199)03/21 (080) 06/26 (177) 07/19 (200)03/22 (081) 06/26 (177) 07/20 (201)03/23 (082) 06/26 (177) 07/21 (202)03/24 (083) 06/27 (178) 07/24 (205)03/25 (084) 06/28 (179) 07/24 (205)03/26 (085) 06/29 (180) 07/24 (205)03/27 (086) 06/30 (181) 07/25 (206)03/28 (087) 07/03 (184) 07/26 (207)03/29 (088) 07/03 (184) 07/27 (208)03/30 (089) 07/03 (184) 07/28 (209)03/31 (090) 07/05 (186) 07/31 (212)04/01 (091) 07/05 (186) 07/31 (212)04/02 (092) 07/06 (187) 07/31 (212)04/03 (093) 07/07 (188) 08/01 (213)04/04 (094) 07/10 (191) 08/02 (214)04/05 (095) 07/10 (191) 08/03 (215)04/06 (096) 07/10 (191) 08/04 (216)04/07 (097) 07/11 (192) 08/07 (219)04/08 (098) 07/12 (193) 08/07 (219)04/09 (099) 07/13 (194) 08/07 (219)04/10 (100) 07/14 (195) 08/08 (220)04/11 (101) 07/17 (198) 08/09 (221)04/12 (102) 07/17 (198) 08/10 (222)04/13 (103) 07/17 (198) 08/11 (223)04/14 (104) 07/18 (199) 08/14 (226)04/15 (105) 07/19 (200) 08/14 (226)04/16 (106) 07/20 (201) 08/14 (226)04/17 (107) 07/21 (202) 08/15 (227)04/18 (108) 07/24 (205) 08/16 (228)04/19 (109) 07/24 (205) 08/17 (229)04/20 (110) 07/24 (205) 08/18 (230)04/21 (111) 07/25 (206) 08/21 (233)04/22 (112) 07/26 (207) 08/21 (233)04/23 (113) 07/27 (208) 08/21 (233)04/24 (114) 07/28 (209) 08/22 (234)04/25 (115) 07/31 (212) 08/23 (235)04/26 (116) 07/31 (212) 08/24 (236)04/27 (117) 07/31 (212) 08/25 (237)04/28 (118) 08/01 (213) 08/28 (240)04/29 (119) 08/02 (214) 08/28 (240)04/30 (120) 08/03 (215) 08/28 (240)05/01 (121) 08/04 (216) 08/29 (241)05/02 (122) 08/07 (219) 08/30 (242)05/03 (123) 08/07 (219) 08/31 (243)05/04 (124) 08/07 (219) 09/01 (244)05/05 (125) 08/08 (220) 09/05 (248)05/06 (126) 08/09 (221) 09/05 (248)05/07 (127) 08/10 (222) 09/05 (248)05/08 (128) 08/11 (223) 09/05 (248)05/09 (129) 08/14 (226) 09/06 (249)05/10 (130) 08/14 (226) 09/07 (250)05/11 (131) 08/14 (226) 09/08 (251)05/12 (132) 08/15 (227) 09/11 (254)05/13 (133) 08/16 (228) 09/11 (254)05/14 (134) 08/17 (229) 09/11 (254)05/15 (135) 08/18 (230) 09/12 (255)05/16 (136) 08/21 (233) 09/13 (256)05/17 (137) 08/21 (233) 09/14 (257)05/18 (138) 08/21 (233) 09/15 (258)05/19 (139) 08/22 (234) 09/18 (261)05/20 (140) 08/23 (235) 09/18 (261)05/21 (141) 08/24 (236) 09/18 (261)05/22 (142) 08/25 (237) 09/19 (262)05/23 (143) 08/28 (240) 09/20 (263)05/24 (144) 08/28 (240) 09/21 (264)05/25 (145) 08/28 (240) 09/22 (265)05/26 (146) 08/29 (241) 09/25 (268)05/27 (147) 08/30 (242) 09/25 (268)05/28 (148) 08/31 (243) 09/25 (268)

05/29 (149) 09/01 (244) 09/26 (269)05/30 (150) 09/05 (248) 09/27 (270)05/31 (151) 09/05 (248) 09/28 (271)06/01 (152) 09/05 (248) 09/29 (272)06/02 (153) 09/05 (248) 10/02 (275)06/03 (154) 09/06 (249) 10/02 (275)06/04 (155) 09/07 (250) 10/02 (275)06/05 (156) 09/08 (251) 10/03 (276)06/06 (157) 09/11 (254) 10/04 (277)06/07 (158) 09/11 (254) 10/05 (278)06/08 (159) 09/11 (254) 10/06 (279)06/09 (160) 09/12 (255) 10/09 (282)06/10 (161) 09/13 (256) 10/09 (282)06/11 (162) 09/14 (257) 10/09 (282)06/12 (163) 09/15 (258) 10/10 (283)06/13 (164) 09/18 (261) 10/11 (284)06/14 (165) 09/18 (261) 10/12 (285)06/15 (166) 09/18 (261) 10/13 (286)06/16 (167) 09/19 (262) 10/16 (289)06/17 (168) 09/20 (263) 10/16 (289)06/18 (169) 09/21 (264) 10/16 (289)06/19 (170) 09/22 (265) 10/17 (290)06/20 (171) 09/25 (268) 10/18 (291)06/21 (172) 09/25 (268) 10/19 (292)06/22 (173) 09/25 (268) 10/20 (293)06/23 (174) 09/26 (269) 10/23 (296)06/24 (175) 09/27 (270) 10/23 (296)06/25 (176) 09/28 (271) 10/23 (296)06/26 (177) 09/29 (272) 10/24 (297)06/27 (178) 10/02 (275) 10/25 (298)06/28 (179) 10/02 (275) 10/26 (299)06/29 (180) 10/02 (275) 10/27 (300)06/30 (181) 10/03 (276) 10/30 (303)07/01 (182) 10/04 (277) 10/30 (303)07/02 (183) 10/05 (278) 10/30 (303)07/03 (184) 10/06 (279) 10/31 (304)07/04 (185) 10/09 (282) 11/01 (305)07/05 (186) 10/09 (282) 11/02 (306)07/06 (187) 10/09 (282) 11/03 (307)07/07 (188) 10/10 (283) 11/06 (310)07/08 (189) 10/11 (284) 11/06 (310)07/09 (190) 10/12 (285) 11/06 (310)07/10 (191) 10/13 (286) 11/07 (311)07/11 (192) 10/16 (289) 11/08 (312)07/12 (193) 10/16 (289) 11/09 (313)07/13 (194) 10/16 (289) 11/10 (314)07/14 (195) 10/17 (290) 11/13 (317)07/15 (196) 10/18 (291) 11/13 (317)07/16 (197) 10/19 (292) 11/13 (317)07/17 (198) 10/20 (293) 11/14 (318)07/18 (199) 10/23 (296) 11/15 (319)07/19 (200) 10/23 (296) 11/16 (320)07/20 (201) 10/23 (296) 11/17 (321)07/21 (202) 10/24 (297) 11/20 (324)07/22 (203) 10/25 (298) 11/20 (324)07/23 (204) 10/26 (299) 11/20 (324)07/24 (205) 10/27 (300) 11/21 (325)07/25 (206) 10/30 (303) 11/22 (326)07/26 (207) 10/30 (303) 11/27 (331)07/27 (208) 10/30 (303) 11/27 (331)07/28 (209) 10/31 (304) 11/27 (331)07/29 (210) 11/01 (305) 11/27 (331)07/30 (211) 11/02 (306) 11/27 (331)07/31 (212) 11/03 (307) 11/28 (332)08/01 (213) 11/06 (310) 11/29 (333)08/02 (214) 11/06 (310) 11/30 (334)08/03 (215) 11/06 (310) 12/01 (335)08/04 (216) 11/07 (311) 12/04 (338)08/05 (217) 11/08 (312) 12/04 (338)08/06 (218) 11/09 (313) 12/04 (338)08/07 (219) 11/10 (314) 12/05 (339)08/08 (220) 11/13 (317) 12/06 (340)08/09 (221) 11/13 (317) 12/07 (341)08/10 (222) 11/13 (317) 12/08 (342)

08/11 (223) 11/14 (318) 108/12 (224) 11/15 (319) 108/13 (225) 11/16 (320) 108/14 (226) 11/17 (321) 108/15 (227) 11/20 (324) 108/16 (228) 11/20 (324) 108/17 (229) 11/20 (324) 108/18 (230) 11/21 (325) 108/19 (231) 11/22 (326) 108/20 (232) 11/27 (331) 108/21 (233) 11/27 (331) 108/22 (234) 11/27 (331) 108/23 (235) 11/27 (331) 108/24 (236) 11/27 (331) 108/25 (237) 11/28 (332) 108/26 (238) 11/29 (333) 108/27 (239) 11/30 (334) 108/28 (240) 12/01 (335) 108/29 (241) 12/04 (338) 108/30 (242) 12/04 (338) 108/31 (243) 12/04 (338) 109/01 (244) 12/05 (339) 009/02 (245) 12/06 (340) 009/03 (246) 12/07 (341) 009/04 (247) 12/08 (342) 009/05 (248) 12/11 (345) 009/06 (249) 12/11 (345) 009/07 (250) 12/11 (345) 009/08 (251) 12/12 (346) 009/09 (252) 12/13 (347) 009/10 (253) 12/14 (348) 009/11 (254) 12/15 (349) 009/12 (255) 12/18 (352) 009/13 (256) 12/18 (352) 009/14 (257) 12/18 (352) 009/15 (258) 12/19 (353) 009/16 (259) 12/20 (354) 009/17 (260) 12/21 (355) 009/18 (261) 12/22 (356) 009/19 (262) 12/27 (361) 009/20 (263) 12/27 (361) 009/21 (264) 12/27 (361) 009/22 (265) 12/27 (361) 009/23 (266) 12/27 (361) 009/24 (267) 12/28 (362) 009/25 (268) 12/29 (363) 009/26 (269) 01/02 (002) 009/27 (270) 01/02 (002) 009/28 (271) 01/02 (002) 009/29 (272) 01/02 (002) 009/30 (273) 01/03 (003) 010/01 (274) 01/04 (004) 010/02 (275) 01/05 (005) 010/03 (276) 01/08 (008) 010/04 (277) 01/08 (008) 010/05 (278) 01/08 (008) 010/06 (279) 01/09 (009) 010/07 (280) 01/10 (010) 010/08 (281) 01/11 (011) 010/09 (282) 01/12 (012) 010/10 (283) 01/16 (016) 010/11 (284) 01/16 (016) 010/12 (285) 01/16 (016) 010/13 (286) 01/16 (016) 010/14 (287) 01/17 (017) 010/15 (288) 01/18 (018) 010/16 (289) 01/19 (019) 010/17 (290) 01/22 (022) 010/18 (291) 01/22 (022) 010/19 (292) 01/22 (022) 010/20 (293) 01/23 (023) 010/21 (294) 01/24 (024) 010/22 (295) 01/25 (025) 010/23 (296) 01/26 (026) 0

Date of Service or Disposition 95 Days 120 Days



Date of Service or Disposition 95 Days

NOTE: If the 95th or 120th day falls on a weekend or holiday, the fi ling deadline is extended to the next business day.

CPT only copyright 2

005 Am

erican Medical Association. All rights reserved.

4–1

7

Reim

bursement, Authorizations, and C

laims Filing

4

4.

10/24 (297) 01/28 (028) 02/21 (052)10/25 (298) 01/28 (028) 02/22 (053)10/26 (299) 01/29 (029) 02/25 (056)10/27 (300) 01/30 (030) 02/25 (056)10/28 (301) 01/31 (031) 02/25 (056)10/29 (302) 02/01 (032) 02/26 (057)10/30 (303) 02/04 (035) 02/27 (058)10/31 (304) 02/04 (035) 02/28 (059)11/01 (305) 02/04 (035) 02/29 (060)11/02 (306) 02/05 (036) 03/03 (063)11/03 (307) 02/06 (037) 03/03 (063)11/04 (308) 02/07 (038) 03/03 (063)11/05 (309) 02/08 (039) 03/04 (064)11/06 (310) 02/11 (042) 03/05 (065)11/07 (311) 02/11 (042) 03/06 (066)11/08 (312) 02/11 (042) 03/07 (067)11/09 (313) 02/12 (043) 03/10 (070)11/10 (314) 02/13 (044) 03/10 (070)11/11 (315) 02/14 (045) 03/10 (070)11/12 (316) 02/15 (046) 03/11 (071)11/13 (317) 02/19 (050) 03/12 (072)11/14 (318) 02/19 (050) 03/13 (073)11/15 (319) 02/19 (050) 03/14 (074)11/16 (320) 02/19 (050) 03/17 (077)11/17 (321) 02/20 (051) 03/17 (077)11/18 (322) 02/21 (052) 03/17 (077)11/19 (323) 02/22 (053) 03/18 (078)11/20 (324) 02/25 (056) 03/19 (079)11/21 (325) 02/25 (056) 03/20 (080)11/22 (326) 02/25 (056) 03/21 (081)11/23 (327) 02/26 (057) 03/24 (084)11/24 (328) 02/27 (058) 03/24 (084)11/25 (329) 02/28 (059) 03/24 (084)11/26 (330) 02/29 (060) 03/25 (085)11/27 (331) 03/03 (063) 03/26 (086)11/28 (332) 03/03 (063) 03/27 (087)11/29 (333) 03/03 (063) 03/28 (088)11/30 (334) 03/04 (064) 03/31 (091)12/01 (335) 03/05 (065) 03/31 (091)12/02 (336) 03/06 (066) 03/31 (091)12/03 (337) 03/07 (067) 04/01 (092)12/04 (338) 03/10 (070) 04/02 (093)12/05 (339) 03/10 (070) 04/03 (094)12/06 (340) 03/10 (070) 04/04 (095)12/07 (341) 03/11 (071) 04/07 (098)12/08 (342) 03/12 (072) 04/07 (098)12/09 (343) 03/13 (073) 04/07 (098)12/10 (344) 03/14 (074) 04/08 (099)12/11 (345) 03/17 (077) 04/09 (100)12/12 (346) 03/17 (077) 04/10 (101)12/13 (347) 03/17 (077) 04/11 (102)12/14 (348) 03/18 (078) 04/14 (105)12/15 (349) 03/19 (079) 04/14 (105)12/16 (350) 03/20 (080) 04/14 (105)12/17 (351) 03/21 (081) 04/15 (106)12/18 (352) 03/24 (084) 04/16 (107)12/19 (353) 03/24 (084) 04/17 (108)12/20 (354) 03/24 (084) 04/18 (109)12/21 (355) 03/25 (085) 04/21 (112)12/22 (356) 03/26 (086) 04/21 (112)12/23 (357) 03/27 (087) 04/21 (112)12/24 (358) 03/28 (088) 04/22 (113)12/25 (359) 03/31 (091) 04/23 (114)12/26 (360) 03/31 (091) 04/24 (115)12/27 (361) 03/31 (091) 04/25 (116)12/28 (362) 04/01 (092) 04/28 (119)12/29 (363) 04/02 (093) 04/28 (119)12/30 (364) 04/03 (094) 04/28 (119)12/31 (365) 04/04 (095) 04/29 (120)01/01 (001) 04/07 (098) 04/30 (121)


5.3 Authorization and/or Filing Deadline Calendar for 2007

01/01 (001) 04/06 (096) 05/01 (121)01/02 (002) 04/09 (099) 05/02 (122)01/03 (003) 04/09 (099) 05/03 (123)01/04 (004) 04/09 (099) 05/04 (124)01/05 (005) 04/10 (100) 05/07 (127)01/06 (006) 04/11 (101) 05/07 (127)01/07 (007) 04/12 (102) 05/07 (127)01/08 (008) 04/13 (103) 05/08 (128)01/09 (009) 04/16 (106) 05/09 (129)01/10 (010) 04/16 (106) 05/10 (130)01/11 (011) 04/16 (106) 05/11 (131)01/12 (012) 04/17 (107) 05/14 (134)01/13 (013) 04/18 (108) 05/14 (134)01/14 (014) 04/19 (109) 05/14 (134)01/15 (015) 04/20 (110) 05/15 (135)01/16 (016) 04/23 (113) 05/16 (136)01/17 (017) 04/23 (113) 05/17 (137)01/18 (018) 04/23 (113) 05/18 (138)01/19 (019) 04/24 (114) 05/21 (141)01/20 (020) 04/25 (115) 05/21 (141)01/21 (021) 04/26 (116) 05/21 (141)01/22 (022) 04/27 (117) 05/22 (142)01/23 (023) 04/30 (120) 05/23 (143)01/24 (024) 04/30 (120) 05/24 (144)01/25 (025) 04/30 (120) 05/25 (145)01/26 (026) 05/01 (121) 05/29 (149)01/27 (027) 05/02 (122) 05/29 (149)01/28 (028) 05/03 (123) 05/29 (149)01/29 (029) 05/04 (124) 05/29 (149)01/30 (030) 05/07 (127) 05/30 (150)01/31 (031) 05/07 (127) 05/31 (151)02/01 (032) 05/07 (127) 06/01 (152)02/02 (033) 05/08 (128) 06/04 (155)02/03 (034) 05/09 (129) 06/04 (155)02/04 (035) 05/10 (130) 06/04 (155)02/05 (036) 05/11 (131) 06/05 (156)02/06 (037) 05/14 (134) 06/06 (157)02/07 (038) 05/14 (134) 06/07 (158)02/08 (039) 05/14 (134) 06/08 (159)02/09 (040) 05/15 (135) 06/11 (162)02/10 (041) 05/16 (136) 06/11 (162)02/11 (042) 05/17 (137) 06/11 (162)02/12 (043) 05/18 (138) 06/12 (163)02/13 (044) 05/21 (141) 06/13 (164)02/14 (045) 05/21 (141) 06/14 (165)02/15 (046) 05/21 (141) 06/15 (166)02/16 (047) 05/22 (142) 06/18 (169)02/17 (048) 05/23 (143) 06/18 (169)02/18 (049) 05/24 (144) 06/18 (169)02/19 (050) 05/25 (145) 06/19 (170)02/20 (051) 05/29 (149) 06/20 (171)02/21 (052) 05/29 (149) 06/21 (172)02/22 (053) 05/29 (149) 06/22 (173)02/23 (054) 05/29 (149) 06/25 (176)02/24 (055) 05/30 (150) 06/25 (176)02/25 (056) 05/31 (151) 06/25 (176)02/26 (057) 06/01 (152) 06/26 (177)02/27 (058) 06/04 (155) 06/27 (178)02/28 (059) 06/04 (155) 06/28 (179)03/01 (060) 06/04 (155) 06/29 (180)03/02 (061) 06/05 (156) 07/02 (183)03/03 (062) 06/06 (157) 07/02 (183)03/04 (063) 06/07 (158) 07/02 (183)03/05 (064) 06/08 (159) 07/03 (184)03/06 (065) 06/11 (162) 07/05 (186)03/07 (066) 06/11 (162) 07/05 (186)03/08 (067) 06/11 (162) 07/06 (187)03/09 (068) 06/12 (163) 07/09 (190)03/10 (069) 06/13 (164) 07/09 (190)03/11 (070) 06/14 (165) 07/09 (190)03/12 (071) 06/15 (166) 07/10 (191)03/13 (072) 06/18 (169) 07/11 (192)03/14 (073) 06/18 (169) 07/12 (193)03/15 (074) 06/18 (169) 07/13 (194)

03/16 (075) 06/19 (170) 07/16 (197)03/17 (076) 06/20 (171) 07/16 (197)03/18 (077) 06/21 (172) 07/16 (197)03/19 (078) 06/22 (173) 07/17 (198)03/20 (079) 06/25 (176) 07/18 (199)03/21 (080) 06/25 (176) 07/19 (200)03/22 (081) 06/25 (176) 07/20 (201)03/23 (082) 06/26 (177) 07/23 (204)03/24 (083) 06/27 (178) 07/23 (204)03/25 (084) 06/28 (179) 07/23 (204)03/26 (085) 06/29 (180) 07/24 (205)03/27 (086) 07/02 (183) 07/25 (206)03/28 (087) 07/02 (183) 07/26 (207)03/29 (088) 07/02 (183) 07/27 (208)03/30 (089) 07/03 (184) 07/30 (211)03/31 (090) 07/05 (186) 07/30 (211)04/01 (091) 07/05 (186) 07/30 (211)04/02 (092) 07/06 (187) 07/31 (212)04/03 (093) 07/09 (190) 08/01 (213)04/04 (094) 07/09 (190) 08/02 (214)04/05 (095) 07/09 (190) 08/03 (215)04/06 (096) 07/10 (191) 08/06 (218)04/07 (097) 07/11 (192) 08/06 (218)04/08 (098) 07/12 (193) 08/06 (218)04/09 (099) 07/13 (194) 08/07 (219)04/10 (100) 07/16 (197) 08/08 (220)04/11 (101) 07/16 (197) 08/09 (221)04/12 (102) 07/16 (197) 08/10 (222)04/13 (103) 07/17 (198) 08/13 (225)04/14 (104) 07/18 (199) 08/13 (225)04/15 (105) 07/19 (200) 08/13 (225)04/16 (106) 07/20 (201) 08/14 (226)04/17 (107) 07/23 (204) 08/15 (227)04/18 (108) 07/23 (204) 08/16 (228)04/19 (109) 07/23 (204) 08/17 (229)04/20 (110) 07/24 (205) 08/20 (232)04/21 (111) 07/25 (206) 08/20 (232)04/22 (112) 07/26 (207) 08/20 (232)04/23 (113) 07/27 (208) 08/21 (233)04/24 (114) 07/30 (211) 08/22 (234)04/25 (115) 07/30 (211) 08/23 (235)04/26 (116) 07/30 (211) 08/24 (236)04/27 (117) 07/31 (212) 08/27 (239)04/28 (118) 08/01 (213) 08/27 (239)04/29 (119) 08/02 (214) 08/27 (239)04/30 (120) 08/03 (215) 08/28 (240)05/01 (121) 08/06 (218) 08/29 (241)05/02 (122) 08/06 (218) 08/30 (242)05/03 (123) 08/06 (218) 08/31 (243)05/04 (124) 08/07 (219) 09/04 (247)05/05 (125) 08/08 (220) 09/04 (247)05/06 (126) 08/09 (221) 09/04 (247)05/07 (127) 08/10 (222) 09/04 (247)05/08 (128) 08/13 (225) 09/05 (248)05/09 (129) 08/13 (225) 09/06 (249)05/10 (130) 08/13 (225) 09/07 (250)05/11 (131) 08/14 (226) 09/10 (253)05/12 (132) 08/15 (227) 09/10 (253)05/13 (133) 08/16 (228) 09/10 (253)05/14 (134) 08/17 (229) 09/11 (254)05/15 (135) 08/20 (232) 09/12 (255)05/16 (136) 08/20 (232) 09/13 (256)05/17 (137) 08/20 (232) 09/14 (257)05/18 (138) 08/21 (233) 09/17 (260)05/19 (139) 08/22 (234) 09/17 (260)05/20 (140) 08/23 (235) 09/17 (260)05/21 (141) 08/24 (236) 09/18 (261)05/22 (142) 08/27 (239) 09/19 (262)05/23 (143) 08/27 (239) 09/20 (263)05/24 (144) 08/27 (239) 09/21 (264)05/25 (145) 08/28 (240) 09/24 (267)05/26 (146) 08/29 (241) 09/24 (267)05/27 (147) 08/30 (242) 09/24 (267)05/28 (148) 08/31 (243) 09/25 (268)

05/29 (149) 09/04 (247) 09/26 (269)05/30 (150) 09/04 (247) 09/27 (270)05/31 (151) 09/04 (247) 09/28 (271)06/01 (152) 09/04 (247) 10/01 (274)06/02 (153) 09/05 (248) 10/01 (274)06/03 (154) 09/06 (249) 10/01 (274)06/04 (155) 09/07 (250) 10/02 (275)06/05 (156) 09/10 (253) 10/03 (276)06/06 (157) 09/10 (253) 10/04 (277)06/07 (158) 09/10 (253) 10/05 (278)06/08 (159) 09/11 (254) 10/09 (282)06/09 (160) 09/12 (255) 10/09 (282)06/10 (161) 09/13 (256) 10/09 (282)06/11 (162) 09/14 (257) 10/09 (282)06/12 (163) 09/17 (260) 10/10 (283)06/13 (164) 09/17 (260) 10/11 (284)06/14 (165) 09/17 (260) 10/12 (285)06/15 (166) 09/18 (261) 10/15 (288)06/16 (167) 09/19 (262) 10/15 (288)06/17 (168) 09/20 (263) 10/15 (288)06/18 (169) 09/21 (264) 10/16 (289)06/19 (170) 09/24 (267) 10/17 (290)06/20 (171) 09/24 (267) 10/18 (291)06/21 (172) 09/24 (267) 10/19 (292)06/22 (173) 09/25 (268) 10/22 (295)06/23 (174) 09/26 (269) 10/22 (295)06/24 (175) 09/27 (270) 10/22 (295)06/25 (176) 09/28 (271) 10/23 (296)06/26 (177) 10/01 (274) 10/24 (297)06/27 (178) 10/01 (274) 10/25 (298)06/28 (179) 10/01 (274) 10/26 (299)06/29 (180) 10/02 (275) 10/29 (302)06/30 (181) 10/03 (276) 10/29 (302)07/01 (182) 10/04 (277) 10/29 (302)07/02 (183) 10/05 (278) 10/30 (303)07/03 (184) 10/09 (282) 10/31 (304)07/04 (185) 10/09 (282) 11/01 (305)07/05 (186) 10/09 (282) 11/02 (306)07/06 (187) 10/09 (282) 11/05 (309)07/07 (188) 10/10 (283) 11/05 (309)07/08 (189) 10/11 (284) 11/05 (309)07/09 (190) 10/12 (285) 11/06 (310)07/10 (191) 10/15 (288) 11/07 (311)07/11 (192) 10/15 (288) 11/08 (312)07/12 (193) 10/15 (288) 11/09 (313)07/13 (194) 10/16 (289) 11/12 (316)07/14 (195) 10/17 (290) 11/12 (316)07/15 (196) 10/18 (291) 11/12 (316)07/16 (197) 10/19 (292) 11/13 (317)07/17 (198) 10/22 (295) 11/14 (318)07/18 (199) 10/22 (295) 11/15 (319)07/19 (200) 10/22 (295) 11/16 (320)07/20 (201) 10/23 (296) 11/19 (323)07/21 (202) 10/24 (297) 11/19 (323)07/22 (203) 10/25 (298) 11/19 (323)07/23 (204) 10/26 (299) 11/20 (324)07/24 (205) 10/29 (302) 11/21 (325)07/25 (206) 10/29 (302) 11/26 (330)07/26 (207) 10/29 (302) 11/26 (330)07/27 (208) 10/30 (303) 11/26 (330)07/28 (209) 10/31 (304) 11/26 (330)07/29 (210) 11/01 (305) 11/26 (330)07/30 (211) 11/02 (306) 11/27 (331)07/31 (212) 11/05 (309) 11/28 (332)08/01 (213) 11/05 (309) 11/29 (333)08/02 (214) 11/05 (309) 11/30 (334)08/03 (215) 11/06 (310) 12/03 (337)08/04 (216) 11/07 (311) 12/03 (337)08/05 (217) 11/08 (312) 12/03 (337)08/06 (218) 11/09 (313) 12/04 (338)08/07 (219) 11/12 (316) 12/05 (339)08/08 (220) 11/12 (316) 12/06 (340)08/09 (221) 11/12 (316) 12/07 (341)08/10 (222) 11/13 (317) 12/10 (344)

08/11 (223) 11/14 (318) 12/10 (344)08/12 (224) 11/15 (319) 12/10 (344)08/13 (225) 11/16 (320) 12/11 (345)08/14 (226) 11/19 (323) 12/12 (346)08/15 (227) 11/19 (323) 12/13 (347)08/16 (228) 11/19 (323) 12/14 (348)08/17 (229) 11/20 (324) 12/17 (351)08/18 (230) 11/21 (325) 12/17 (351)08/19 (231) 11/26 (330) 12/17 (351)08/20 (232) 11/26 (330) 12/18 (352)08/21 (233) 11/26 (330) 12/19 (353)08/22 (234) 11/26 (330) 12/20 (354)08/23 (235) 11/26 (330) 12/21 (355)08/24 (236) 11/27 (331) 12/27 (361)08/25 (237) 11/28 (332) 12/27 (361)08/26 (238) 11/29 (333) 12/27 (361)08/27 (239) 11/30 (334) 12/27 (361)08/28 (240) 12/03 (337) 12/27 (361)08/29 (241) 12/03 (337) 12/27 (361)08/30 (242) 12/03 (337) 12/28 (362)08/31 (243) 12/04 (338) 12/31 (365)09/01 (244) 12/05 (339) 12/31 (365)09/02 (245) 12/06 (340) 12/31 (365)09/03 (246) 12/07 (341) 01/02 (002)09/04 (247) 12/10 (344) 01/02 (002)09/05 (248) 12/10 (344) 01/03 (003)09/06 (249) 12/10 (344) 01/04 (004)09/07 (250) 12/11 (345) 01/07 (007)09/08 (251) 12/12 (346) 01/07 (007)09/09 (252) 12/13 (347) 01/07 (007)09/10 (253) 12/14 (348) 01/08 (008)09/11 (254) 12/17 (351) 01/09 (009)09/12 (255) 12/17 (351) 01/10 (010)09/13 (256) 12/17 (351) 01/11 (011)09/14 (257) 12/18 (352) 01/14 (014)09/15 (258) 12/19 (353) 01/14 (014)09/16 (259) 12/20 (354) 01/14 (014)09/17 (260) 12/21 (355) 01/15 (015)09/18 (261) 12/27 (361) 01/16 (016)09/19 (262) 12/27 (361) 01/17 (017)09/20 (263) 12/27 (361) 01/18 (018)09/21 (264) 12/27 (361) 01/22 (022)09/22 (265) 12/27 (361) 01/22 (022)09/23 (266) 12/27 (361) 01/22 (022)09/24 (267) 12/28 (362) 01/22 (022)09/25 (268) 12/31 (365) 01/23 (023)09/26 (269) 12/31 (365) 01/24 (024)09/27 (270) 12/31 (365) 01/25 (025)09/28 (271) 01/02 (002) 01/28 (028)09/29 (272) 01/02 (002) 01/28 (028)09/30 (273) 01/03 (003) 01/28 (028)10/01 (274) 01/04 (004) 01/29 (029)10/02 (275) 01/07 (007) 01/30 (030)10/03 (276) 01/07 (007) 01/31 (031)10/04 (277) 01/07 (007) 02/01 (032)10/05 (278) 01/08 (008) 02/04 (035)10/06 (279) 01/09 (009) 02/04 (035)10/07 (280) 01/10 (010) 02/04 (035)10/08 (281) 01/11 (011) 02/05 (036)10/09 (282) 01/14 (014) 02/06 (037)10/10 (283) 01/14 (014) 02/07 (038)10/11 (284) 01/14 (014) 02/08 (039)10/12 (285) 01/15 (015) 02/11 (042)10/13 (286) 01/16 (016) 02/11 (042)10/14 (287) 01/17 (017) 02/11 (042)10/15 (288) 01/18 (018) 02/12 (043)10/16 (289) 01/22 (022) 02/13 (044)10/17 (290) 01/22 (022) 02/14 (045)10/18 (291) 01/22 (022) 02/15 (046)10/19 (292) 01/22 (022) 02/19 (050)10/20 (293) 01/23 (023) 02/19 (050)10/21 (294) 01/24 (024) 02/19 (050)10/22 (295) 01/25 (025) 02/19 (050)10/23 (296) 01/28 (028) 02/20 (051)





NOTE: If the 95th or 120th day falls on a weekend or holiday, the fi ling deadline is extended to the next business day.

4–18

Chapter 4

4.6 Coding

4.6.1 Diagnosis CodingThe only diagnosis coding structure accepted by the CSHCN Services Program is the International Classi-fication of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). The CSHCN Services Program requires providers to provide ICD-9-CM diagnosis codes on their claims. Diagnosis codes must corre-spond to the highest level of specificity available. A written description of the diagnosis is not required.

If the diagnosis code submitted is a valid three- or four-digit code, do not add zeroes to the code to make it five digits. Claims submitted with an invalid diagnosis code are denied.

Specific diagnosis codes related to program benefits and coverage are listed in chapters that follow. These listings are intended to provide helpful information, but should not be considered all-inclusive. From time to time, diagnosis codes are added, deleted, or revised. Coverage and coding information is updated in the CSHCN Provider Bulletin. Call the TMHP-CSHCN Contact Center at 1-800-568-2413 with questions regarding diagnosis codes.

4.6.2 Procedure Coding

4.6.2.1 Healthcare Common Procedure Coding System (HCPCS)

The procedure coding system used by the CSHCN Services Program is called Healthcare Common Procedure Coding System, more commonly known as HCPCS. HCPCS gives health care providers and third-party payers a common coding structure for determining reimbursement.

HCPCS is designed around a five-character numeric or alphanumeric base for all procedure codes. To ensure an up-to-date coding structure, HCPCS is updated annually using the latest edition of the Current Procedural Terminology (CPT) manual and nationally established Centers for Medicare & Medicaid Services (CMS) codes. The coding systems comply with Health Insurance Portability and Accountability Act (HIPAA) requirements.

Specific procedure codes related to program benefits and coverage are listed in chapters that follow. These listings are intended to provide helpful information, but should not be considered all-inclusive. From time to time, procedure codes are added, deleted, or revised. Coverage and coding information is updated in the CSHCN Provider Bulletin. Call the TMHP-CSHCN Contact Center at 1-800-568-2413 with questions regarding procedure coding.

4.6.2.2 Level I

The following is information about the American Medical Association’s (AMA) physicians’ CPT codes:

• The codes are all numeric, consisting of five digits.

• CPT codes represent 80 percent of HCPCS.

• Maintenance of CPT is the responsibility of the AMA (AMA updates on a yearly basis).

• Updates by the AMA are coordinated with CMS before distribution of modifications to third-party payers.

• Anesthesia codes from CPT must be used.

Note: Claims for anesthesia must list the CPT anesthesia procedure codes. Use of narrative descrip-tions or CPT surgical codes result in claim denial.

4.6.2.3 Level II

The following is information about CMS (HCPCS) Codes:

• CMS (HCPCS) provides codes for both physician and nonphysician services that are not contained in CPT (such as ambulance, durable medical equipment, prostheses, and some medical codes).

• Updating of HCPCS codes is the responsibility of the CMS Maintenance Task Force.

• The codes are all alphanumeric, consisting of a single alpha character (A–V) followed by four numeric digits.



4

The single alpha character signifies the following:

HCPCS codes are used by all the CSHCN Services Program providers to identify the procedures they perform.

Exception: Inpatient facility charges submitted on a HCFA-1450 (UB-92) claim form must be billed using revenue codes.

4.6.2.4 Modifiers

Modifiers further describe and qualify services provided. A modifier is placed after the five-digit procedure code. Refer to current issues of CPT and/or HCPCS coding resources for modifiers and their descriptions.

4.6.2.5 Place of Service (POS) Coding

The place of service identifies where services are performed. Indicate the place of service (POS) by using the appropriate numeric code for each service listed on the claim. The following POS codes must be used:

4.7 Claims Filing InstructionsProviders must read the instructions in this section carefully and supply all the requested information on the claim form.

Claims must contain the billing provider’s complete name, address, provider identifier, and signature, or “signature on file” statement. A claim without the provider’s complete name, address, provider identifier, signature, or “signature on file” statement cannot be processed.

Character Description

A Supplies, ambulance, chiropractic

B Enteral and parenteral therapy

D Dental

E DME and oxygen

H Rehabilitation services

J Drugs (administered other than orally)

K ICD-9-CM surgery (informational only)

L Orthotic and prosthetic procedures

M Medical

P Laboratory

Q Temporary procedures

R Radiology

T Diapers

V Vision and hearing services (nonphysician); speech/language pathology services (nonphysician)

Place of ServiceTwo-Digit Numeric Codes (Electronic Billers)

One-Digit Numeric Codes (Paper Billers)

Office 11, 65, 71, 72 1

Home 12 2

Inpatient hospital 21, 51, 52, 55, 56, 61 3

Outpatient hospital 22, 23, 24, 62 5

Other location 26, 34, 53, 99 9

Independent lab 81 6

Destination of ambulance Indicate destination using above codes

Indicate destination using above codes


4–20

Chapter 4

4.7.1 Provider Types and Selection of Claim Forms

4.7.1.1 CMS-1500

The following services must be billed on a CMS-1500 claim form or electronic claim format when requesting payment for medical services and supplies under the CSHCN Services Program:

• Ambulance

• DME

• Freestanding ambulatory surgery center

• Gastrostomy devices

• Independent laboratory, radiology, and radiation therapy

• Medical nutritional products and services

• Orthosis and prosthesis

• Outpatient therapy (physical therapy [PT], occupational therapy [OT], and speech-language pathology [SLP])

• Physician (Doctor of Medicine [MD] and Doctor of Osteopathy [DO])

• Podiatry

• TPN/hyperalimentation

• Transportation of deceased clients (providers should contact the CSHCN Services Program for assis-tance in obtaining and completing forms)

• Any other authorized provider of medical services and supplies not specifically required to use a different claim form when submitting claims to TMHP

Providers are responsible for obtaining these forms from a supplier of their choice (see Appendix B, “CMS-1500 Example,” on page B-6).

4.7.1.2 HCFA-1450 (UB-92)

The following services must be billed using the HCFA-1450 (UB-92) claim form or electronic claim format when requesting payment:

• Home health (skilled nursing service)

• Inpatient hospital

• Outpatient hospital

• Ambulatory surgical center (hospital based)

• Inpatient rehabilitation

Providers are responsible for obtaining these forms from a supplier of their choice (see Appendix B, “HCFA-1450 (UB-92) Example,” on page B-15).

4.7.1.3 Dental Claim Filing

Dental and orthodontia services must be billed using the 2002, 2004 American Dental Association (ADA) Dental Claim Form when requesting payment.

Providers are responsible for obtaining these forms from a supplier of their choice (see the Appendix B, “ADA Dental Claim Form Example,” on page B-19).

Specific dental procedures and applicable diagnosis codes related to program benefits and coverage are listed in Chapter 8, “Dental.” These listings are intended to provide helpful information, but should not be considered all-inclusive. From time to time, codes are added, deleted, or revised. Coverage and coding information is updated in the CSHCN Provider Bulletin. Call the TMHP-CSHCN Contact Center at 1-800-568-2413 with questions regarding dental procedure or diagnosis coding.

4.7.1.4 Electronic Claims Submission

For claim submission, eligibility inquiry, and electronic R&S (ER&S) report transactions, billing vendors use National Standard Transaction Formats such as CMS-1500, HCFA-1450 (UB-92), American National Standards Institute (ANSI), or EDIFACT.



4

TDHconnect software is available free of charge. Updates to TDHconnect 3.0 are available for download at www.tmhp.com or contact the TMHP EDI Help Desk at 1-888-863-3638 for an upgrade to the newest version.

Claims submitted electronically to TMHP must be submitted using the updated specifications in TDHconnect 3.0 or online through the TMHP website at www.tmhp.com.

Refer to: Chapter 23, “TMHP Electronic Data Interchange (EDI),” for more information about electronic claims submission.

4.7.1.5 CMS-1500 Online Claims Submission

TMHP, in partnership with the Texas Health and Human Services Commission (HHSC), has enhanced the TMHP website at www.tmhp.com to allow CMS-1500 claim submissions. This functionality allows the submission of professional CSHCN Services Program claims that do not require attachments and are not in a zero allowed, zero paid status. Claims are submitted and appealed over secure pages of the TMHP website.

Visit the TMHP website at www.tmhp.com or call the TMHP-CSHCN Contact Center at 1-800-568-2413 for additional information.

4.7.1.6 Dates on Claims

All dates (such as date of birth and date of service) entered on the claim (electronic and paper) must be eight digits in MMDDYYYY format.

Example: August 6, 2007, is entered as 08062007.

4.7.1.7 Span Dates

Providers currently submitting paper claims and that have provided services on consecutive days may bill multiple consecutive days per claim detail as long as the dates are in the same month and year. Providers must indicate (in the quantity billed) the number of dates they are billing.

Example: Services were provided each day from August 6, 2007, to August 16, 2007. When submitting the paper claim, enter the from date of service as 08062007 and the to date of service as 08162007. The quantity is 11.

Note: Claims submitted with a quantity billed not equal to the number of days indicated in the date of service fields are denied. When the claim is processed, the system creates multiple details consisting of four consecutive days each so that the claim appears on the provider’s R&S report with one detail for each four days billed. Using the example above, there are three details as illustrated below. If the number of details created during this process is greater than 28, the claim is denied for exceeding the maximum details per claim, and the provider must resubmit the claim, dividing the dates of service into multiple claims, to convey complete billing information.

4.7.1.8 Hospital Billing

Hospitals submitting inpatient claims on paper may submit up to 56 service lines per claim. When the claim is submitted, the system performs a merge function that combines like revenue codes to reduce the number of service lines to 28 or less. Because of the merge function, it is important to understand that when the claim appears on the R&S report the provider does not see the 56 service lines submitted, but rather the results of merged details. If the merge function is unable to merge the number of service lines to 28, the claim is denied for exceeding the maximum details per claim, and the claim needs to be subdivided and resubmitted as more than one claim.

For more information on electronic claim submission, contact the TMHP EDI Help Desk at 1-888-863-3638.

Detail From DOS To DOS Qty Billed

1 08062007 08092007 4

2 08102007 08132007 4

3 08142007 08162007 3


Documents

Chapter Claims Filing Reimbursement, Authorizations, and 4 2007/04_Reimbursement-Auth... · Complete the EFT form, include a deposit slip or canceled check, ... on the claim form