index [] 2008/c_index.pdf · index–1 1 index a abdominal flat plate (afp) 26-3 ... administrative...

1Index

AAbdominal flat plate (AFP) 26-3Abuse and neglect reporting requirements 3-10Accident resources and refunds 5-12Accident-related claims 5-12Accounts receivables 6-5ACD

see Augmentative communication devicesAcquired immunodeficiency syndrome (AIDS) 2-3Acronyms and Initialisms Dictionary A-1Acute lymphoblastic leukemia (ALL) 24-42, 24-85Acute medical episodes 18-10Acute nonlymphoblastic leukemia (ANLL) 24-85Adaptive feeder seats 14-6Adaptive strollers 14-6Add date 2-14Addresses

administrative review requests 4-5, 7-5authorization requests 4-2change of address request 3-5CLIA applications 19-2CLIA number notification 19-2DSHS-CSHCN Enrollment 3-5DSHS-CSHCN Provider Relations 1-5fair hearing requests 4-6, 7-6Provider Information Change Form B-58, B-59TMHP Provider Enrollment 3-2TMHP Publications i-iiTMHP-CSHCN Appeals 1-2TMHP-CSHCN Appeals and Adjustments 1-2TMHP-CSHCN Claims 1-2TMHP-CSHCN electronic claims and rejected reports 1-2TMHP-CSHCN Enrollment 1-2TMHP-CSHCN other correspondence 1-2TMHP-CSHCN Prior Authorization and Authorization 1-2TMHP-CSHCN TPR 1-2

Adenoidectomies 24-83Adjustment to claims 6-4Administration procedure codes for vaccines/toxoids 24-59Advanced practice nurse (APN)

authorization requirements 8-2benefits and limitations 8-2claim information 8-2electronic claims submission 5-18enrollment 8-2reimbursement 8-3

Aerosol treatments 24-7benefits and limitations 24-7pentamidine 24-7

AFPsee Abdominal flat plate

AIDSsee Acquired immunodeficiency syndrome

Air ambulance transport 9-4Air transportation (deceased clients) 31-2

benefits and limitations 31-2AIS

see Automated inquiry systemALL

see Acute lymphoblastic leukemiaAllergy services

benefits and limitations 24-7Ambulance

air ambulance transport 9-4authorization 9-4benefits and limitations 9-3billing for ambulance services 9-4claims information 9-4electronic claims submission 5-18emergency air ambulance transportation 9-3emergency ground transport 9-3, 9-4enrollment 9-2nonemergency ground transport 9-3, 9-4reimbursement 9-2

Ambulation aidscanes 14-7crutches 14-7gait trainers 14-13gait/ambulation belts 14-7prescription shoes 21-6prone/supine standers 14-18walkers 14-7

Ambulatory electroencephalogramdiagnosis codes 24-28

Ambulatory surgery authorizations 18-15Ambulatory surgical center (ASC)

benefits and limitations 18-10claims information 18-16hospital-based 18-7

electronic claims submission 5-25reimbursement 18-7

Americans with Disabilities Act 14-21Anatomical pathology services 19-5Anesthesia

administered by surgeon 24-70anesthesiology/anesthesiologists 24-8base units 24-8benefits and limitations 24-10dental 13-29, 13-33

anesthesia provided in a ASC/HASC 13-29anesthesia provided in an office setting 13-26

epidural 24-10

CPT only copyright 2007 American Medical Association. All rights reserved. Index–1

Index–2

Anesthesia (continued)modifiers 24-8nerve block 24-10regional 24-10reimbursement 24-9services incidental to anesthesia 24-9services incidental to surgery 24-9spinal 24-10time units 24-9

Anesthesiologysee Anesthesia

ANLLsee Acute nonlymphoblastic leukemia

Anterior temporal lobectomies 26-31authorization 24-85for complex partial seizures 24-85

Antibiotic desensitization 24-7, 24-8APN

see Advanced practice nurseApnea monitors 28-2, 28-6Appeals

120-day 3-2administrative claim appeals 7-5administrative review 4-5, 7-4

address 4-5, 7-5AIS appeals 6-9, 7-3allowed AIS appeals 7-3claims filed prior to enrollment 3-2clients eligible for Medicaid 2-12corrections and resubmissions 6-8disallowed AIS appeals 7-3electronic 6-9

advantages of electronic appeal submission 7-2disallowed electronic appeals 7-2electronic submission 7-2

exceptions to claims filing deadlines 5-8address 5-8

fair hearing 4-6address 4-6, 7-6

medical necessity denials 7-4paper 6-9, 7-3submitted incorrectly 7-4telephone appeals 7-3time limits 5-13TMHP administrative claim 7-5

ASCsee Ambulatory surgical center

Assistant surgeons 24-70Audiometry/hearing services

benefits and limitations 24-10hearing aids 24-10PACT 24-10procedure codes 24-10

Augmentative communication devices (ACDs)authorization requirements for ACD purchases or rental 10-3authorization requirements for ACD repairs 10-4authorization requirements for ACDs modifications 10-4benefits and limitations 10-2

modification 10-2

Augmentative communication devices (ACDs) (continued)

purchases or rentals 10-2repairs 10-3replacement 10-2

claims information 10-5electronic claims submission 5-18enrollment criteria 10-2noncovered ACD system items 10-5prior authorization requirements 10-3

Prior Authorization Request for Augmentative Communication Devices B-3

prior authorization requirements replacement 10-4reimbursement 10-5trial period requirements 10-4

Authorization/prior authorizationaddress 1-2advanced practic nurse (APN) 8-2ambulance 9-4ambulatory surgical centers 18-15anterior temporal lobectomies 24-85augmentative communication devices 10-3, 10-4

Prior Authorization Request for Augmentative Communication Devices B-3repairs 10-4replacement 10-4

augmentative communication devices purchase and rental 10-3authorization deadline calendar for 2007 4-7, 7-8authorization deadline calendar for 2008 4-8, 7-9bone marrow/stem cell transplants 24-85

Prior Authorization Request for Bone Marrow/Stem Cell or Renal Transplant B-4

car seats, documentation of 14-18certified registered nurse anesthetist 11-2certified respiratory care practitioner 12-2cleft/craniofacial surgeries 24-90clinician directed care coordination services 24-55

Authorization Request for Non-Face-to-Face Clinician-Directed Coordinated Care Service B-29

cochlear implants 24-15cranial molding devices 21-5definition of authorization 4-2definition of prior authorization 4-3dental 13-3

diagnostic procedures 13-4orthodontia 13-7preventive procedures 13-11Prior Authorization Request for Dental or Orthodontia Services B-6therapeutic procedures 13-13

diapers, pull-ups, underpads, briefs, or liners 15-6, B-27DME 14-5, B-7

Prior Authorization and Authorization Request for Durable Medical Equipment (DME) B-7

expendable medical supplies 15-8fair hearing 4-6freestanding surgical centers 18-15home health (skilled nursing) 16-2

CPT only copyright 2007 American Medical Association. All rights reserved.

Authorization/prior authorization (continued)hospice 17-2

Prior Authorization Request for Hospice Services B-10

hospital admissions 18-12hospital, inpatient 18-13

Prior Authorization Request for Inpatient Hospital Admission B-12

immunizations 24-59inpatient behavioral health

Prior Authorization Request for Inpatient Psychiatric Care B-11

inpatient rehabilitation services 18-14Prior Authorization Request for Inpatient Rehabilitation Admission B-14

medical nutrition services 20-3medical foods 20-3

Prior Authorization Request for Medical Foods B-16

medical nutrition products 20-4medical nutritional counseling services 20-10nutritional assessment, counseling, and products (additional) services

Prior Authorization Request for Nutritional Assessment, Counseling, and Products (Additional) B-17

medical nutritional productsformulary 20-4

omalizumab 24-50Authorization Request for omalizumab B-31

oral surgery procedures 24-90orthodontia

Prior Authorization Request for Dental or Orthodontia Services B-6

orthotics and prosthetics 21-3outpatient behavioral health 22-3outpatient physical therapy and occupational therapy 23-4

Authorization Request for Outpatient Therapy (TP1), Initial B-34Authorization Request for Outpatient Therapy (TP2), Extension B-32

physician services requiring authorization 24-84physician services requiring prior authorization 24-84podiatry 24-68prescription shoes 21-7radiology services 26-32reduction mammoplasty 24-91renal dialysis 27-7

Prior Authorization Request for Renal Dialysis Treatment B-20

renal transplants 18-14Prior Authorization Request for Bone Marrow/Stem Cell or Renal Transplant B-4

respiratory equipment 28-4Authorization Request for Apnea Monitor Rental B-25Authorization Request for Chest Physiotherapy Devices B-26

Authorization/prior authorization (continued)Authorization Request for Pulse Oximeter Devices B-35Prior Authorization Request for Respiratory Care—CRCP B-21

respiratory syncytial virus 24-61Prior Authorization Request for Palivizumab (Synagis) B-18

rhizotomy 24-92services requiring authorization by TMHP 4-2specialty team/center 24-4, 24-84speech-language pathology services 29-3stem cell transplants 24-85surgery 24-70

Prior Authorization and Authorization Request for Outpatient Surgery—For Outpatient Facilities and Surgeons B-23Prior Authorization Request for Inpatient Surgery—For Surgeons Only B-22

telemedicine services 24-93therapeutic apheresis 24-79total parenteral nutrition (TPN)/hyperalimentation 30-19vision related services 32-3

Authorizationssee Authorization/prior authorization

Automated inquiry system (AIS) 1-3AIS appeals 6-9claim corrections 7-3services provided 1-3User’s Guide 1-3verifying client eligibility 2-9

BBacille Calmette-Guérin (BCG) 24-60Banner messages 33-3Banner pages 6-2Base units 24-8BCG

see Bacille Calmette-GuérinBilateral procedures 24-71Bi-level positive airway pressure 15-6, 28-3Billing clients 3-9BiPAP

see Bi-level positive airway pressureBlood factor products 18-6, 18-10

benefits and limitations 24-52procedure codes 24-53

Blood pressure devices 14-7Blue Cross Blue Shield 5-11

nonparticipating physicians 5-11Bone growth stimulators 24-72Bone marrow/stem cell transplants 4-5, 18-4

benefits and limitations 18-15, 24-85facility reimbursement 18-4physician reimbursement 24-90prior authorization 24-85

Botulinum toxin, types A and B 24-39type A diagnosis codes 24-39type B diagnosis code 24-41


Index–4

Bus transportation (deceased clients)benefits and limitations 31-2

CCalendars

authorization and filing deadline calendar for 2007 5-14, 7-8authorization and filing deadline calendar for 2008 5-15, 7-9fair hearing and administrative review 7-7

Cancer screening 19-6benefits and limitations 24-12colorectal diagnosis codes 24-13procedure codes 19-6

Canes 14-7CAPD

see Continuous ambulatory peritoneal dialysisCar seats 14-17Cardiac blood pool imaging 26-4Casting 24-73CBC

see Complete blood countCCPD

see Continuous cycling peritoneal dialysisCerebrovascular accident (CVA) 24-89, 29-4Certificate

independent laboratory waiver 19-3physician-performed microscopy procedure 19-3

Certification and IRS W-9 form 3-3Certified registered nurse anesthetist (CRNA)

authorization requirements 11-2benefits and limitations 11-2claims information 11-3electronic claims submission 5-18enrollment 11-2reimbursement 11-3

Certified respiratory care practitioner (CRCP)benefits and limitations 12-2claims information 12-3electronic claims submission 5-18enrollment criteria 12-2prior authorization requirements 12-2reimbursement 12-3

CHAMPUS/CHAMPVA 5-8Change of address request 3-5

Provider Information Change Form B-58, B-59Chemistry tests 19-24Chemotherapy

benefits and limitations 24-13noncovered procedure 24-14procedure codes 24-13

Child support 3-10Children’s Health Insurance Program of Texas (CHIP)

eligibility 2-11CHIP

see Children’s Health Insurance Program of TexasChronic myelogenous leukemia (CML) 24-85Cidofovir 24-42Circumcision 24-74Claim number, explanation 6-3Claim refunds 6-7

Claim reissues 6-6Claim status inquiry (CSI) 33-2Claim voids 6-7Claims

processed by the Vendor Drug Program 2-3Claims filing

adjustments 6-4billing 5-41CMS-1450 5-25CMS-1500 5-18dates on claims 5-41deadlines 5-6dental emergency claims 13-35dental paper billing 13-34electronic claims submission 1-2, 5-41exception requests 5-8exceptions, holiday or weekend 5-6hospital

inpatient claims 5-6interim claims 5-6outpatient claims 5-6

incomplete information 5-13other insurance resources 5-7span dates 5-41third-party resources 5-7TMHP processing procedures 5-6when a service is a benefit of Medicare 5-6

Claims filing instructions 5-18CMS-1450 5-25CMS-1500 5-18deadlines 5-6dental 13-35DSHS 5-5exceptions 5-6modifier requirements 14-22multipage claim forms 5-12provider types and selection of claim forms 5-18TMHP 5-5TPR 5-9

Claims in process 6-8Claims information

advanced practice nurse 8-2ambulance 9-4ambulatory surgical centers 18-16augmentative communication devices 10-5certified registered nurse anesthetist 11-3certified respiratory care practitioner 12-3dental 5-37, 13-33durable medical equipment Durable medical equipment (DME)

claims information 14-22expendable medical supplies 15-8freestanding surgical centers 18-16home health (skilled nursing) 16-3Hospital

inpatient behavioral health 18-16hospital 18-15hospital-based surgical center claims 18-16laboratory services 19-31


Claims information (continued)medical nutrition services 20-11

medical foods 20-11medical nutritional counseling services 20-11medical nutritional products 20-11

occupational therapy 23-6orthodontics 13-7orthotics and prosthetics 21-7outpatient behavioral health 22-3outpatient physical therapy 23-6physician 24-94radiation therapy services 25-7

inpatient 25-8outpatient 25-8professional 25-8

radiology services 26-32inpatient 26-32outpatient 26-32

renal dialysis 27-7respiratory equipment 28-8speech-language pathology services 29-5total parenteral nutrition (TPN)/hyperalimentation 30-19transportation of remains of deceased clients 31-2vision related services 32-4

Claims payment summary 6-7claims - paid or denied 6-4claims in process 6-8EOB codes appendix 6-8

Clearinghouse 2-13Cleft lip/palate 29-3Cleft/craniofacial center team approval requirements 3-4Cleft/craniofacial surgery 13-32

prior authorization 24-90surgical procedures 4-5

CLIAsee Clinical Laboratory Improvement Amendments of 1988

Client benefits 2-2claims processed by the Vendor Drug Program 2-3Medical Transportation Program 2-3program limitations and exclusions 2-4services provided outside Texas 2-3

Client eligibility 2-1, 2-7CHIP/CSHCN benefits 2-11Medicaid/CSHCN benefits 2-12Medically Needy Program

claims filing 2-13spend down processing 2-13

telephone appeals 7-3verifying 2-9

Clients eligible for MedicaidMedically Needy Program (MNP) 2-12

Clinical Laboratory Improvement Amendments (CLIA) of 1988 19-2

regulations 3-10, 19-3requirements 3-10, 19-2

Clinical laboratory services outpatient services 19-4

Clinical treatmentmanagement 25-4planning 25-3

Clinician directed care coordination services 24-53authorization 24-55reimbursement 24-56

CMLsee Chronic myelogenous leukemia

CMS-1500 5-18claim form example 5-24claim form instructions 5-19

Cochlear implantauthorization requirements 24-15benefits and limitations 24-14, 29-5claims filing and reimbursement 24-15sound processor replacement guidelines 24-15

Codescoding 5-16

diagnosis coding 5-16procedure coding 5-16

CPT 5-16HCPCS 5-16ICD-9-CM 5-16

Complete blood count (CBCs) 19-25, 24-65Computed tomography (CT) scan 18-6, 26-4Consultations 24-34Contact information

CSHCN regional offices 1-5CSHCN telephone and fax communication 1-2TMHP Contact Center 1-2TMHP-CSHCN regional representatives 1-3TMHP-CSHCN Services Program Contact Center i-ii

Continuous ambulatory peritoneal dialysis (CAPD) 27-3, 27-4, 27-5, 27-6Continuous cycling peritoneal dialysis (CCPD) 27-3, 27-4, 27-5, 27-6Continuous positive airway pressure (CPAP) 15-6, 28-3Corrections and resubmissions (appeals) 6-8

automated inquiry system (AIS) 6-9electronic 6-9paper 6-9time limits 5-13

Cosurgery 24-71Cough stimulating devices 28-7CPAP

see Continuous positive airway pressureCPT codes

see CodesCranial molding devices 21-4Craniofacial anomaly 29-3CRCP

see Certified respiratory care practitionerCritical care 24-30CRNA

see Certified registered nurse anesthetist Crutches 14-7CSHCN

Eligibility Form 2-8program history i-iProvider Manual i-iregional offices 1-5


Index–6

CSHCN (continued)Region 1 1-6Region 11 1-14Region 2 1-6Region 3 1-7Region 4 1-8Region 5 North 1-9Region 5 South and 6 1-11Region 7 1-12Region 8 1-13Region 9 and 10 1-14

CSIsee Claim status inquiry

CTsee Computed tomography (CT) scan

Custom DMEcar seats 14-17documentation for authorization of car seats 14-18travel restraints 14-18

see Durable medical equipmentCVA

see Cerebrovascular accidentCytogenetics testing for leukemia and lymphoma 19-6Cytopathology

sites other than vaginal/cervical/uterine 19-19studies 24-66vaginal, cervical, and uterine sites 19-19

DDarbepoietin 24-44

diagnosis codes 24-44, 24-46Dates on claims 5-41Denials

verbal 5-10Denileukin diftitox 24-42Dental

anesthesia provided in an ASC/HASC 13-29Criteria for Dental Therapy Under General Anesthesia B-36

authorization requirements 13-3benefits and limitations 13-3claims filing 5-37

claim filing instructions 13-35electronic billing 13-34emergency claims 13-35paper billing 13-34

claims information 13-33dental treatment in ASC/HASC 13-29

anesthesia 13-29dental rehabilitation or restoration services 13-29

diagnostic proceduresbenefits and limitations 13-4clinical oral evaluation 13-4prior authorization 13-4radiographs or diagnostic imaging 13-4reimbursement 13-4tests and oral pathology procedures 13-5

doctor of dentistry services as a limited physician 13-30

Dental (continued)anesthesia 13-33cleft/craniofacial surgery 13-32evaluation and management 13-32surgery 13-30

surgical procedure codes 13-30X-ray 13-33

enrollment 13-3hosptial call 13-27orthodontia services

benefits and limitations 13-6prior authorization requirements 13-7


reimbursement 13-7required documentation 13-7

preventive proceduresauthorization requirements 13-11benefits and limitations 13-11dental nutrition counseling 13-11oral hygiene instruction 13-11reimbursement 13-11

dental prophylaxis and topical fluoride treatment 13-11sealants 13-12space maintainers 13-12

tobacco counseling 13-11reimbursement 13-33

supernumerary tooth identification 13-34tooth identification and surface identification systems 13-33

therapeutic proceduresadjunctive general services 13-28authorization requirements 13-13

interrupted treatment plan 13-13benefits and limitations 13-12dental anesthesia provided in an office setting 13-26dental behavior management 13-27dental hospital call 13-27endodontics 13-16

pulp caps 13-17root canals 13-17

implants 13-22internal bleaching of tooth 13-28maxillofacial prosthetics 13-21oral and maxillofacial surgery 13-25periodontics 13-18prosthodontics (removable) and maxillofacial prosthetics 13-20prosthodontics, fixed 13-23reimbursement 13-13restorations 13-13therapeutic drug injection 13-27

treatment in hospitals 13-29Diagnosis codes

allogenic transplants 24-87ambulatory electroencephalogram 24-28autologous and allogenic transplants 24-86, 24-89


Diagnosis codes (continued)blood pressure devices 14-7bone growth stimulation 24-72botulinum toxin type A 24-39botulinum toxin type B 24-41cancer screening, colorectal 24-13clubfoot casting 24-73darbepoietin 24-44, 24-46docetaxel 24-43electroencephalogram (ambulatory) 24-28epirubicin hydrochloride 24-44erythropoietin alfa (EPO) 24-44, 24-46gamma globulin 24-48hyperbaric oxygen therapy 24-38ibutilide fumarate 24-48intraoperative echography 24-15magnetic resonance imaging (MRI)

brain 26-11jaw joint 26-6, 26-9lower extremities 26-29lumbar spine 26-20neck and spine 26-13orbit/face/neck 26-8, 26-10pelvis 26-24thoracic spine 26-18upper extremities 26-27

orthodontia 13-6porfimer sodium 24-51positron emission tomography 26-31proton beam therapy 25-4radiation treatment delivery/port films 25-6septoplasty 24-75Strontium 89 25-6therapeutic apheresis 24-82total parenteral nutrition (TPN)/hyperalimentation 30-3

Diagnosis coding 5-16Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV)Diagnostic dental procedures

benefits and limitations 13-4clinical oral evaluations 13-4prior authorization 13-4radiographs or diagnostic imaging 13-4reimbursement 13-4tests and oral pathology procedures 13-5

Diapers 15-6Authorization Request for Diapers, Pull-ups, Underpads, Briefs, or Liners B-27

Direct supervision 24-5DME

see Durable medical equipmentDocetaxel 24-43

diagnosis codes 24-43Doctor of dentistry services as a limited physician 13-30

anesthesia 13-33cleft/craniofacial surgery 13-32evaluation and management 13-32X-ray procedures 13-33

Documentation requirements 3-6medical records 24-6

DSHS Health Region map 1-16DSM-IV

see Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision

Durable medical equipment (DME)adaptive feeder seats 14-6adaptive strollers 14-6ambulation aids 14-7authorization 14-5

Prior Authorization and Authorization Request for Durable Medical Equipment (DME) B-7

benefits and limitations 14-5blood pressure devices 14-7canes 14-7car seats/travel restraints 14-17claims filing 5-18cochlear implants 29-4, 29-5crutches 14-7custom DME 14-6Documentation of Receipt B-39Documentation of Receipt (Spanish) B-39enrollment 14-3gait trainers 14-13gait/ambulation belts 14-7gastrostomy devices 14-13glucose monitors 14-14hospital beds (manual and electric) 14-14hospital cribs 14-15hygiene equipment 14-16modifier requirements 14-22noncovered rehabilitative and therapeutic DME 14-21portable hydrocollator units 14-17portable paraffinn units 14-17portable wheelchair ramps 14-21pressure reducing pads 14-15prone/supine standers 14-18reimbursement 14-4respiratory equipment

enrollment 28-2Standard DME 14-6standers, prone and supine 14-18TENS units 14-19transfer boards 14-7travel chairs 14-19walkers 14-7wheelchairs 14-19

assessment 14-19manual wheelchairs 14-20positioning equipment 14-21power wheelchairs 14-20ramps 14-21Wheelchair Seating Evaluation Form B-48

Dysphagia/swallowing disorder 29-3


Index–8

EE/M

see Evaluation and management servicesECG

see ElectrocardiogramEchoencephalography 24-15EDI

see Electronic Data InterchangeEEG

see Electroencephalogram (ambulatory)EFT

see Electronic funds transferElectrocardiogram (ECG) 2-6, 19-27Electroencephalogram (EEG) (ambulatory) 24-28

benefits and limitations 24-28diagnosis codes 24-28procedure codes 24-28

Electromyogram (EMG) 19-26Electronic claim submission 5-41Electronic Data Interchange (EDI)

billing agents 33-4electronic transmission reports 33-5forms 33-6getting help 33-2overview 33-2services available 33-2setting up access 33-5submitting claims 33-4supported file types 33-6TexMedConnect 33-4TMHP website 33-3training 33-5vendor implementation 33-5vendor software 33-4

Electronic funds transfer (EFT) 5-3, 6-7advantages 5-3enrollment procedures 5-3Information and Authorization Agreement B-54

Electronic Remittance and Status (ER&S) report 5-41Electronic Remittance and Status (ER&S) Agreement B-56

Electronic transmission reports 33-5Electro-oculogram (EOG) 19-26Eligibility Form sample 2-10Eligibility verification (EV)

client 2-7Medicaid 2-12

Embalmingbenefits and limitations 31-2

Emergency air ambulance transportation 9-3Emergency ground ambulance transportation 9-4Emergency ground transportation 9-3Emergency Medical Transportation and Labor Act (EMTALA) 18-6Emergency services

benefits and limitations 24-33defined 9-3, 9-4emergency room 24-33hospital emergency room 24-6hospital-based emergency department services 18-6

Emergency services (continued)observation room 24-35prolonged physician services 24-35

EMGsee Electromyogram

EMTALAsee Emergency Medical Transportation and Labor Act

Enrollmentadvanced practice nurse (APN) 8-2ambulance 9-2augmentative communication devices 10-2certified registered nurse anesthetist (CRNA) 11-2certified respiratory care practitioner (CRCP) 12-2dental/orthodontia 13-3durable medical equipment (DME) 14-3, 28-2electronic funds transfer 5-3expendable medical supplies 15-2home health (skilled nursing) 16-2hospice 17-2hospital 18-3hospital-based and freestanding ambulatory surgical center 18-3inpatient behavioral health 18-4laboratory services 19-2medical foods 20-2medical nutrition services 20-2medical nutritional counseling 20-2occupational therapy 23-2orthotics and prosthetics 21-2outpatient behavioral health 22-2outpatient physical therapy 23-2physician 24-4

group billing procedure 24-94independent practices 24-4personal supervision versus direct supervision 24-5specialty team/center 24-4

radiation therapy 25-2radiology services 26-2renal dialysis 27-2respiratory equipment 28-2specialty team/center 18-4speech-language pathology services 29-2TMHP-CSHCN address 1-2total parenteral nutrition (TPN)/hyperalimentation 30-2vision related services 32-2

EOBsee Explanation of benefits

EOGsee Electro-oculogram

EOPSsee Explanation of pending status

Epidural, anesthesia 24-10Epirubicin hydrochloride 24-44EPO

see Erthropoietin AlfaEpoprostenol 24-44ER&S

see Electronic Remittance and Status (ER&S) report


Erythropoietin alfa (EPO) 24-44diagnosis codes 24-44, 24-46

ESWLsee Extracorporeal shock wave lithotripsy

EVsee Eligibility verification

Evaluation and management (E/M) servicesbenefits and limitations 24-29consultations 24-34emergency services 24-33initial and subsequent hospital care 24-29inpatient professional services 24-29new patient visits 24-29observation room services 24-35procedure codes 24-34prolonged physician services 24-35

Expendable medical suppliesauthorization requirements 15-8benefits and limitations 15-2claims information 15-8diapers 15-6enrollment 15-2examples of covered supplies 15-5reimbursement 15-2

Explanation of benefits (EOB) 2-12, 5-9codes appendix 6-8

Explanation of pending status (EOPS) 6-8, 7-2Extracorporeal shock wave lithotripsy (ESWL) 24-74Eye prostheses 21-6

FFair hearing 4-6

address 7-6Family nurse practitioner (FNP)

enrollment 8-2Fees

global 24-74lab handling 19-31

Ferritin and iron studies 19-25Filing deadlines 5-6

120-day 5-1390-day 2-1495-day 5-6calendar 5-14, 5-15, 7-8, 7-9exceptions 5-8fair hearing and administrative review calendar 7-7third-party resources 5-10

Financial transactions 6-5void and stop 6-7

Foods 20-3Forms

Authorization Request for Apnea Monitor Rental B-25Authorization Request for Chest Physiotherapy Devices B-26Authorization Request for Diapers, Pull-ups, Underpads, Briefs, or Liners B-27Authorization Request for Non-Face-to-Face Clinician-Directed Coordinated Care Services B-29Authorization Request for Omalizumab B-31Authorization Request for Outpatient Therapy (TP1),

Forms (continued)Initial B-34Authorization Request for Outpatient Therapy (TP2), Extension B-32Authorization Request for Pulse Oximeter Devices B-35Claim Status Inquiry (CSI) Authorization B-53Criteria for Dental Therapy Under General Anesthesia B-36Documentation of Receipt B-39Documentation of Receipt (Spanish) B-39Electronic Funds Transfer (EFT) Information and Authorization Agreement B-54Electronic Remittance and Status (ER&S) Agreement B-56Home Health (Skilled Nursing) Referral and Treatment Plan B-40Instructions for Completing the Provider Information Change Form B-58Physician/Dentist Assessment Form (PAF) B-43Physician/Dentist Assessment Form (PAF) Instructions B-42Prior Authorization and Authorization Request for Durable Medical Equipment (DME) B-7Prior Authorization and Authorization Request for Outpatient Surgery—For Outpatient Facilities and Surgeons B-23Prior Authorization Request for Augmentative Communication Devices B-3Prior Authorization Request for Bone Marrow/Stem Cell or Renal Transplant B-4Prior Authorization Request for Dental or Orthodontia Services B-6Prior Authorization Request for Hospice Services B-10Prior Authorization Request for Inpatient Hospital Admission B-12Prior Authorization Request for Inpatient Psychiatric Care B-11Prior Authorization Request for Inpatient Rehabilitation Admission B-14Prior Authorization Request for Inpatient Surgery—For Surgeons Only B-22Prior Authorization Request for Medical Foods B-16Prior Authorization Request for Nutritional Assessment, Counseling, and Products (Additional) B-17Prior Authorization Request for Palivizumab (Synagis) B-18Prior Authorization Request for Renal Dialysis Treatment B-20Prior Authorization Request for Respiratory Care—CRCP B-21Provider Information Change Form B-59Reimbursement Request for Transportation of the Remains of Deceased Clients B-45Vision Care Eyeglass Client Certification Form B-47Vision Care Eyeglass Client Certification Form (Spanish) B-47Wheelchair Seating Evaluation Form B-48

Formula 20-4


Index–1

Fraud and abuse 3-8Freestanding ambulatory surgical centers

claims information 18-16electronic claims submission 5-18reimbursement 18-7

GGait trainers 14-13Gait/ambulation belts 14-7Gamma globulin

diagnosis codes 24-48Gastrostomy devices 14-13

benefits and limitations 24-37electronic claims submission 5-18

Genetic services 24-37electronic claims submission 5-18

Global fees 24-74anesthesiologists 24-74surgeons 24-74

Glucose monitors 14-14Granisetron hydrochloride 24-47Group

billing procedure 3-3, 24-94practices 3-3, 24-4practices enrollment 24-4

GynechologicalPap smears 24-66

Gynecologicalcytopathology studies 24-66

HHBOT

see Hyperbaric oxygen therapyHCPCS

see Healthcare common procedure coding systemHealth Insurance Portability and Accountability Act (HIPAA) 3-7, 5-16, 7-2, 13-9, 33-2Health maintenance organization (HMO) 5-9Healthcare common procedure coding system (HCPCS)

Level I codesLevel II codes 5-16modifiers 5-17place of service coding 5-17

Hearing aids 24-10processed by Program for Amplification for Children of Texas (PACT) 2-3

Hearing servicessee Audiometry

Helicobacter pylori (H. pylori) 19-20HFCWCS

see High frequency chest wall compression systemsHigh frequency chest wall compression systems (HFCWCS) 28-2, 28-3, 28-4, 28-6, 28-7Hip knee ankle foot orthotics (HKAFO) 21-3Hip orthotics (HO) 21-3HIPAA

see Health Insurance Portability and Accountability Act

HIVsee Human immunodeficiency virus

HKAFOsee Hip knee ankle foot orthotics

HLAsee Human leukocyte antigen

HOsee Hip orthotics

Home health (skilled nursing)authorization requirements 16-2

Home Health (Skilled Nursing) Referral and Treatment Plan B-40

benefits and limitations 16-2claims filing 5-25claims information 16-3enrollment 16-2reimbursement 16-2

Hospicebenefits and limitations 17-2claims filing 5-25enrollment 17-2prior authorization requirements 17-2

Prior Authorization Request for Hospice Services B-10

reimbursement 17-3Hospital

ambulatory surgical center 18-7beds (manual and electric) 14-14benefits and limitations 18-8billing 5-41blood factor products 18-6, 18-10change of ownership 18-3claims information 18-15clinical treatment management 25-4cribs 14-15dental treatment in hospital/ambulatory surgical centers 13-29eligibility 18-3emergency inpatient hospital admissions 18-13enrollment 18-3freestanding surgical center claims 18-16hospital admission prior authorization requirements

Prior Authorization Request for Inpatient Hospital Admission B-12

hospital-based emergency department services 18-6hospital-based surgical center claims 18-16inpatient 18-13

claims filing 5-25hospital admission prior authorization requirements 18-12hospital extensions 18-13radiology reimbursement 26-4rehabilitation services 18-9, 18-14

inpatient behavioral healthbenefits and limitations 18-9claims information 18-16enrollment 18-4prior authorization


reimbursement 18-5

0 CPT only copyright 2007 American Medical Association. All rights reserved.

Hospital (continued)laboratory services 18-5, 19-5magnetic resonance angiography (MRA) 26-4magnetic resonance imaging (MRI) 26-5medical radiation physics, dosimetry, treatment devices, and special services 25-6outpatient 18-10

claims filing 5-25observation 18-11, 18-12radiology reimbursement 26-4services 18-10

positron emission tomography (PET) 26-31radiation therapy services 18-12radiation treatment delivery/port films 25-5radiology services 18-12rehabilitation services

Prior Authorization Request for Inpatient Rehabili-tation Admission B-14

reimbursement 18-4renal transplants 18-9


specialty team/center 18-4stem cell transplants 18-9


Strontium-89 25-6Technetium TC 99M 25-7

Hospital-based and freestanding ambulatory surgical centers 18-3Hospital-based emergency department professional services 24-33Human immunodeficiency virus (HIV) 2-3, 24-7, 24-48Human leukocyte antigen (HLA) 18-9, 24-85, 24-89Hydrochloride

diagnosis codes 24-44Hygiene equipment 14-16Hyperbaric oxygen therapy (HBOT)

benefits and limitations 24-37diagnosis codes 24-38

IIbutilide fumarate 24-48ICD-9-CM

see International Classification of Diseases, Ninth Revision, Clinical Modification

ICNsee Internal control number

IEPsee Individualized education plan

Immune globulin 24-48Immunizations

authorization requirements 24-59benefits and limitations 24-58noncovered vaccines/toxoids 24-60reimbursement 24-59Texas Vaccines for Children (TVFC) Program 24-58vaccines/toxoids 24-58

Incomplete claims 6-4appeal deadlines 5-13

Independent laboratory 19-1electronic claims submission 5-18physician-performed microscopy procedure certificates 19-3reimbursement 19-4services 19-1waiver certificate 19-3

Independent practices 24-4Individualized education plan (IEP) 23-4, 23-6Infliximab 24-50Inhalation therapy 24-7

benefits and limitations 24-7see Aerosol treatments

Initial and subsequent hospital carebenefits and limitations 24-29

Injectable medicationsbenefits and limitations 24-39botulinum toxin 24-39cidofovir 24-42darbepoietin 24-44denileukin diftitox 24-42docetaxel 24-43epirubicin hydrochloride 24-44epoprostenol 24-44erythropoietin alfa (EPO) 24-44granisetron hydrochloride 24-47ibutilide fumarate 24-48immune globulin 24-48immunizations 24-58infliximab 24-50lioresal 24-50porfimer sodium 24-51rituximab 24-51sumatriptan succinate 24-51topotecan HCL 24-51trastuzumab 24-52valrubicin 24-52

Injection administrationbenefits and limitations 24-39

Injections 24-39billed by physician 24-39modifiers 24-39

Inpatienthospital extensions 18-13hospital services 18-13professional services 24-29

benefits and limitations 24-29critical care 24-30emergency services 24-33hospital-based emergency department 24-33initial and subsequent hospital care (nonintensive) 24-29observation room services 24-35

radiation therapy 25-8rehabilitation services 18-9, 18-13reimbursement 18-4

Inpatient behavioral healthbenefits and limitations 18-9enrollment 18-4reimbursement 18-5

Inpatient hospital 18-8


Index–1

Insurance Premium Payment Assistance Program (IPPA) 2-2Intermittent peritoneal dialysis (IPD) 27-3Intermittent positive pressure breathing (IPPB) 2-6, 28-3Internal control number (ICN) 6-2International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) 5-30, 9-3, 24-89Intraocular lenses (IOL) 24-67Intraoperative echography 24-15

diagnosis codes 24-15Intrapulmonary percussive ventilation (IPV) system 28-3, 28-4, 28-7IOL

see Intraocular lensesIPD

see Intermittent peritoneal dialysisIPPA

see Insurance Premium Payment Assistance ProgramIPPB

see Intermittent positive pressure breathingIPV

see Intrapulmonary percussive ventilation systemIRS levies 6-6

JJuvenile rheumatoid arthritis (JRA) 23-4, 23-5, 23-6

KKidneys, ureters, and bladder (KUB) 26-3Knee ankle foot orthotics (KAFO) 21-3Knee orthotics (KO) 21-3

LLaboratory panel tests

complete blood count (CBCs) 19-25panel tests 19-24

Laboratory services 18-5benefits and limitations 19-4, 24-65chemistry tests 19-24claims information 19-31CLIA 19-2cytogenetics testing for leukemia and lymphoma 19-6cytopathology of sites other than vaginal, cervical, and uterine 19-19cytopathology of vaginal, cervical, and uterine sites 19-19cytopathology studies 24-66enrollment 19-2ferritin and iron studies 19-25handling fees 19-31Helicobacter pylori (H. pylori) 19-20hospital laboratory services 19-5hospital reimbursement 18-8independent laboratory services 19-5latex sensitivity testing 19-26panel tests 19-24physician laboratory services 19-5physician services 24-65

Laboratory services (continued)reference labs 19-31reimbursement 19-4urinalysis 19-30

Land transportation (deceased clients)benefits and limitations 31-2

Latex sensitivity testing 19-26LBW

see Low birth weightLDL

see Low density lipoproteinLimitations and exclusions 2-4Lioresal 24-50Low birth weight (LBW) 24-30, 24-33Low density lipoprotein (LDL) 24-83

MMagnetic resonance angiography (MRA) 26-4

abdomen 26-5chest 26-5head and/or neck 26-5lower extremities 26-5pelvis 26-5

Magnetic resonance imaging (MRI) 26-5brain 26-11lower extremities 26-29lumbar spine 26-20neck and spine 26-13orbit/face/neck 26-8pelvis 26-24temporomandibular (jaw) joint 26-6thoracic spine 26-18upper extremities 26-27

Manual pricingreimbursement 5-4

Manufacturer’s suggested retail price (MSRP) 20-12, 28-8Maximum allowable fee schedule

reimbursement 5-4Medicaid

eligibility 2-12spend down claims filing 2-14

Medical foodsauthorization 20-3benefits and limitations 20-3electronic claims submission 5-18enrollment 20-2prior authorization requirements 20-3

Prior Authorization Request for Medical Foods B-16

Medical necessity denial appeals 7-4Medical nutrition products 20-2Medical nutrition services

authorization requirements 20-3medical foods 20-3medical nutrition products 20-4medical nutritional counseling services 20-10medical nutritional products formulary 20-4

benefits and limitations 20-2medical foods 20-3medical nutrition products 20-3


Medical nutrition services (continued)medical nutritional counseling services 20-3

claims information 20-11medical foods 20-11medical nutritional counseling services 20-11medical nutritional products 20-11

enrollment 20-2medical foods 20-2medical nutrition products 20-2medical nutritional counseling 20-2

reimbursement 20-12medical foods 20-12medical nutrition products 20-12medical nutritional counseling services 20-12

Medical nutritional counseling servicesPrior Authorization Request for Nutritional Assessment, Counseling, and Products (Additional) B-17

Medical nutritional products and serviceselectronic claims submission 5-18

Medical radiation physics, dosimetry, treatment devices, and special services 25-6Medical record documentation requirements 3-6Medical Transportation Program (MTP) 2-3Medically Needy Program (MNP) 2-7, 2-12Medications

injectable 24-39oral 24-39

Methylmalonic acidemia and maple syrup urine disease (MSUD) 20-3, 20-8MNP

see Medically Needy ProgramModifier requirements for DME 14-22Modifiers 5-17

anesthesiology 24-8assistant surgeons 24-70injections and oral medications 24-39

MRAsee Magnetic resonance angiography

MRIsee Magnetic resonance imaging

MSRPsee Manufacturer’s suggested retail price

MSUDsee Methylmalonic acidemia and maple syrup urine disease

Multiple surgeries 24-74Myringotomies 24-83

NNational provider identifier (NPI) 5-20, 5-23, 5-30, 5-32, 5-39Nebulizers 28-4Nerve block

anesthesia 24-10Nerve conduction studies

benefits and limitations 24-68New patient visits 24-29Noncovered

benefits and limitations 2-4orthotics 21-4

Noncovered (continued)rehabilitative and therapeutic DME 14-21shoes/shoe inserts 21-6

Nonemergency ground transportation 9-4, 9-3Nonobturated gastrostomy devices 14-13NPI

see National provider identifier

OObservation room services

benefits and limitations 24-35Obturated gastrostomy devices 14-14Occupational therapy (OT) 2-2, 5-18, 17-2, 18-9, 18-10, 23-3, 23-4

benefits and limitations 23-3Office procedures

surgery 24-75Omalizumab 24-50

Authorization Request for Omalizumab B-31OMT

see Osteopathic manipulative treatmentOphthalmology

benefits and limitations 24-67intraocular lenses (IOL) 24-67ophthalmologists 32-4Vitrasert ganciclovir implant 24-67

Oral medicationsbenefits and limitations 24-39modifiers 24-39

Oral surgery proceduresprior authorization 24-90

Orthodontiabenefits and limitations 13-6claims filing 5-37diagnosis codes 13-6prior authorization requirements 13-7


reimbursement 13-7required documentation 13-7

Orthotics and prostheticsauthorization requirements 21-3benefits and limitations 21-2claims information 5-18, 21-7cranial molding devices 21-4enrollment 21-2eye prostheses 21-6noncovered orthotics 21-4noncovered shoes/shoe inserts 21-6orthotics 21-3prescription shoes and lifts 21-6prosthetics 21-5reimbursement 21-2

Osteopathic manipulative treatment (OMT) 23-3benefits and limitations 24-67

OTsee Occupational therapy

Out-of-office servicesbenefits and limitations 24-35physician 24-35


Index–1

Out-of-state providers 2-3, 3-5Outpatient (hospital)

hospital services 18-10observation 18-12reimbursement 18-4services 18-10

Outpatient behavioral health servicesauthorization requirements 22-3benefits and limitations 22-2claims information 22-3electronic claims submission 5-18enrollment 22-2reimbursement 22-4

Outpatient observation 18-11Outpatient physical therapy and occupational therapy

authorization requirements 23-4Authorization Request for Outpatient Therapy (TP1), Initial B-34Authorization Request for Outpatient Therapy (TP2), Extension B-32

benefits and limitations 23-3claims information 23-6coordination with the public school system 23-6enrollment 23-2reimbursement 23-2

Outpatient speech-language pathology servicesauthorization requirements 29-3benefits and limitations 29-2claims information 29-5coordination with the public school system 29-5enrollment 29-2reimbursement 29-2

Outpatient therapyelectronic claims submission 5-18

Oxygen concentrators 28-3

PPACT

see Program for Amplification for Children of TexasPAF

see Physician/Dentist Assessment FormPaid or denied claims 6-4PAN

see Prior authorization numberPap smears 24-66Pathology

enrollment 18-3Patient control number (PCN) 5-25Payouts 6-6PCN

see Patient control numberPediatric nurse practitioner (PNP)

enrollment 8-2Pentamidine aerosol 24-7Personal supervision 24-5

versus direct supervision 3-7PET

see Positron emission tomographyPhenylketonura (PKU) 20-3, 20-9Physical medicine 23-4, 24-68

Physical therapy (PT)benefits and limitations 23-4, 24-67

Physicianaerosol treatments 24-7after-hours services 24-35anesthesia 24-8authorization 24-83benefits and limitations 24-7bone growth stimulators 24-72bone marrow/stem cell transplants 24-85chemotherapy 24-13claims information 24-94cochlear implants 24-14

authorization requirements 24-15claims filing and reimbursement 24-15sound processor replacement guidelines 24-15

consultations 24-34electronic claims submission 5-18emergency services 24-6enrollment 24-4

group billing procedure 24-94independent practices 24-4personal supervisions versus direct supervisions 24-5specialty team/center 24-4

evaluation and management services 24-29genetics 24-37group practices 24-4hospital-based emergency 24-33laboratory services 19-5, 24-65office and outpatient services 24-29physical therapy 24-67prolonged services 24-35radiation therapy 24-69radiology services 24-69reimbursement 24-6renal transplants 24-91supervision 3-7, 24-5

Physician/Dentist Assessment Form 2-7Physician/Dentist Assessment Form (PAF)

form B-43instructions B-42

PKUsee Phenylketonura

Place of service (POS) 5-17, A-4Podiatry

authorization 24-68benefits and limitations 24-68electronic claims submission 5-18nerve conduction studies 24-68reimbursement 24-68

Polysomnography 19-26, 24-68Porfimer sodium 24-51

diagnosis codes 24-51Portable hydrocollator units 14-17Portable paraffin units 14-17Positron emission tomography (PET) 26-31Prescription shoes and lifts 21-6Preventive care check-ups 24-36

preventive health/medicine services 24-36


Preventive proceduresauthorization requirements 13-11benefits and limitations 13-11dental nutrition counseling 13-11oral hygiene instruction 13-11reimbursement 13-11

dental prophylaxis and topical fluoride treatment 13-11

sealants 13-12tobacco counseling 13-11

Prior authorizationdefinition of 4-3see Authorization/prior authorizationservices requiring prior authorization 4-4

Prior authorization number (PAN) 5-20, 5-30, 7-3Procedure codes

administration of vaccines/toxoids 24-59anesthesia 24-10audiometry 24-10augmentative communication devices 10-5blood factor products 18-11, 24-53body and upper extremity casts 24-73body and upper extremity splints 24-73body and upper extremity strapping 24-73bone marrow transplants 24-85cancer screening 19-6cardiac blood pool imaging 26-4cast removal or repair 24-73chemotherapy 24-13

noncovered codes 24-14cleft/craniofacial procedures 24-90clinical brachytherapy 25-4clinical treatment management 25-4clinical treatment planning 25-3, 25-4cytopathology, vaginal/cervical/uterine 19-19dental surgery 13-30dentist-physician 13-30

anesthesia 13-33cleft/craniofacial surgery 13-32evaluation and management 13-32surgery 13-30X-ray 13-33

electroencephalogram (ambulatory) 24-28eye examinations and ophthalmoscopy or ophthalmological services 32-8eye prostheses 21-6immunizations 24-58lenses

bifocal 32-8contact 32-9high power 32-9single vision 32-8trifocal 32-8

lower extremity casts 24-73lower extremity splints 24-73lower extremity strapping 24-73magnetic resonance angiography (MRA)

abdomen 26-5chest 26-5

Procedure codes (continued)head and/or neck 26-5lower extremities 26-5pelvis 26-5

magnetic resonance imaging (MRI)brain 26-11lower extremities 26-29lumbar spine 26-20neck and spine 26-13orbit/face/neck 26-8pelvis 26-24temporomandibular (jaw) joint 26-6thoracic spine 26-18upper extremities 26-27

medical radiation physics, dosimetry, treatment devices, and special services 25-6occupational therapy 23-2oral surgery procedures 24-90outpatient behavioral health 22-3outpatient physical therapy 23-2, 23-3positron emission tomography (PET) 26-31proton beam therapy 25-4radiation treatment delivery/port films 25-5renal transplant 24-92rhizotomy 24-93special lenses 32-9special vision services 32-5speech-language pathology 29-2surgery/anesthesia

noncovered (codes) 24-9surgical procedures 24-75tonsillectomies, adenoidectomies, and/or myringotomies 24-83total parenteral nutrition (TPN)/hyperalimentation 30-2vaccines/toxoids 24-58vision examination 32-4waiver certificate 19-3

Procedure codingCPT 5-16modifiers 5-17place of service (POS) 5-17

Program for Amplification for Children of Texas (PACT) 24-10

hearing aids 2-3Program limitations and exclusions 2-4Prolonged services

benefits and limitations 24-35physician 24-35

Prone/supine standers 14-18Prosthetics

see Orthotics and prostheticsProtective helmets 21-5Proton beam therapy 25-4

diagnosis codes 25-4Provider Agreement 3-3Provider and principal information forms 3-3Provider certification/assignment 3-8


Index–1

Provider enrollmentcertification and IRS W-9 form 3-3change of address request 3-5general information 3-2group billing procedure 3-3group practices 3-3out-of-state providers 3-5personal supervision versus direct supervision 3-7Provider Agreement 3-3provider and principal information forms 3-3Provider Enrollment Application 3-3provider’s license (copy) 3-4providers paid by DSHS-CSHCN 3-5requirements for bone marrow/stem cell transplant center approval 3-4requirements for cleft/craniofacial center team approval 3-4specialty team/center 3-4

Provider responsibilitiesbilling clients 3-9fraud and abuse 3-8general requirements 3-6Instructions for Completing the Provider Information Change Form B-58provider certification/assignment 3-8Provider Information Change Form B-59retention of records 3-6utilization control 3-8

Provider types and selection of claim forms 5-18Provider’s license 3-4Psychological testing 24-69PT

see Physical therapyPublic school system

coordination with outpatient physical and occupational therapy 23-6coordination with speech-language pathology services 29-5

Pulse oximeters 28-3, 28-8

RR&S

see Remittance and Status (R&S) reportsRadiation therapy services

benefits and limitations 25-3claims filing 5-18, 25-7

inpatient 25-8outpatient 25-8professional 25-8

clinical treatment management 25-4proton beam therapy 25-4

clinical treatment planning 25-3enrollment 25-2inpatient services 25-8limitations 25-3medical radiation physics, dosimetry, treatment devices, and special services 25-6noncovered services 25-7radioisotope therapy 25-6reimbursement 25-2stereotactic radiosurgery 25-5

Radiation therapy services (continued)radiation treatment delivery/port films 25-5

Strontium-89 25-6Technetium TC 99M 25-7

Radiation treatment delivery/port films 25-5Radioallergosorbent (RAST) 24-7, 24-50Radioisotope therapy 25-6Radiologist

reimbursement 26-4Radiology services

authorization/prior authorization 26-32benefits and limitations 24-69, 26-4cardiac blood pool imaging 26-4claims filing 5-18, 26-32

inpatient 26-32outpatient 26-32

computed tomography (CT) scan 26-4contrast material 26-4enrollment 26-2hospital inpatient radiology 26-4hospital outpatient radiology 26-4hospital reimbursement 18-8hospital services 18-12magnetic resonance angiography (MRA) 26-4magnetic resonance imaging (MRI) 26-5physician 24-69positron emission tomography (PET) 26-31provided by physician or at physician offices or clinics 26-3

abdominal flat plates 26-3radiologist 26-4reimbursement 26-2, 26-3

provided by or at an ASC/HASC 26-4reimbursement provided by or at an ASC/HASC 26-4X-rays 26-2

Rail transportation (deceased clients)benefits and limitations 31-2

RASTsee Radioallergosorbent

Reciprocating gait orthoses (RGO) 21-4, 23-6Record retention 3-6Reduction mammoplasty

prior authorization 24-91Reference labs and handling fees 19-31Referrals to other providers 24-69Refunds 7-4

accident resources 5-12other insurance 5-11

Regional anesthesia 24-10Regional offices

DSHS 1-5TMHP 1-3

Rehabilitationinpatient claims filing 5-25inpatient services 18-13

Reimbursementadvanced practice nurse (APN) 8-3ambulance 9-2ambulatory surgical centers 18-7anesthesiology 24-9augmentative communication devices 10-5


Reimbursement (continued)bone marrow/stem cell transplants 24-85, 24-90certified registered nurse anesthetist (CRNA) 11-3, 24-10certified respiratory care practitioner (CRCP) 12-3clinical laboratory services outpatient services 19-4clinician directed care coordination services 24-56dental/orthodontia 13-33durable medical equipment (DME) 14-4expendable medical supplies 15-2freestanding surgical centers 18-7home health (skilled nursing) 16-2hospice 17-3hospital 18-4

inpatient 18-4, 18-13laboratory 18-8outpatient 18-6, 18-10radiology 18-8, 18-12

hospital-based ambulatory surgical center 18-7immunizations (vaccines/toxoids) 24-59inpatient behavioral health 18-5laboratory services 19-4manual pricing 5-4maximum allowable fee schedule 5-4medical nutrition services 20-12

medical foods 20-12medical nutrition products 20-12medical nutritional counseling services 20-12

medical services provided outside of Texas 3-5, 10-2orthotics and prosthetics 21-2out-of-state providers 2-3outpatient behavioral health 22-4outpatient physical therapy and occupational therapy 23-2physician 24-6podiatrists 24-68radiation therapy services 25-2radiology services 26-2

provided by or at an ASC/HASC 26-4provided by or at physician offices or clinics 26-3

renal dialysis 27-8respiratory equipment 28-2speech-language pathology services 29-2telemedicine services 24-93Texas Medicaid Reimbursement Methodology (TMRM) 5-4total parenteral nutrition (TPN)/hyperalimentation 30-2transportation of remains of deceased clients 31-2vision related services 32-10

Relative value units (RVUs) 5-4Remittance and Status (R&S) reports

accounts receivables 6-5adjustments to claims 6-4appeals 6-8banner pages 6-2claim refunds 6-7claim reissues 6-6claim voids 6-7claims - paid or denied, incomplete claims 6-4

Remittance and Status (R&S) reports (continued)claims in process 6-8claims payment summary 6-7corrections and resubmissions 6-8electronic

see Electronic Remittance and Status (ER&S) report 5-41

EOB codes 6-8examples 6-9

accounts receivable 6-13adjustments 6-12backup withholding penalty information 6-14banner page 6-10claims - paid or denied 6-11explanation of EOPS messages 6-22explanation of EOB messages 6-21IRS levy information 6-15manual payouts 6-17refunds 6-18summary 6-20system payouts 6-16

explanation of row headings 6-3explanation of section headings 6-4financial transactions 6-5

void and stop 6-7general formatting guidelines 6-2incomplete claims 6-4IRS levies 6-6payouts 6-6stale-dated checks 6-7voids and stops 6-19

Renal dialysisbenefits and limitations 27-2claims filing 5-25claims information 27-7dialysis services 27-4dialysis training 27-6enrollment 27-2evaluation and management 27-7maintenance hemodialysis 27-6method I (composite rate) 27-4method II (dealing direct) 27-5prior authorization requirements 27-7

Prior Authorization Request for Renal Dialysis Treatment B-20

reimbursement 27-8ultrafiltration 27-7

Renal transplants 18-5, 18-14benefits and limitations 24-91

Respiratory equipmentapnea monitors 28-2, 28-6

Authorization Request for Apnea Monitor Rental B-25

benefits and limitations 28-3rental or purchase 28-3

claims information 28-8enrollment 28-2high frequency chest wall compression systems 28-2


Index–1

Respiratory equipment (continued)high frequency chest wall compression systems (HFCW) 28-6

Request for Chest Physiotherapy Devices B-26intrapulmonary percussive ventilation system (IPV) 28-7nebulizers 28-4other unspecified equipment 28-8oxygen concentrators 28-3prior authorization requirements 28-4

Prior Authorization Request for Respiratory Care—CRCP B-21

pulse oximeters 28-3, 28-8Authorization Request for Pulse Oximeter Devices B-35

reimbursement 28-2suction equipment 28-3tracheostomy tubes 28-3, 28-8

Respiratory syncytial virus (RSV) 24-60, 24-61prior authorization requirements 24-61

Prior Authorization Request for Palivizumab (Synagis) B-18

prophylaxis 24-61RGO

see Reciprocating gait orthosesRhizotomy 24-92Rituximab 24-51RSV

see Respiratory syncytial virus

SSecond opinions 24-75Septoplasty 24-75Services incidental to surgery and/or anesthesia

benefits and limitations 24-9Services outside of business hours

benefits and limitations 24-35physician 24-35

Services provided outside of Texasbenefits and limitations 2-3, 3-5

Services requiring authorization 4-2Services requiring prior authorization 4-4

physician 24-84Skilled nursing

see Home health (skilled nursing)Sleep studies

see PolysomnographySLP

see Speech-language pathologySO

see Spinal orthoticsSpace maintainers, dental

Preventive proceduresspace maintainers 13-12

Span dates 5-41Specialty team/center 24-84

enrollment 24-4prior authorization 24-4procedures 18-4services 4-5

Speech-language pathology (SLP) 5-18, 29-1authorization requirements 29-3benefits and limitations 29-2claims information 29-5cochlear implant surgery 29-5coordination with the public school system 29-5dysphagia/swallowing disorder 29-3enrollment 29-2reimbursement 29-2

Spend-down processingMedically Needy Program 2-13

Spinal orthotics (SO) 21-4Spinal, anesthesia 24-10Stale-dated checks 6-7Standard DME 14-6Standers, prone or supine 14-18Stem cell transplant

see Bone marrow/stem cell transplantsStem cell transplant facility requirements and reimbursement 18-4Strontium-89 25-6Suction equipment 28-3Sumatriptan succinate 24-51Surgery

adenoidectomies 24-83anesthesia administered by surgeon 24-70assistant surgeons 24-70authorization 24-70authorization/prior authorization

Prior Authorization and Authorization Request for Outpatient Surgery—For Outpatient Facilities and Surgeons B-24

benefits and limitations 24-70bilateral procedures 24-71bone growth stimulators 24-72casting 24-73circumcision 24-74cleft/craniofacial 13-32cochlear implant 29-5cosurgery 24-71extracorporeal shock wave lithotripsy 24-74global fees 24-74incidental services 24-9multiple surgeries 24-74myringotomies 24-83office procedures 24-75prior authorization

Prior Authorization Request for Inpatient Surgery—For Surgeons Only B-22

second opinions 24-75septoplasty 24-75tonsillectomies 24-83unlisted surgical codes 24-83Vitrasert ganciclovir implant 24-67

TTeam/center requirements 24-83Technetium TC 99M tetrofosmin 25-7Telemedicine services 24-93

authorization 24-93benefits/limitations 24-93


Telemedicine services (continued)reimbursement 24-93

Telephone appeals 7-2Telephone numbers

CSHCN regional offices 1-5CSHCN VIPS 2-9TMHP-CSHCN regional representatives 1-3TMHP-CSHCN Services Program Contact Center i-ii, 1-2

TENSsee Transcutaneous electric nerve stimulator

Texas Family Code compliance 3-10abuse and neglect reporting requirements 3-10child support 3-10

Texas Health Steps (THSteps)client eligibility 2-12Comprehensive Care Program (THSteps-CCP)

outpatient behavioral health benefits 22-2Texas Medicaid & Healthcare Partnership (TMHP)

Contact Center i-ii, 1-2, 3-11, 4-6Electronic Data Interchange (EDI) 33-1

appeal submission 7-2Provider Enrollment 3-2Regional Representatives 1-3website 33-3

banner messages 33-3file libraries 33-3publications 33-3

Texas Medicaid Reimbursement Methodology (TMRM) 5-4Texas State Board of Dental Examiners (TSBDE) 13-26Texas Vaccines for Children (TVFC) Program 24-58, 24-60TexMedConnect

getting started 33-6orthodontia claims 13-8overview 33-4

Therapeutic apheresisauthorization 24-79

Therapeutic proceduresadjunctive general services 13-28authorization requirements 13-13benefits and limitations 13-12dental anesthesia provided in an office setting 13-26dental behavior management 13-27dental hospital call 13-27endodontics 13-16

pulp caps 13-17root canals 13-17

implants 13-22internal bleaching of tooth 13-28interrupted treatment plan 13-13maxillofacial prosthetics 13-21oral and maxillofacial surgery 13-25periodontics 13-18prosthodontics (removable) and maxillofacial prosthetics 13-20prosthodontics, fixed 13-23reimbursement 13-13restorations 13-13

Therapeutic procedures (continued)therapeutic drug injections 13-27

Therapyhyperbaric oxygen (HBOT) 24-37occupational 23-2physical 24-67speech-language pathology 29-1

Third-party resources (TPR) 5-8, 5-30accident resources 5-12accident-related claims 5-12address 1-2, 5-11Blue Cross Blue Shield nonparticipating providers 5-11claims filing 5-9filing deadlines 5-10health maintenance organization 5-9payment sources 5-8refunds involving claims for accidents 5-12refunds to TMHP resulting from other insurance 5-11verbal denials 5-10

THKAOsee Thoracic hip, knee, and ankle orthotics

Thoracic hip, knee, and ankle orthotics (THKAO) 21-4THSteps

see Texas Health StepsTHSteps-CCP

see THSteps-Comprehensive Care ProgramTID

see Tooth identificationTMHP

see Texas Medicaid & Healthcare PartnershipTMRM

see Texas Medicaid Reimbursement MethodologyTonsillectomies 24-83Tooth identification (TID) 6-4, 13-23

surface identification 13-33Topotecan HCL 24-51Total parenteral nutrition (TPN)/hyperalimentation 2-2, 5-18

authorization 30-19authorization requirements 16-3benefits and limitations 30-3claims information 30-19electronic claims submission 5-18enrollment 30-2reimbursement 17-3, 30-2

TPNsee Total parenteral nutrition (TPN)/ hyperalimentation

TPRsee Third-party resources

Tracheostomy tubes 28-3, 28-8Transcutaneous electric nerve stimulator (TENS) 14-19Transfer boards 14-7Transplants

allogenic transplants 24-87autologous transplants 24-86bone marrow/stem cell 3-4, 24-85renal 18-14, 24-91


Index–2

Transportationair ambulance transport 9-4ambulance 9-1deceased client 31-1

air transportation 31-2benefits and limitations 31-2bus transportation 31-2claims information 31-2electronic claims submission 5-18embalming 31-2land transportation 31-2rail transportation 31-2reimbursement 31-2Reimbursement Request for Transportation of the Remains of Deceased Clients B-45

nonemergency ground ambulance transport 9-4Trastuzumab 24-52Travel restraints 14-18TriCare (formerly CHAMPUS/CHAMPVA) 5-8, A-1TSBDE

see Texas State Board of Dental ExaminersTVFC

see Texas Vaccines for Children (TVFC) Program

UUB04 (CMS 1450) 5-25

claim form instructions 5-25example 5-36

Unlisted surgical procedures 24-83Urinalysis 19-30Utilization control 3-8

VVaccines/toxoids 24-58

administration procedure codes 24-59authorization requirements 24-59noncovered 24-60procedure codes 24-58reimbursement 24-59

Valrubicin 24-52Vendor Drug Program (VDP) 2-3Vendor implementation for TMHP EDI services 33-5Verifying client eligibility 2-8Very low birth weight (VLBW) 24-30, 24-33Vision related services

authorization requirements 32-3benefits and limitations 32-2bifocal lenses 32-8claims information 32-4electronic claims submission 5-18enrollment 32-2high power lenses 32-9ophthalmologists 32-4optometrists 32-4reimbursement 32-10single vision lenses 32-8specialized lenses 32-9trifocal lenses 32-8Vision Care Eyeglass Client Certification Form B-46Vision Care Eyeglass Client Certification Form (Spanish) B-47

Vision related services (continued)vision related services eyewear 32-8

Vitrasert ganciclovir implant 24-67VLBW

see Very low birth weight

WWaiting list information 2-11Walkers 14-7Wheelchairs 14-19

assessment 14-19manual wheelchairs 14-20portable ramps 14-21positioning equipment 14-21power wheelchairs 14-20ramps 14-21

XX-ray

see Radiology services


index [] 2008/c_index.pdf · index–1 1 index a abdominal flat plate (afp) 26-3 ... administrative...

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