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TEXAS MEDICAID BULLETIN NO. 202

INSIDE

All Providers 1

NPI Overview 1

NPI Attestation Overview 2

Atypical Provider Identifiers 3

Completing the Online Attestation Process 4

Important Medicare Crossover Information 8

Crosswalk Solution Developed for Claims Processing 9

Implementation Timelines 10

NPI Information and Help 10

New Claim Forms 11

Correspondence Changes 14

TDHconnect 15

EDI Companion Guide 15

Third Party Biller Enrollment 15

Forms 16

Revised CMS-1500 16

Revised CMS-1450 (UB-04) 17

Revised ADA Dental Claim Form 18

Long Term Care Providers

See reverse side

This is a combined, special bulletin for all Medicaid, Children with Special Health Care Needs (CSHCN),

Family Planning, and Long Term Care providers. (Long Term Care providers will find information applicable

to them on the reverse side of this bulletin.) This bulletin is intended to notify providers of program changes

related to the National Provider Identifier (NPI) implementation occurring May of 2007.

JANUARY 2007

NPI Overview

The National Provider Identifier (NPI) final rule, Federal Register 45, Code of Federal Regulations (CFR) Part 162, was published on January 23, 2004, by the U.S. Department of Health and Human Services (DHHS) as part of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. The rule established the NPI as the standard unique identifier for health care providers and requires covered health care providers, clearinghouses, and health plans to use this identifier in HIPAA-covered transactions by May 23, 2007. The Texas Medicaid, Family Planning, and CSHCN Services Programs meet the definition of “health plan” and, therefore, must accommodate the NPI requirements for HIPAA-covered transactions received on and after May 23, 2007.

To ensure providers continue to receive accurate and timely payment while transitioning to the NPI, HHSC and TMHP have developed a phased approach for NPI implementation. In order to meet the May 23, 2007, implementation date, providers will be allowed to submit and receive NPI and related information on most electronic transactions and paper forms. However, providers will be required to continue to submit Texas Provider Identifiers (TPIs) until July 31, 2007.

A crosswalk solution (see page 9) has been developed that allows providers to submit their assigned NPI while TMHP processes the transactions using the provider’s TPI. The crosswalk of the NPI back to TPI is crucial for

accurate payment of services. It is your responsibility to inform TMHP of your assigned NPI. Refer to page 4 for information regarding how to report your NPI to TMHP. The intent of this special bulletin is to summarize the first phase, or interim process, and detail what actions providers must take to ensure a smooth transition to the NPI.

Copyright AcknowledgmentsUse of the American Medical Association’s (AMA) copyrighted Current Procedural Terminology (CPT) is allowed in this publication with the following disclosure: “Current Procedural Terminology (CPT) is copyright 2007 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/Department of Defense Regulation System (FARS/DFARS) restrictions apply to government use.”The American Dental Association requires the following copyright notice in all publications containing Current Dental Terminology (CDT) codes: “CDT4/2007 [including procedure codes, definitions (descriptions), and other data] is copyrighted by the American Dental Association. (c) 2006 American Dental Association. All Rights Reserved. Applicable Federal Acquisition Regulation System/Department of Defense Acquisition Regulation System (FARS/DFARS) restrictions apply.”

SPECIAL BULLETINNATIONAL PROVIDER IDENTIFIER (NPI)

for Medicaid and CSHCN Services Program providers

http://www.tmhp.com/LTC_Provider_Bulletin/2007/LTC%20NPI%20Special%20Bulletin%20202.pdf

CPT only copyright 2005 American Medical Association. All rights reserved.

NPI Attestation Overviewtype and specialty. Providers may have more than one taxonomy code. (Taxonomy codes can be obtained from the Washington Publishing Company [WPC] website at www.wpc-edi.com.)

During the online attestation process, providers must select a primary and, if applicable, secondary taxonomy code associated with their provider type. Providers will be supplied a list of taxonomy codes to choose from that correspond to their specific TPI. Only the code will be displayed. Due to copyright laws, TMHP is unable to publish the taxonomy description. Therefore, providers must verify the taxonomy code associated with their provider type and specialty before beginning the online attestation process.

Providers who submit claims to Medicare should identify to TMHP all taxonomy codes that they will submit to Medicare for each of their TPIs. The provider may identify a primary taxonomy code, but TMHP strongly recommends that providers identify all codes to ensure timely processing of claims.

Provider AddressesDuring the attestation process, all providers must verify the physical address for each TPI. Providers will have the ability to update these addresses online if they are incorrect. During this process, TMHP does not require providers to submit the Provider Information Change Form and strongly encourages providers to take this opportunity to correct their contact data:

Physical Address—If the physical address is incorrect, the provider may update it online. When updating the physical address, enter the current physical address. If needed, the provider can update this address through the attestation process again at a later date. The physical address cannot be a PO Box.

Hint: If you are a Medicare provider, the physical address should match the primary physical address that is attached to your Medicare number.

ZIP + 4 Code—Providers must include the correct ZIP+4 code. This code is used during the crosswalk process (see page 9) by TMHP to identify the provider’s specific account. Information about ZIP+4 codes can be found on the U.S. Postal Service website at www.usps.com.

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Before submitting claims, it is the provider’s responsibility to report their NPI to TMHP. If an NPI is not reported, claims will deny or reject.

Providers must attest to NPI data for each of their current Texas Provider Identifiers (TPI). TMHP strongly suggests that providers attest at their earliest convenience.

TMHP has created a webpage on the TMHP website (www.tmhp.com) to enable providers to report their NPI. This page will be available on January 22, 2007. Providers will be guided through the process and must supply and attest to the accuracy of their NPI and related data (see Completing the Online Attestation Process, on page 4). Access to the attestation pages is granted through current administrative permissions; only account administrators will be able to attest online.

The following items are required to complete the online attestation process:

The NPI assigned by the National Plan and Provider Enumeration System (NPPES)

The provider’s identifying taxonomy code(s) (see below)

The tax identification (ID) or Social Security number (SSN) associated with the NPI

The physical address, including ZIP+4

Additionally, the following items are optional:

The individual provider or group name associated with the NPI

The “doing business as” (dba) as provided to NPPES

Mailing/Billing address, including ZIP+4

Hint: Reference the confirmation page you received from NPPES while completing the online attestation process.

Taxonomy CodesThe Health Care Provider Taxonomy Code Set is an external, nonmedical collection of alphanumeric codes designed to classify health care providers by provider

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Texas Medicaid Bulletin, No. 202 2 National Provider Identifier Special Bulletin

Acute Care Providers


Note: For state-funded programs, a change in ZIP code does not require a copy of the Medicare letter.

Mailing Address—If the mailing address is incorrect, the provider may update it online. When updating the mailing address, enter the current mailing address. If needed, the provider can update this address through the attestation process at a later date.

Note: For state-funded programs, a change to the mailing (accounting) address does not require a copy of the W-9 form.

Benefit CodeA benefit code is an additional data element that TMHP uses to identify state programs. Benefit codes may be used as part of the crosswalk process (see page 9). Providers participating in the following programs must use the associated benefit code when submitting claims and authorizations:

Program Benefit CodeComprehensive Care Program (CCP) CCPCSHCN Services Program CSNTexas Health Steps (THSteps) Medical EP1THSteps Dental DE1Family Planning Agencies* FP3Hearing Aid Dispensers HA1Maternity MA1County Indigent Health Care Program CA1Early Childhood Intervention (ECI) Providers

ECI

TB Clinics TB1* Agencies only. Benefit code should not be used for individual

family planning providers.

If a benefit code is necessary, it will appear on the Attestation Data Screen (see page 5). This code will be required on all claims and authorizations and will appear on the provider’s paper check, if applicable.

Group Practices and Performing ProvidersAn administrator of a group practice will have the ability to view all performing provider numbers associated with the group. A performing provider (a provider that renders services within a group practice) may not change accounting information.

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For the purposes of attestation, TMHP encourages group administrators to complete the NPI attestation process for all performing providers within that group. All providers that have a TPI listed as a performing provider should verify and coordinate with their group administrator who will complete attestation for their TPI.

Atypical Provider Identifiers All providers that are eligible to enroll in state-funded programs also have a taxonomy code that defines their services. TMHP encourages all providers to attempt to receive an NPI using the appropriate taxonomy code. If a provider is unable to locate a taxonomy code that describes their services, the provider should contact their Provider Relations representative for assistance and to discuss the possible need for an Atypical Provider Identifier (API).

As defined by NPPES, any entity that does not render health care is not eligible for an NPI. Examples of entities that are not eligible for NPIs include billing services, value-added networks, re-pricers, and clearinghouses. Although some atypical providers may be reimbursed by some health plans for their services, their services are not considered

“health care” services.

All providers that can be enrolled in state-funded programs but cannot obtain an NPI, may be assigned an API to use for HIPAA-covered transactions.

Any provider who has been assigned an API by state-funded programs and later obtains an NPI will no longer be able to use the API and will be required to use the NPI.

For more information, call the TMHP Contact Center at 1-800-925-9126.

Texas Medicaid Bulletin, No. 2023National Provider Identifier Special Bulletin



Completing the Online Attestation ProcessAll providers must notify TMHP of their NPI. The following details the online attestation process.

Note: The following screen shots are for demonstration purposes only. Actual screens may have minor variations.

1. To begin online attestation, log in to your account at www.tmhp.com and select Attest an NPI from the “I Would Like to…” links on the right-hand side of the page. The following screen appears:

The table below describes each field:

Field Description

Type This field will identify the type of provider for the TPI listed in the TPI field. Select Group (+) to expand the TPI listing to include performing providers in the group. Note: “Individual” as defined for this screen can refer to a person or organization.

TPI A list of all TPIs associated with the provider. Select the TPI to attest by clicking Attest in the Action column. Providers will be prompted to return to this screen at the end of attestation to attest another NPI. Providers may attest only one TPI at a time.

NPI This will populate with the provider’s NPI upon completion of attestation. The provider will enter the NPI on the following screen.

Action Supplies the attestation status of the TPI for each provider’s account. Attest will appear if the TPI has not been attested; View/Update will appear for TPIs already attested to. Providers will have the ability to update an account after attestation is completed.

Attestation Home Screen. Providers may attest only one TPI at a time.




2. Click Attest for the appropriate TPI. The following screen appears:

3. Enter the NPI associated with the TPI and click Continue. The following screens appear. The information on these screens must match the information provided to NPPES for the associated NPI. Reference the confirmation page you received from NPPES. Required fields are indicated by a “ ”

Note: The following two screens will appear as a single webpage. For purposes of illustration, the screens have been separated here.

4. Select the appropriate options (see the following page for a description of each field above).

Attestation Data Screen.

NPI Entry Screen.




Field DescriptionBenefit Code This will be auto-populated if the code is required. To ensure timely payment, this

code will be required for all claims submissions to TMHP for this NPI-to-TPI association.

Primary Taxonomy Code* Taxonomy code that TMHP will print on provider communications. Select the taxonomy code with the highest level of specificity.

Secondary Taxonomy Code* Additional codes to be used for service identification purposes. Non-Texas Enrolled Taxonomies This code is informational and describes services the provider performs but for

which the provider does not currently bill Texas Medicaid.Physical Address Physical location where services are rendered. If billing Medicare crossover claims,

the address should match the physical address on file with Medicare.Mailing/Billing Address Address for all provider correspondence. ZIP+4 Full nine-digit ZIP code as provided by the US Postal Service (www.usps.com)

* Texas Health Steps (THSteps) providers will also be able to type in taxonomy codes if their taxonomy choice is not listed in the primary or secondary fields.

Field DescriptionProvider or Organization Name Provider and organization name (if applicable) submitted to NPPES.Practice Location Address Address submitted to NPPES when applying for an NPI. This field can be updated

online.Tax ID/SSN Tax ID or SSN associated with NPI via NPPES.DBA Name “Doing Business As” name. Enter only if applicable.Mailing Address Current address associated with the NPI. This field can be updated online.

NPPES Details Page.




5. Update any information that needs to be updated. Click Continue. The following screen appears:

6. Click Edit if any corrections are necessary. If all information is accurate, read the terms and conditions (below) and select We Agree. (If you do not agree with the terms and conditions, you may select Cancel to exit the attestation process. Providers who do not select “We Agree” will not be able to complete online attestation.)

Terms and Conditions / Certification Statement“The Provider certifies that the information entered herein and any attachments or accompanying information constitute true, correct, and complete information. The Provider understands that payment based on this information will be from Federal and State funds, and that falsifying entries, concealment of a material fact, or pertinent omissions may constitute fraud and may be prosecuted under applicable federal and/or state law. Fraud is a felony, which can result in fines or imprisonment.

A provider who delegates signature authority for claims preparation to an office staff member or to a billing service is responsible for the accuracy of all information on a claim submitted for payment. This, however, does not absolve these other individuals for their participation in any documents provided to the state or designee with false, inaccurate, or misleading information.

Important Note: Submitting a false statement or misrepresentation or omitting pertinent facts on any application or any documents requested as a prerequisite for Medicaid or other HHSC program partici-pation may result in provider or individual exclusion or suspension from the Texas Medicaid Program. Providers or individuals are notified in writing of action taken, including appeal procedures.”

Confirm Details Page.




7. After selecting “We Agree” and clicking Submit, the following screen appears:

The provider may print and keep a copy of this screen for his or her records. At this point, the provider may exit the attestation pages or attest NPI data for another TPI (selecting this options takes the provider back to the NPI Attestation Home screen.)

Throughout the online attestation process, the provider can return to the previous screen by using the back button on their browser. For help with the online attestation process, contact the TMHP Contact Center at 1-800-925-9126. For more information on getting help, see NPI Information and Help on page 10.

Successful Attestation Screen.

Important Medicare Crossover Information

Medicare does not require a taxonomy code for Part B claims (see page 2 for more information on taxonomy codes). Therefore, some claims submitted to TMHP from Medicare for payment of coinsurance and deductible may not include the taxonomy code needed for accurate processing.

To ensure timely payment for claims that are sent to TMHP from Medicare, providers should submit all claims to Medicare with their primary taxonomy code. The provider should also verify their physical address for Medicare matches their physical address for their TPI.

Beginning May 21, 2007, all paper Medicare crossover claims must include an attached claim form.




Crosswalk Solution Developed for Claims ProcessingTo accommodate the NPI requirement, TMHP is implementing a crosswalk solution, which will allow providers to submit their assigned NPI while TMHP processes the transactions using the provider’s Texas Provider Identifier (TPI). The following table illustrates the crosswalk process:

Hospital ExampleProvider Submits: TMHP Processes With:

NPI Taxonomy Physical Address (ZIP + 4 code) Benefit Code TPI

1234567891 282N00000X 1234 Main St. Austin, TX 78727-6401

1234567-01 (Hospital)

1234567891 261QA1903X 1234 Main St. Austin, TX 78727-6401

1234567-02 (HASC)

1234567891 282N00000X 5432 Different St. Austin, TX 78729-6406

1234567-03 (Hospital)

Physician ExampleProvider Submits: TMHP Processes With:


1234567890 208Q00000X 1300 Doctor Lane Austin, TX 78727-6401

2233557-01 (Physician)

1234567890 208Q00000X 1300 Doctor Lane, Austin, TX 78727-6401

EP1 2233557-02 (Physician – THSteps Medical)

1234567890 208Q00000X 1234 Hospital Blvd. Austin, TX 78729-6405

2233557-03 (Performing Provider)

Home Health ExampleProvider Submits: TMHP Processes With:


1234567895 251E00000X 1234 E. First St. Austin TX 78727-6403

3344556-01 (Home Health)

1234567895 332B00000X 1234 E. First St. Austin TX 78727-6403

3344556-02 (Home Health DME)

1234567895 332B00000X 1234 E. First St. Austin TX 78727-6403

CCP 3344556-02 (Home Health DME - CCP)

If there is a one-to-one match for NPI to TPI, the claims processing system uses the associated TPI. If there is not a one-to-one match, the system will use the following criteria to obtain the associated TPI:

• Taxonomy code (for more information about taxonomy codes, see page 2)

• Benefit code, if necessary (for more information, see page 3)

• Physical address (including ZIP + 4 code)

For more information, call the TMHP Contact Center at 1-800-925-9126.




Implementation TimelinesThe NPI rule will be implemented in two phases. Effective May 21, 2007, providers will have the option to continue under current submission processes or they can participate in an Enhanced Dual Strategy approach from May 21, 2007, through July 29, 2007. If electing to participate in the Enhanced Dual Strategy, providers must continue to submit their TPI or Provider IDs for all claims. During this process, the electronic 835 response will return an NPI, which will be based on the NPI for which the provider has attested. On July 30, 2007, TMHP will implement NPI-only processes. Tentative timeline details are provided below:

Date Action

December 2006 NPI webpage available on www.tmhp.com.January 2007 Contact Center NPI Provider Line available.January 22, 2007 TMHP NPI attestation process begins.January 31, 2007 Enhanced Dual Strategy EDI Companion Guides available.April 2, 2007 Discontinue use of current CMS-1500. Only revised CMS-1500 claim form with current provider

number will be accepted.May 21, 2007 Optional Enhanced Dual Strategy for electronic transaction (837, 835, 270, 271) available.

Enhanced Dual Strategy includes NPI, TPI, taxonomy, and benefit code.*May 21, 2007 Submit both TPI and NPI (optional) for paper claims.May 21, 2007 Accept only revised ADA Dental, Family Planning, and UB-04 claim forms for processing.May 23, 2007 Continue TPI only for all authorization requests. May 23, 2007 Continue TPI only for paper Remittance and Status (R&S) reports and paper checks.July 30, 2007 Receive and submit only NPI and related information for electronic transactions.July 30, 2007 Submit both TPI and NPI for paper claims.July 30, 2007 Submit both TPI and NPI for all paper authorizations.July 30, 2007 Replatform TDHconnect to web-based processing.July 30, 2007 Contact Center provider phone lines request NPI and TPI.July 30, 2007 Electronic R&S will contain NPI only and related data.

* If a provider submits an eligibility verification request with an NPI, the NPI will appear on the response from TMHP.

During Enhanced Dual Strategy, providers have the option of submitting an NPI for all claim transactions. To ensure timely processing of claims, providers must continue to submit their TPI or provider IDs for all claims.

For questions, call the TMHP Contact Center at 1-800-925-9126.

NPI Information and Help

A dedicated NPI webpage is available on the TMHP website (www.tmhp.com/C13/NPI Announcements/default.aspx) and will be updated continually as more information about NPI is made available. In addition, TMHP is introducing a new option from the Contact Center’s main menu, dedicated to assisting providers with NPI issues. (The TMHP-CSHCN Contact Center will not have an option dedicated to NPI questions. CSHCN providers may call the TMHP Contact Center for questions related to NPI.) Call the TMHP Contact Center at 1-800-925-9126 and select option 4 for additional NPI assistance.




New Claim Forms The claim forms providers use to submit claims to TMHP are changing to accommodate the NPI. These changes, and information about when TMHP will begin accepting the new claim forms, are detailed below. TMHP will provide additional information regarding claim form changes in future bulletins and banner messages.

CMS-1500 Professional Claim FormThe National Uniform Claim Committee (NUCC) has released the revised version of the CMS-1500 claim form (version 08/05), which includes fields for the NPI. The revised CMS-1500 (see page 16) will not be accepted by TMHP until April 2, 2007. Any new version of the CMS-1500 received before April 2, 2007, will be returned to the provider. Effective April 2, 2007, providers must use the revised CMS-1500 claim form to file or re-file claims, regardless of which version of the CMS-1500 claim form was used for prior submissions.

The table below provides an overview of fields affected by the NPI on the revised CMS-1500 (version 08/05). The fields indicated below are specific to the NPI Implementation and have specific requirements effective April 2, 2007, and May 21, 2007. TMHP will supply a detailed description of the updated CMS-1500 in future bulletins and banner messages.

Field Definition Description Requirement Effective April 2, 2007

Requirement Effective May 21, 2007

11 c Insurance Plan or Program Name

Enter the benefit code, if applicable, for the billing or performing provider. (See page 3 for more information about benefit codes.)

N/A Benefit code, if applicable

17 Referring Provider or Other Source

Name of the professional who referred or ordered the service(s) or supply(s) on the claim.

Same as current use Same as current use

17a Other ID# The Other ID number of the referring provider, ordering provider, or other source should be reported in 17a.

TPI or Provider ID (such as UPIN) required, if applicable

TPI or Provider ID (such as a UPIN), if applicable

17b NPI Enter the NPI of the referring provider, ordering provider, or other source.

N/A NPI (optional)

24j Rendering Provider ID#

(Performing)

The individual rendering the service should be reported in 24j. Enter the TPI in the shaded area of the field. Enter the NPI in the unshaded area of the field.

TPI in shaded field TPI in shaded field

NPI in unshaded area of the field (optional)

32 Service Facility Location Information

Enter the name, address, city, state, and ZIP code of the location where the services were rendered.

Enter facility information when applicable

Enter facility information when applicable

32a NPI Enter the NPI of the service facility location.

N/A NPI (optional)

32b Other ID# Enter the non-NPI ID number of the service facility. This refers to the payer-assigned unique identifier of the facility.

TPI or Provider ID (such as a UPIN) required

TPI or Provider ID (such as a UPIN) required




Field Definition Description Requirement Effective April 2, 2007

Requirement Effective May 21, 2007

33 Billing Provider Info and Ph. No.

Enter the provider’s or supplier’s billing name, address, ZIP code, and telephone number.

The billing provider’s information

The billing provider’s information.

33a NPI Enter the NPI of the billing provider. N/A NPI (optional)33b Other ID# Enter the non-NPI ID number of

the service facility. This refers to the payer-assigned unique identifier of the facility.

TPI required TPI required

UB-04 Institutional Claim FormThe NUCC approved the UB-04 CMS-1450 claim form (see page 17) as the replacement for the UB-92 HCFA-1450 claim form. The new UB-04 CMS-1450 claim form will be available on March 1, 2007; however, TMHP will not accept the revised UB-04 CMS-1450 claim form until May 21, 2007. Any new version of the UB-04 CMS-1450 claim form received before May 21, 2007, will be returned to the provider.

The Centers for Medicare & Medicaid Services (CMS) plans to discontinue acceptance of the UB-92 HCFA-1450 claim form beginning May 21, 2007.

Effective May 21, 2007, providers must use the revised UB-04 CMS-1450 claim form to submit or resubmit claims, including appeals, regardless of the version used for prior submissions.

The table below provides an overview of fields affected by the NPI on the revised UB-04 for claims effective May 21, 2007. The fields indicated below are specific to the NPI Implementation. TMHP will supply a detailed description of the updated UB-04 in future bulletins and banner messages.

Field Definition Description Requirement Effective May 21, 2007

56 NPI Enter the NPI of the billing provider. NPI (optional)57a Other ID# Enter the non-NPI ID number of the billing provider. TPI required73 Benefit Code Enter the benefit code, if applicable, for the billing

provider. (See page 3 for more information about benefit codes.)

Benefit code, if applicable (optional)

76 Attending Provider

Attending provider name and identifiers (including NPI):

Required when claim/encounter contains any services other than nonscheduled transportation services. The attending provider is the individual who has overall responsibility for the patient’s medical care and treatment reported in this claim/encounter

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NPI (optional)

TPI in field to the right of Qualifier box, if applicable

77 Operating Provider

Operating provider name and identifiers (including NPI):

Required when a surgical procedure code is listed on the claim. The name and ID number of the individual with the primary responsibility for performing the surgical procedure(s).

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NPI (optional)






78-79 Other (a or b) Provider

Other provider name and identifiers (including NPI):

The name and ID number of the individual corre-sponding to the action of the claim:

Referring Provider – The provider who sends the patient to another provider for services. Required on an outpatient claim when the referring provider is different than the attending physician. Other Operating Physician – An individual performing a secondary surgical procedure or assisting the operating physician. Required when another operating physician is involved. Rendering Provider – The health care professional who performs, delivers, or completes a particular medical service or non-surgical procedure.

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NPI (optional)


ADA Dental Claim FormThe American Dental Association (ADA) approved the new 2006 ADA Dental Claim Form (see page 18) as the replacement for the 2002 ADA Dental Claim Form. The revised version of the ADA Dental Claim Form allows for reporting of an NPI in addition to a current TPI. This version of the form will be available on January 1, 2007; however, TMHP will not accept the revised ADA Dental Claim Form until May 21, 2007. Any new version of the ADA Dental Claim Form received before May 21, 2007, will be returned to the provider. Effective May 21, 2007, providers must submit or resubmit claims, including appeals on the revised ADA Dental Claim Form, regardless of the version of the ADA Dental Claim Form used for prior submissions.

The table below provides an overview of fields affected by the NPI on the revised ADA Dental Claim Form for claims effective May 21, 2007. The fields indicated below are specific to the NPI Implementation. TMHP will supply a detailed description of the updated ADA Dental claim form in future bulletins and banner messages.


16 Plan/Group Enter the benefit code, if applicable, for the billing or performing provider. (See page 3 for more information about benefit codes.)

Benefit code, if applicable

48 Billing Dentist or Dental Entity

Name and address of billing Group or Individual provider (not the name and address of a provider employed within a group).

Enter name and address

49 NPI Enter required billing dentist’s NPI for a group or an individual (not the NPI for a provider employed within a group).

NPI (optional)

52 A Additional Provider ID

Enter the TPI assigned to the billing dentist or dental entity. TPI required

54 NPI Enter the performing dentist’s NPI. Field is required for all providers that are rendering services within a group.

NPI (optional)

58 Additional Provider ID

Enter the performing dentist’s TPI. TPI required




Family Planning Claim FormBeginning May 21, 2007, the new Family Planning 2017 claim form (not available at press time) that supports the NPI will be the only form accepted for family planning services. TMHP will provide the new form and detailed instructions in future bulletins and banner messages.

The table below provides an overview of the fields affected by the NPI on the revised Family Planning 2017 claim form effective May 21, 2007.


2a Billing Provider The provider that is billing for the services rendered.

TPI required

2b Billing Provider Field is not currently on claim. NPI (optional)24a Insured Group Clients Insurance Policy or Group Number. Required when applicable24b Benefit Code Field is not currently on claim. Benefit code, if applicable (optional)26 Referring Provider Supply the name of the provider that

referred the client for services.Name of provider

27a Other ID Field is not currently on claim. TPI required27b NPI Field is not currently on claim. NPI (optional)32h (a) Performing

Provider # (Other ID)

Field is not currently on claim. TPI required

32h (b) Performing Provider # (NPI)

Field is not currently on claim. NPI (optional)

38a Service Facility (Other ID)

Field is not currently on claim. TPI required, if applicable

38b Service Facility (NPI)

Field is not currently on claim. NPI (optional)

For questions, call the TMHP Contact Center at 1-800-925-9126.

Correspondence ChangesProviders will notice several additional NPI-related changes on the correspondence they receive from TMHP. These changes are described below.

Remittance and Status (R&S) ReportsFrom May 23, 2007, through July 2007, providers will receive the TPI only on paper R&S reports. Effective July 2007, paper R&S reports will continue to include the TPI in addition to the NPI, taxonomy, and benefit code.

Effective July 2007, the following changes will appear on Electronic Remittance and Status (ER&S) responses:

Name Description of Change

Provider ID Eliminate TPI information, replace with NPIBenefit Code Add benefit code, if applicable, based on the provider informationTaxonomy Code Add the primary taxonomy code for additional provider identifier




Paper ChecksFrom May 23, 2007, through July 2007, no changes will appear on paper checks. The following information will be placed on paper checks effective July 2007:

Report Field Name DescriptionProvider Number The provider’s NPI will be includedBenefit Code The provider’s benefit code, if applicable, will be included

Electronic Funds Transfer (EFT)EFT transactions will not be affected from May 23, 2007 through July 2007. The following information will be included on EFTs effective July 2007:

Name Description of Change

Provider’s NPI NPI number will be added to the EFT fileProvider’s TPI TPI number will be removed from the EFT fileProvider’s Benefit Code The provider’s benefit code, if applicable, will be added to the EFT file

1099sTMHP will release one 1099 report for 2007 earnings. The 1099 will include the provider’s TPI, NPI, and the first character of the Program Code (100, 200, 300, or 400).

TDHconnectA new web-based application, available July 31, 2007, will be replacing TDHconnect. TMHP will not be making changes to TDHconnect at this time. Please monitor the NPI Announcements webpage (www.tmhp.com/C13/NPI Announcements/default.aspx ) for further information.

EDI Companion GuideElectronic Data Interchange (EDI) Companion Guides for Enhanced Dual Strategy will be available at www.tmhp.com in January/February. Monitor the NPI Announcements webpage (www.tmhp.com/C13/NPI Announcements/default.aspx) for further information on future releases.

Third Party Biller Enrollment

Any providers utilizing a billing service for their claims submission should be confirming that their billing service is making arrangements to submit their claims using the Enhanced Dual Strategy NPI requirements beginning May 23, 2007, and the full compliance NPI requirements in late July 2007. It is ultimately the provider’s responsibility to ensure that their claims are submitted in accordance with all guidelines.

Effective June 30, 2007, third party billers (TPBs) will be required to contract with HHSC before submitting electronic claims. TPBs are persons, businesses, or entities that submit claims on behalf of a provider, but are not the provider or an employee of the provider.

For more information, call the TMHP EDI Help Desk at 1-888-863-3638.




1a. INSURED’S I.D. NUMBER (For Program in Item 1)

4. INSURED’S NAME (Last Name, First Name, Middle Initial)

7. INSURED’S ADDRESS (No., Street)

CITY STATE

ZIP CODE TELEPHONE (Include Area Code)

11. INSURED’S POLICY GROUP OR FECA NUMBER

a. INSURED’S DATE OF BIRTH

b. EMPLOYER’S NAME OR SCHOOL NAME

d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorizepayment of medical benefits to the undersigned physician or supplier forservices described below.

SEX

F

HEALTH INSURANCE CLAIM FORM

OTHER1. MEDICARE MEDICAID TRICARE CHAMPVA

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary

to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignmentbelow.

SIGNED DATE

ILLNESS (First symptom) ORINJURY (Accident) ORPREGNANCY(LMP)

MM DD YY15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.

GIVE FIRST DATE MM DD YY14. DATE OF CURRENT:

19. RESERVED FOR LOCAL USE

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line)

FromMM DD YY

ToMM DD YY

1

2

3

4

5

625. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT?

(For govt. claims, see back)

31. SIGNATURE OF PHYSICIAN OR SUPPLIERINCLUDING DEGREES OR CREDENTIALS(I certify that the statements on the reverseapply to this bill and are made a part thereof.)

SIGNED DATE

SIGNED

MM DD YY

FROM TO

FROM TO

MM DD YY MM DD YY

MM DD YY MM DD YY

CODE ORIGINAL REF. NO.

$ CHARGES

28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE

$ $ $

PICA PICA

2. PATIENT’S NAME (Last Name, First Name, Middle Initial)

5. PATIENT’S ADDRESS (No., Street)

CITY STATE

ZIP CODE TELEPHONE (Include Area Code)

9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)

a. OTHER INSURED’S POLICY OR GROUP NUMBER

b. OTHER INSURED’S DATE OF BIRTH

c. EMPLOYER’S NAME OR SCHOOL NAME

d. INSURANCE PLAN NAME OR PROGRAM NAME

YES NO

( )

If yes, return to and complete item 9 a-d.

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

20. OUTSIDE LAB? $ CHARGES

22. MEDICAID RESUBMISSION

23. PRIOR AUTHORIZATION NUMBER

MM DD YY

CA

RR

IER

PA

TIE

NT

AN

D IN

SU

RE

D IN

FO

RM

AT

ION

PH

YS

ICIA

N O

R S

UP

PL

IER

INF

OR

MA

TIO

N

M F

YES NO

YES NO

1. 3.

2. 4.

DATE(S) OF SERVICEPLACE OFSERVICE

PROCEDURES, SERVICES, OR SUPPLIES(Explain Unusual Circumstances)

CPT/HCPCS MODIFIERDIAGNOSISPOINTER

FM

SEXMM DD YY

YES NO

YES NO

YES NO

PLACE (State)

GROUPHEALTH PLAN

FECABLK LUNG

Single Married Other

3. PATIENT’S BIRTH DATE

6. PATIENT RELATIONSHIP TO INSURED

8. PATIENT STATUS

10. IS PATIENT’S CONDITION RELATED TO:

a. EMPLOYMENT? (Current or Previous)

b. AUTO ACCIDENT?

c. OTHER ACCIDENT?

10d. RESERVED FOR LOCAL USE

Employed Student Student

Self Spouse Child Other

(Medicare #) (Medicaid #) (Sponsor’s SSN) (Member ID#) (SSN or ID) (SSN) (ID)

( )

M

SEX

DAYSOR

UNITS

F. H. I. J.24. A. B. C. D. E.

PROVIDER ID. #

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a.

EMGRENDERING

32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH #

NUCC Instruction Manual available at: www.nucc.org

c. INSURANCE PLAN NAME OR PROGRAM NAME

Full-Time Part-Time

17b. NPI

a. b. a. b.

NPI

NPI

NPI

NPI

NPI

NPI

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05

G.EPSDTFamilyPlan

ID.QUAL.

NPI NPI

CHAMPUS

( )

1500

APPROVED OMB-0938-0999 FORM CMS-1500 (08/05)


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__ __ __

1 2 4 TYPEOF BILL

FROM THROUGH5 FED. TAX NO.

a

b

c

d

DX

ECI

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

A

B

C

A B C D E F G HI J K L M N O P Q

a b c a b c

a

b c d

ADMISSION CONDITION CODESDATE

OCCURRENCE OCCURRENCE OCCURRENCE OCCURRENCE SPAN OCCURRENCE SPANCODE DATE CODE CODE CODE DATE CODE THROUGH

VALUE CODES VALUE CODES VALUE CODESCODE AMOUNT CODE AMOUNT CODE AMOUNT

TOTALS

PRINCIPAL PROCEDURE a. OTHER PROCEDURE b. OTHER PROCEDURE NPICODE DATE CODE DATE CODE DATE

FIRST

c. d. e. OTHER PROCEDURE NPICODE DATE DATE

FIRST

NPI

b LAST FIRST

c NPI

d LAST FIRST

UB-04 CMS-1450

7

10 BIRTHDATE 11 SEX 12 13 HR 14 TYPE 15 SRC

DATE

16 DHR 18 19 20

FROM

21 2522 26 2823 27

CODE FROMDATE

OTHER

PRV ID

THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.

b

.INFO BEN.

CODEOTHER PROCEDURE

THROUGH

29 ACDT 30

3231 33 34 35 36 37

38 39 40 41

42 REV. CD. 43 DESCRIPTION 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49

52 REL51 HEALTH PLAN ID

53 ASG.54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI

57

58 INSURED’S NAME 59 P.REL 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

66 67 68

69 ADMIT 70 PATIENT 72 73

74 75 76 ATTENDING

80 REMARKS

OTHER PROCEDURE

a

77 OPERATING

78 OTHER

79 OTHER

81CC

CREATION DATE

3a PAT.CNTL #

24

b. MED.REC. #

44 HCPCS / RATE / HIPPS CODE

PAGE OF

APPROVED OMB NO. 0938-0997

e

a8 PATIENT NAME

50 PAYER NAME

63 TREATMENT AUTHORIZATION CODES

6 STATEMENT COVERS PERIOD

9 PATIENT ADDRESS

17 STAT STATE

DX REASON DX71 PPS

CODE

QUAL

LAST

LAST

National UniformBilling CommitteeNUBC

™

OCCURRENCE

QUAL

QUAL

QUAL

CODE DATE

A

B

C

A

B

C

A

B

C

A

B

C

A

B

C

a

b

a

b


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