Appendix Forms and Form Examples C - TMHP 2006/C_Forms.pdfC–3 Forms and Form Examples C 17 17a...

A p p e n d i x

C
CForms and Form Examples
C.1 CMS-1500 Claim Form Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-2

C.2 CMS-1500 Example . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-6

C.3 Instructions for Completing the HCFA-1450 (UB-92) Claim Form. . . . . . . . . . . . . . . . . . C-7

C.3.1 Occurrence Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-14C.4 HCFA-1450 (UB-92) Example. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-15

C.5 Instructions for Completing the ADA Dental Claim Form. . . . . . . . . . . . . . . . . . . . . . . C-16

C.6 ADA Dental Claim Form Example . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-19

C.7 Instructions for Completing the Physician/Dentist Assessment Form . . . . . . . . . . . . . C-20

C.8 CSHCN Physician/Dentist Assessment Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-21

C.9 Prior Authorization Request for Inpatient Hospital Admission . . . . . . . . . . . . . . . . . . . C-23

C.10 Prior Authorization Request for Inpatient Rehabilitation Admission . . . . . . . . . . . . . . C-24

C.11 Prior Authorization Request for Bone Marrow/Stem Cell or Renal Transplant . . . . . . C-26

C.12 Authorization Request for Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-27

C.13 Request for Dental Authorization or Orthodontia Prior Authorization . . . . . . . . . . . . . C-28

C.14 Authorization Request for Durable Medical Equipment (DME). . . . . . . . . . . . . . . . . . C-29

C.15 Wheelchair Seating Evaluation Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-32

C.16 Documentation of Receipt for Durable Medical Equipment (DME). . . . . . . . . . . . . . . C-37

C.17 Authorization Form for Diapers or Nutritional Counseling . . . . . . . . . . . . . . . . . . . . . C-38

C.18 Authorization Request for Initial Outpatient Therapy (TP1) . . . . . . . . . . . . . . . . . . . . C-39

C.19 Authorization Request for Extension of Outpatient Therapy (TP2) . . . . . . . . . . . . . . . C-40

C.20 Home Health (Skilled Nursing) Plan of Care Form . . . . . . . . . . . . . . . . . . . . . . . . . . C-42

C.21 Authorization Request for Apnea Monitor Rental . . . . . . . . . . . . . . . . . . . . . . . . . . . C-44

C.22 Authorization Request for Chest Physiotherapy Devices. . . . . . . . . . . . . . . . . . . . . . C-45

C.23 Authorization Request for Pulse Oximeter Devices . . . . . . . . . . . . . . . . . . . . . . . . . C-46

C.24 Authorization Request for Omalizumab. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-47

C.25 Authorization Request for Hemophilia Blood Factor Products . . . . . . . . . . . . . . . . . . C-48

C.26 Transportation of the Remains of Deceased Clients Reimbursement Request. . . . . . C-49

C.27 Instructions for Completing the Provider Information Change Form . . . . . . . . . . . . . . C-50

C.28 Provider Information Change Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-51

C.29 Electronic Funds Transfer (EFT) Information and Authorization Agreement . . . . . . . . . C-52

C.30 Claim Status Inquiry (CSI) Authorization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-54

C.31 Electronic Remittance and Status (ER&S) Agreement . . . . . . . . . . . . . . . . . . . . . . . C-55

C.32 TDHconnect Order Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-57

Appendix C

C.1 CMS-1500 Claim Form InstructionsThe following instructions describe the information that must be entered in each of the block numbers of the CMS-1500 claim form. Block numbers not referenced in the table may be left blank. They are not required for claim processing by TMHP.

Block No. Description Guidelines

1a Insured’s ID number (for program checked above, include all letters)

Enter the patient’s nine-digit CSHCN client number.

2 Patient’s name Enter the patient’s last name, first name, and middle initial.

3 Patient’s date of birth Patient’s sex

Enter numerically the month, day, and year (MM/DD/YYYY) the client was born. Indicate the patient’s sex by checking the appropriate box.

5 Patient’s address Enter the patient’s complete address as described (street, city, state, and ZIP code).

9 Other insured’s name For special situations, use this space to provide additional information. Other uses include, but are not limited to the following:• If the patient is deceased, enter the date of death. If the services were

rendered on the date of death, indicate the time of death.

• If the patient has chronic renal disease, enter the date of onset of dialysis treatment.

Hospital to Hospital Transfers. Indicate the services required from the second facility and unavailable at the first facility.

10 Was condition related to:A) Patient’s employmentB) Auto accidentC) Other accident

Indicate by checking the appropriate box. If applicable, enter all available information in Block 11, Other Health Insurance Coverage.

11 Other health insurance coverage

• If another insurance resource has made payment, write: (Name) Insurance Company paid $(Amount) on (Date).

• If another insurance resource was billed and denied the claim, write: (Name) Insurance Company denied claim on (Date). Attach a copy of the denial letter or form to the claim. See section 1.24.4, Verbal Denials, for information on verbal denials and the 110-day rule.

• If the patient has health, accident, or other insurance policies or is covered by private or government benefit system that may pay in full or in part for the services billed on this form, enter all pertinent information available. If the patient is enrolled in Medicare, enter the patient’s Health Insurance Claim (HIC) number from the Medicare Identification Card. The notation of “Denied” indicates the third party resource denied the claim.

12 Patient or authorized person’s signature

Providers are encouraged to obtain the patient’s signature on claim forms; however, TMHP will process the claim without the signature of the patient. The patient’s signature authorizes the release of the medical information on the claim.

14 Date of current illness or injury If the services provided are accident-related, indicate the date of injury for the accident.

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Forms and Form Examples

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1717a

Name of referring physician or other source

Enter the complete name, address, ZIP code, and/or the Texas Provider Identifier (TPI) or (universal provider identification number [UPIN] in Block 17a), in the following situations:• Electronic billers should enter the six-digit Medicare number or UPIN.

• Clinical pathology consultations to hospital inpatients or outpatients must identify the attending physician.

• Consultation services must identify the referring physician.

• Laboratory and radiology services must identify the ordering physician.

• Speech-language therapy must identify the ordering physician.

• Physical therapy must identify the ordering physician.

• Occupational therapy must identify the ordering physician.

• In-home hyperalimentation services must identify the ordering physician.

19 Reserved for local use Multiple Transfers—Indicate that the claim is part of a multiple transfer and provide the other client’s complete name and nine-digit CSHCN number. Provide information about the accident including the date of occurrence, how it happened, whether it was self-inflicted or employment-related.

20 Was laboratory work performed outside your office?

Check the appropriate box. The information is not required to process claims, but it may be requested for retrospective review. If YES, enter the name and address or TPI of the facility that performed the service in block 32. The CSHCN Services Program regulations require a provider bill only for those laboratory services that he or she actually performed. Any services performed outside of the provider’s office must be billed by the performing laboratory or radiology center.

21 Diagnosis or nature of illness or injury

Enter the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code to the highest level of specificity available.

23 Prior authorization no. (PAN) Enter the prior authorization or authorization number (PAN) issued by TMHP if applicable.

24A Date of service (DOS) Enter the date of service for each procedure provided in a MM/DD/YYYY format. If more than one date of service is for a single procedure, each date must be given (such as 03/16, 17, 18/2005).Electronic Billers—The CSHCN Services Program does not accept multiple (to-from) dates on a single line detail. Bill only one date per line. “To” dates of service are not used on electronic claims.

24B Place of service (POS) Select the appropriate POS code for each service. If the patient is registered at a hospital, the POS must indicate inpatient or outpatient status at the time of service.Ambulance. The place of service for all ambulance transfers is the destination.


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Appendix C

24D Fully describe procedures, medical services, or supplies furnished for each date given

Enter the appropriate procedure codes for all procedures/services billed. If a procedure code is not available, enter a concise description.Give complete information for:• Injections. Provide a breakdown of each injection and separate the charge

for an injection from the office visit charge. Indicate the name of the drug, strength, and dosage; and the necessity for the injection by using one of the modifiers.

• Sutures. Indicate number of sutures, length, and location of laceration.

• Laboratory. Indicate the specific type of laboratory procedure.

• X-ray. Indicate the number of views and type.

• When unusual or extenuating circumstances occur, give a brief medical report.

Anesthesiologists. Enter the appropriate Current Procedural Terminology (CPT) anesthesia procedure code for all procedures billed. If the anesthesia is given for more than one procedure, identify all procedures performed and indicate what is considered the major procedure. A breakdown of charges is not necessary. Enter the time in minutes.Enter one of the following modifiers as appropriate:• Anesthesiologists use AA, AD, QJ, QO, or QQ.

• Use modifiers (e.g., acute, left, right) to describe services.

24E Diagnosis code Enter the line item reference (1, 2, 3, or 4) for each service or procedure as it relates to each ICD-9-CM diagnosis code identified in Block 21. If a procedure is related to more than one diagnosis, the primary diagnosis the procedure is related to must be the one identified. Do not enter more than one reference per procedure. This can result in denial of the service.

24F Charges Indicate your usual and customary charges for each service listed. Charges must not be higher than fees charged to private-pay patients.

24G Days or units If multiple services are performed on the same day, enter the number of services performed (such as the quantity billed).

24K Other The space is used to provide additional information such as pertinent comments that may explain an unusual procedure. It also is used to identify laboratory tests sent outside the provider’s office when a laboratory handling fee is billed in addition to laboratory tests. Members of a group practice (except pathology and renal dialysis groups) must identify the TPI of the doctor/clinic within the group who performed the service. The number that identifies the doctor/clinic as a member of that group practice should not appear in Block 33 and must not be used to bill the CSHCN Services Program.The CMS-1500 claim form is designed to list six line items in Block 24. If more than six line items are billed, a provider attaches additional forms.

26 Patient’s account number Optional—Any alphanumeric characters (up to 15) in this block are referenced on the Remittance and Status (R&S) report.

27 Accept assignment Not optional—All providers of CSHCN services must accept assignment to receive payment. Providers must check Yes. Electronic billers must submit a Y.

28 Total charge Enter the total of separate charges for each page of the claim. Enter the total of all pages on last claim if filing a multipage claim.

29 Amount paid Enter any amount paid by an insurance company or other sources known at the time of submission of the claim. Identify the source of each payment and date in Block 11. If the client makes a payment, the reason for the payment must be indicated in Block 11.

30 Balance due If appropriate, subtract Block 29 from Block 28 and enter the balance.


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31 Signature of physician or supplier

The physician/supplier or an authorized representative must sign and date the claim. Billing services may print Signature on File in place of the provider’s signature if the billing service obtains and retains on file a letter signed by the provider authorizing this practice.

32 Name and address of facility where services rendered

If services were provided in a place other than the patient’s home or the provider’s facility, enter name, address, and ZIP code, or the TPI of the facility where the service was provided.Ambulance—For ambulance transfers if the destination is a hospital, enter the name and address, and the TPI of the facility. Laboratory—For laboratory specimens sent to an outside laboratory for additional testing, the complete name and address or the TPI of the outside laboratory should be entered. The laboratory should bill the CSHCN Services Program for the services performed.

33 Physician or supplier’s name, address, ZIP code, and telephone number

Enter the CSHCN TPI, provider name, street, city, state, ZIP code, and telephone number.


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Appendix C

C.2 CMS-1500 Example

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

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

c. INSURANCE PLAN NAME OR PROGRAM 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 FORMOTHER1. MEDICARE MEDICAID CHAMPUS 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:

17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE

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)

17a. I.D. NUMBER OF REFERRING PHYSICIAN

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

32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERERENDERED (If other than home or office)

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 EMG COBRESERVED FOR

LOCAL USE

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

$ $ $

33. PHYSICIAN’S, SUPPLIER’S BILLING NAME, ADDRESS, ZIP CODE& PHONE #

PIN# GRP#

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

(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)

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 SERVICE Typeof

Service

Placeof

Service

PROCEDURES, SERVICES, OR SUPPLIES(Explain Unusual Circumstances)

CPT/HCPCS MODIFIER

DIAGNOSISCODE

PLEASEDO NOTSTAPLEIN THISAREA

FM

SEXMM DD YY

YES NO

YES NO

YES NO

PLACE (State)

GROUPHEALTH PLAN

FECABLK LUNG

■ ■

■ ■ ■ ■

■ Single Married Other

■ ■ ■

■ ■

■ ■

■ ■

■ ■Employed Full-Time Part-Time Student Student

Self Spouse Child Other

(Medicare #) (Medicaid #) (Sponsor’s SSN) (VA File #) (SSN or ID) (SSN) (ID)

( )

■

■ ■ ■ ■ ■ ■

■M

SEX

■

DAYSOR

UNITS

EPSDTFamilyPlan

F G H I J K24. A B C D E

■

■ ■

PLEASE PRINT OR TYPE APPROVED OMB-0938-0008 FORM CMS-1500 (12/90), FORM RRB-1500,APPROVED OMB-1215-0055 FORM OWCP-1500, APPROVED OMB-0720-0001 (CHAMPUS)

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C.3 Instructions for Completing the HCFA-1450 (UB-92) Claim FormThese instructions describe the information that must be entered in each of the block numbers of the HCFA-1450 (UB-92) claim form. Block numbers not referenced in the table may be left blank. They are not required for claim processing by TMHP.


1 Provider name, address, and telephone number

Enter the hospital name, street, city, state, ZIP code, and telephone number.

3 Patient control number (PCN) Optional—Any alphanumeric character (limit 16) entered in this block is refer-enced on the R&S report.

4 Type of bill (TOB)Most commonly used:111 – Inpatient hospital131 – Outpatient hospital141 – Nonpatient (laboratory or radiology charges)331 – Home health agency (Use TOB 331 only. All other TOBs are invalid and will deny.)

Enter the three-digit type of bill (TOB) code1st Digit – Type of Facility1 Hospital3 Home health agency7 Clinic (rural health clinic [RHC], federally qualified health center [FQHC])2nd Digit – Bill Classification1 Inpatient (including Medicare Part A)2 Inpatient (Medicare Part B only)3 Outpatient4 Other (for hospital-referenced diagnostic services, for example, labora-

tories and X-rays)3rd Digit – Frequency0 Nonpayment/zero claim1 Admit through discharge2 Interim – first claim3 Interim – continuing claim4 Interim – last claim5 Late charge(s) only claim

6 Statement covers period For inpatient and home health claims, enter the beginning and ending dates of service billed. For inpatient claims, this is usually the dates of admission and discharge.

7 Covered days For inpatient claims, enter the total days represented on this claim that are to be covered. Usually this is the difference between the admission and discharge dates. In all circumstances the number in this block is equal to the number of covered accommodation days listed in Block 46.

8 Noncovered days For inpatient claims, enter the total days represented on this claim that are not covered. The sum of Blocks 7 and 8 must equal the total days billed as reflected in Block 6.

12 Patient name Enter the patient’s last name, first name, and middle initial.

13 Patient address Enter the patient’s complete address as described (street, city, state, and ZIP code).

14 Patient birth date Enter numerically the month, day, and year (MM/DD/YYYY) the client was born.

15 Patient sex Indicate the patient’s sex by entering an M or F.

17 Admission date Enter numerically the date (MM/DD/YY) of admission for inpatient claims; date of service for outpatient claims; start of care (SOC) for home health claims.

18 Admission hour (required field)

Military time (00 to 23) must be used for the time of admission for inpatient claims or time of treatment for outpatient claims. Code 99 is not acceptable. This block is not required for nonpatients (TOB 141), home health claims (TOB 331), RHCs (TOB 711), or FQHCs (TOB 731).

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Appendix C

19 Type of admission Enter the appropriate type of admission code for inpatient claims:1 Emergency2 Urgent3 Elective4 Newborn (This code requires the use of special source of admission

code in Block 20)

20 Source of admission Enter the appropriate source of admission code for inpatient claims.For type of admission 1, 2, or 3:1 Physician referral2 Clinic referral3 Health maintenance organization (HMO) referral4 Transfer from a hospital5 Transfer from skilled nursing facility6 Transfer from another health care facility7 Emergency room8 Court/law enforcement9 Information not availableFor type of admission 4 (newborn):1 Normal delivery2 Premature delivery3 Sick baby4 Extramural birth5 Information not available

21 Discharge hour (required field)

For inpatient claims, enter the hour of discharge or death. Use military time (00 to 23) to express the hour of discharge. If this is an interim bill (patient status of 30), leave the block blank. Code 99 is not acceptable.


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22 Patient status For inpatient claims, enter the appropriate two-digit code to indicate the patient’s status as of the statement through date.01 Routine Discharge02 Discharged to another short-term general hospital03 Discharged to skilled nursing facility (SNF)04 Discharged to internal control number (ICF)05 Discharged to another type of institution06 Discharged to care of home health service organization07 Left against medical advice08 Discharged/transferred to home under care of a home intravenous (IV)

provider09 Admitted as inpatient to this hospital (for use only on Medicare outpa-

tient [OP] hospital claims)20 Expired or did not recover30 Still patient (Use only when client was in the facility for 30 consecutive

days if payment is based on diagnosis-related group [DRG].)40 Expired at home (hospice use only)41 Expired in a medical facility (hospice use only)42 Expired—place unknown (hospice use only)43 Federal hospital (such as a Veteran’s Administration (VA) hospital)50 Hospice—home51 Hospice—medical facility61 Medicare-approved swing bed62 Inpatient rehabilitation facility, including rehabilitation distinct part of a

hospital63 Long term care hospital64 Medicaid—only nursing facility65 Psychiatric hospital or psychiatric distinct part of a hospital71 Discharged to another institution of outpatient (OP) services72 Discharged to another institution

23 Medical record number Enter the patient’s medical record number (limited to ten digits) assigned by the hospital.

24-30 Condition codes Enter the two-digit condition code 05 and date the legal claim was filed for recovery of funds potentially due a patient as a result of legal action initiated by or on behalf of the patient if this condition is applicable to the claim.

32ab-35ab

Occurrence codes and dates Enter the appropriate code(s) and date(s). Blocks 54, 61, 62, and 84 must also be completed as required. See Section C.3.1, “Occurrence Codes,” on page C-14.

36 Occurrence span codes and dates

For inpatient claims, enter code 82 if this hospital admission is a readmission within 7 days of a previous stay. Enter the dates of the previous stay.

39 Value codes Accident Hour—For inpatient claims, if the patient was admitted as the result of an accident, enter the time of the accident using military time (00 to 23). Use code 99 if the time is unknown.


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Appendix C

42-43 Revenue codes and description

For inpatient hospital services, enter the description and revenue code for the total charges and each accommodation and ancillary provided. List accommo-dations first in the order of occurrence.List ancillaries in ascending order. The space to the right of the dotted line is to be used for the accommodation rate.a) Revenue code 001 is for the total charge and must be the last revenue

code on the list. Exception: Electronic billers must not use revenue code 001. Use of this code

causes the claim billed amount to be doubled. Electronic billers should not put a code in this block.

b) Radiology—Professional services by a physician must be billed separately by the physician.

c) Laboratory—If laboratory work is sent out, the name and address or nine-digit Medicaid TPI of the laboratory where the work was forwarded must be entered.

d) Anesthesia—Professional services by a physician or certified registered nurse anesthetists (CRNA) must be billed separately by the physician or CRNA.

e) Medical/Surgical Supplies—Itemize these services provided in the inpatient facility (such as infusion pumps, traction setups, and crutches only for inpatient use). If provided to all admitted patients, admission kits should be billed using revenue code 270.

f) Fetal Monitoring—Charges must be billed using revenue code 732.


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44 HCPCS/rates Inpatient:Enter the accommodation rate per day.Enter the date of service numerically (MM/DD/YY) for each service rendered along with the block number of the diagnoses listed in Blocks 67 through 75 corresponding to each procedure. If a procedure corresponds to more than one diagnosis, enter the primary diagnosis. Each service and/or supply must be itemized on the claim form. Outpatient:Outpatient claims must have the appropriate Healthcare Common Procedure Coding System (HCPCS) code or narrative description. Do not use revenue codes for billing these services.Enter the date of service numerically, and the block number of the diagnosis listed in Blocks 67 through 75 corresponding to each procedure. If a procedure corresponds to more than one diagnosis, identify the primary diagnosis. Each service except for medical/surgical and intravenous (IV) supplies and medication must be itemized on the claim or an attached statement. Example:

a) Emergency Room—Bill as Emergency room or Emergency room charge per use. If the client visits the emergency room more than once in one day, the time must be given for each visit. The time of the first visit must be identified in Block 18, using 00 to 23 hours military time (such as 1350 for 1:50 p.m.). Indicate other times on the same line as the procedure code.

b) Operating Room—Bill as Operating Room.c) Recovery Room—Bill as Recovery Room or Cast Room as appropriate.d) Injections—Must have Inj. – name, strength, quantity or the injection

code.e) Drugs and Supplies—Take-home drugs and supplies are not a benefit of

the CSHCN Services Program. Drugs administered in the outpatient setting must be billed with the modifier SH. The drug description must include the name, strength, and quantity.

f) Radiology—The description should provide the location and the number of views. As an alternative, identify the HCPCS code. Professional services by a physician must be billed separately by the physician. The license number of the ordering physician must be in Block 83.

g) Laboratory—Provide a complete description or use the procedure codes for the laboratory procedures. Professional services by a physician must be billed separately by the physician. The license number of the ordering physician must be in Block 83. If laboratory work is sent out, the name of the test and the name and address or Medicaid number of the laboratory where the work was forwarded must be entered.

h) Nuclear Medicine—Provide a complete description.i) Day Surgery—Day surgery should be billed as an inclusive charge.

Services provided in conjunction with the surgery (lab, radiology, anesthesia) should not be billed separately.

Note: The HCFA-1450 (UB-92) claim form is limited to 27 items per outpatient claim. If necessary, IV supplies (Y7112) and central supplies (Y7107) may be combined on the charge detail and considered as single items with the appro-priate quantities and total charges.

45 Service date Enter the date of service numerically corresponding to each procedure for outpatient claims.

46 Units of service Provide units of service, if applicable. For inpatient services, enter the number of days for each accommodation listed. If applicable, enter the number of pints of blood. When billing for observation room services, the units indicated in Block 46 should always represent hours spent in observation.


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Appendix C

47 Total charges Enter the total charges for each service provided.

48 Noncovered charges If any of the total charges are noncovered, enter this amount.

51 TPI Enter the nine-digit TPI.

54 Prior payments Enter amounts paid by any third party resource (TPR) and complete Blocks 32, 61, 62, and 84 as required.

58 Insured’s Name If other health insurance is involved, enter the insured’s name.

60 CSHCN identification number Enter the patient’s nine-digit CSHCN number.

61 Insured group name Enter the name and address of the other health insurance.

62 Insurance group number Enter the policy number or group number of the other health insurance.

63 Treatment authorization code Enter the prior authorization number (PAN) for home health services, freestanding psychiatric facilities, freestanding rehabilitation facilities, and for surgery if one was issued.

65 Employer name Enter the name of the client’s employer if health care might be provided. Complete Block 66.

66 Employer location Enter the complete address if an employer name is identified in Block 65.

67 Principal diagnosis code Enter the ICD-9-CM diagnosis code for the principal diagnosis to the highest level of specificity available.

68-75 Other diagnosis codes Enter the ICD-9-CM diagnosis code to the highest level of specificity available for each additional diagnosis. Enter one diagnosis per block.Laboratory—A diagnosis is not required for clinical laboratory services provided to nonpatients (TOB 141).Exception: A diagnosis is required when billing for estrogen receptor assays,

plasmapheresis, cancer antigen CA 125, immunofluorescent studies, surgical pathology, and alpha fetoprotein.

76 Admitting diagnosis Enter the ICD-9-CM diagnosis code in Block E indicating the cause of admission or include narrative.

79 Procedure coding method Enter code 5 for HCPCS or code 9 for ICD-9-CM. Code 9 is used only on inpatient hospital billings.

80-81 a, b, c, d, e

Principal and other procedure codes and dates

Enter the ICD-9-CM procedure code for each surgical procedure and the date each was performed.

82 Attending physician ID For inpatient claims, enter the physician’s license number or UPIN of the provider who performed the service or is responsible for the treatment and plan of care in the following format: 11233333.1 = Two-digit state indicator (for example, TX for Texas)2 = Licensing board indicator examples B = MD or DO C = Chiropractor D = Dentist P = Podiatrist3 = License numberExample: TXBL1234

If the provider has a temporary license number, enter TEMPO.Example: TXBTEMPO


C–12


C

83 a, b Other physician ID For inpatient claims, enter the license number for the provider who performed the principle surgical procedure. If the same as Block 83, state “Same.”For outpatient claims, enter the license number for the following:• The ordering physician for all laboratory and radiology services (If a

different physician ordered laboratory or radiology services, enter his or her license number in Block 82.)

• The designated physician for a limited client when the physician performed or authorized nonemergency care.

• If the referring physician is a resident, Blocks 82 and 83 must identify the physician who is supervising the resident.

84 Remarks This block is used to explain special situations such as the following:• The home health agency must document in writing the number of Medicare

visits used in the nursing plan of care and also in this block.

• If a patient stays beyond dismissal time, indicate the medical reason if any additional charge is made.

• If billing for a private room, the medical necessity must be indicated and signed by the physician.

• If services are the result of an accident the cause and location of the accident must be entered in this block. The time must be entered in Block 39.

• If laboratory work is sent out, the name and address or the TPI of the facility where the work was forwarded must be entered in this field.

• If the patient is deceased, enter the date of death.

• If services were rendered on the date of death, enter the time of death.

• If the services were the result of a referral from a family planning provider, write Family Planning Referral.

• If services were provided at another facility, indicate the name and address of the facility where the services were rendered.

• Enter the date of onset for patients receiving dialysis services.

85 Provider representative signature

The hospital representative must sign their name. Billing services may print Signature on File in place of the provider’s signature if the billing service obtains and retains on file a letter signed by a hospital representative autho-rizing this practice.

86 Date bill submitted Enter the date the bill was signed.


C–13

Appendix C

C.3.1 Occurrence CodesCode Description Guidelines

01 Auto accident/auto liability insurance involved

Enter the date of auto accident. Use this code to report an auto accident that involves auto liability insurance requiring proof of fault.

02 Auto or other accident/no-fault involved

Enter the date of an accident, including auto or other, where no-fault coverage allows insurance immediate claim settlement without proof of fault. Use this code in conjunction with occurrence codes 24, 50, or 51 to document coordination of benefits with the no-fault insurer.

03 Accident/TORT liability Enter the date of an accident (excluding automobile) resulting from a third party’s action. This incident may involve a civil court action in an attempt to require payment by the third party, other than no-fault liability.

04 Accident/employment-related

Enter the date of an accident that allegedly relates to the patient's employment and involves compensation or employer liability. Use this code in conjunction with occur-rence codes 24, 50, or 51 to document coordination of benefits with workers’ compensation insurance or an employer. Only services that are not covered by workers’ compensation may be considered for payment by the CSHCN Services Program.

05 Other accident Enter the date of an accident not described by the above codes. Use this code to report that no other casualty-related payers have been determined.

06 Crime victim Enter the date on which a medical condition resulted from alleged criminal action.

24 Date other insurance denied

Enter the date of denial of coverage by a third party resource.

25 Date benefits terminated by primary payor

Enter the last date for which benefits are claimed.

27 Date home health plan of treatment was established

Enter the date the current plan of treatment was established.

50 Date other insurance paid Enter the date of payment from a third party resource.

51 Date claim filed with other insurance

Enter the date a claim was filed with a third party resource.

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C

C.4 HCFA-1450 (UB-92) Example

234

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APPROVED OMB NO. 0938-0279

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A AB BC C

A AB BC C

OTHER DIAG. CODES

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3 1P

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12 3 PATIENT CONTROL NO. 4 TYPE

OF BILL

5 FED. TAX NO. 6 STATEMENT COVERS PERIOD FROM THROUGH 7 COV D. 8 N-C D. 9 C-I D. 10 L-R D. 11

12 PATIENT NAME 13 PATIENT ADDRESS

14 BIRTHDATE 15 SEX 16 MS 17 DATEADMISSION

18 HR 19 TYPE 20 SRC 21 D HR 22 STAT 23 MEDICAL RECORD NO.CONDITION CODES

24 25 26 27 28 29 3031

32 OCCURRENCECODE DATE




36 OCCURRENCE SPANCODE FROM THROUGH A

37

BC

abcd

39 VALUE CODES CODE AMOUNT



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42 REV. CD. 43 DESCRIPTION 44 HCPCS / RATES 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49○

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50 PAYER 51 PROVIDER NO. 53 ASG52 REL INFO BEN 54 PRIOR P AYMENTS 55 EST. AMOUNT DUE 56

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○DUE FROM PATIENT57

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58 INSURED’S NAME 59 P. REL 60 CERT. - SSN - HIC. - ID NO. 61 GR OUP NAME 62 INSURANCE GR OUP NO.

63 TREATMENT AUTHORIZATION CODES 64 ESC 65 EMPLOYER NAME 66 EMPLO YER LOCATION

67 PRIN. DIAG. CD. 76 ADM. DIAG. CD. 77 E-CODE 7868 CODE 69 CODE 70 CODE 71 CODE 72 CODE 73 CODE 74 CODE 75 CODE

79 P.C. 80 PRINCIPAL PROCEDURECODE DATE

81 OTHER PROCEDURECODE DATE

OTHER PROCEDURECODE DATE

82 ATTENDING PHYS. ID

A BOTHER PROCEDURE

CODE DATEOTHER PROCEDURE

CODE DATEOTHER PROCEDURE

CODE DATE A83 OTHER PHYS. ID

C D E84 REMARKS B

OTHER PHYS. ID

85 PROVIDER REPRESENTATIVE 86 DATE

xUB-92 HCFA-1450 OCR/ORIGINAL I CERTIFY THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.

C–15

Appendix C

C.5 Instructions for Completing the ADA Dental Claim FormThe instructions describe the information that must be entered in each of the block numbers of the 2002 American Dental Association (ADA) Dental Claim Form. Thoroughly complete the dental claim form according to the instructions below to facilitate prompt and accurate reimbursement and reduce follow-up inquiries.

Block No. ADA Description Instructions

1 Type of transaction For the CSHCN Services Program, check Statement of Actual Services Box. The other two boxes are not applicable. Do not use the ADA Dental Claim Form as a CSHCN prior authorization form.

2 Predetermination/ preautho-rization number

Enter prior authorization number if assigned by the CSHCN Services Program.

3 Name, address, city, state, ZIP code

Enter name and address of CSHCN Services Program Contractor payer where the claim is to be sent.

4 Other dental or medical coverage?

Leave blank if no other dental or medical coverage (skip Blocks 5–11). Check Yes, if dental or medical coverage is available other than CSHCN, and complete Blocks 5–11.

5 Subscriber name This line refers to the insured and is not necessarily the patient. May be parent or legal guardian of client receiving treatment.

6 Date of birth (MMDDYYYY) Enter insured’s 8-digit date of birth (MMDDYYYY). This line refers to the insured and is not necessarily the patient. May be parent or legal guardian of client receiving treatment.

7 Gender Check insured’s correct gender. This line refers to the insured and is not neces-sarily the patient. May be parent or legal guardian of client receiving treatment.

8 Subscriber identifier Enter insured’s subscriber identifier. This line refers to the insured and is not necessarily the patient. May be parent or legal guardian of client receiving treatment.

9 Plan/group number Enter insured’s plan/group number. This line refers to the insured and is not necessarily the patient. May be parent or legal guardian of client receiving treatment.

10 Relationship to primary subscriber

Enter insured’s relationship to primary subscriber. This line refers to the insured and is not necessarily the patient. May be parent or legal guardian of client receiving treatment.

11 Other carrier name, address, city, state, ZIP code

Information on other carrier, if applicable.

12 Name (last, first, middle initial, suffix), address, city, state, ZIP code

Enter client's last name, first name, and middle initial as exactly written on the Texas CSHCN Eligibility Verification Form (Form H3087).

13 Date of birth (MMDDYYYY) Enter client’s 8-digit date of birth (MMDDYYYY).

14 Gender Check client’s correct gender.

15 Subscriber identifier Enter client’s CSHCN number.

16 Plan/group number Not applicable for the CSHCN Services Program.

17 Employer name Not applicable for the CSHCN Services Program.

18 Relationship to primary subscriber

Not applicable for the CSHCN Services Program.

19 Student status For exception to periodicity, check the full time student (FTS) box and provide a narrative explanation in the Remarks Block 35.

20 Name (last, first, middle initial, suffix), address, city, state, ZIP code

Must put client name information, same as in Block 12.

21 Date of birth (MMDDYYYY) Must put client’s 8-digit date of birth information, same as in Block 13.

22 Gender Must put client gender information, same as in Block 14.

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C

23 Patient ID/account # (assigned by dentist)

Used by dental office to identify internal patient account number. This field is optional. Not required to process claim.

24 Procedure date (MMDDYYYY) Enter 8-digit date of service (MMDDYYYY).

25 Area of oral cavity Not applicable for the CSHCN Services Program.

26 Tooth system Not applicable for the CSHCN Services Program.

27 Tooth number(s) or letter(s) Enter the Tooth ID as required for procedure code. Select the appropriate tooth number for permanent teeth (01–32 or the appropriate letter for primary teeth 0A–0T).

28 Tooth surface Enter the Surface ID as required for procedure code using M (Mesial); F (Facial); B (Buccal or Labial); O (Occlusal); L (Lingual or Cingulum); D (Distal; and/or I (Incisal).

29 Procedure code Use appropriate Current Dental Terminology, fourth edition (CDT-4) procedure code.

30 Description Enter brief description from the CDT-4 procedure code.

31 Fee Enter usual and customary charges for each line of service used. Charges must not be higher than the fees charged to private pay patients.

32 Other fee(s) Enter other fees (e.g., other insurance payment).

33 Total fee Total all fees in column under Block 31.

34 Place an X on each missing tooth

Place an X on each missing tooth as required for procedure code.

35 Remarks Use the Remarks space for local orthodontia codes, a narrative explanation for exception to periodicity (Block 19), a facility name and address if place of treatment (Block 38) is not a provider office, an emergency narrative (Block 45), or additional information such as reports for 999 codes or multiple supernumerary teeth.

36 Patient/guardian signature Not applicable for the CSHCN Services Program.

37 Subscriber signature Not applicable for the CSHCN Services Program.

38 Place of treatment Check only Provider’s office box or Hospital box. Use Hospital if a day surgery facility was used.

39 Number of enclosures The CSHCN Services Program does not require enclosures to accompany a claim. Do not submit radiographs with claims.

40 Is treatment for orthodontics?

Check Yes or No as appropriate.

41 Date appliance placed Not applicable for the CSHCN Services Program.

42 Months of treatment remaining


43 Replacement of prosthesis? Not applicable for the CSHCN Services Program.

44 Date prior placement Not applicable for the CSHCN Services Program.

45 Treatment resulting from (check applicable box)

Providers are required to check Other Accident box for emergency claim reimbursement. If Other Accident box is checked, information about the emergency must be provided in Block 35.

46 Date of accident (MMDDYYYY)


47 Auto accident state Not applicable for the CSHCN Services Program.

48 Name, address, city, state, ZIP code

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


C–17

Appendix C

49 Provider Identification Required Information—Must enter the billing dentist's individual or group 9-character TPI (not the CSHCN TPI for the performing provider employed within a group).

50 License number Not applicable for the CSHCN Services Program.

51 Social Security number (SSN) or tax identification number (TIN)


52 Telephone number Enter area code and telephone number of billing group or individual (not the telephone number for the provider employed within a group).

53 Treating dentist signature Required signature by treating dentist or authorized personnel must be in Block 53.

54 Provider Identification Required Information—Must enter performing dentist's (provider who treated the client) 9-character TPI.

55 License number Not applicable for the CSHCN Services Program.

56 Address, city, state, ZIP code Not applicable for the CSHCN Services Program.

57 Telephone number Not applicable for the CSHCN Services Program.

58 Treating provider specialty This field is optional.


C–18


C

C.6 ADA Dental Claim Form ExampleDental Claim Form

1. Type of Transaction (Check all applicable boxes)

EPSDT/ Title XIX

HEADER INFORMATION

OTHER COVERAGE

Statement of Actual Services Request for Predetermination / Preauthorization

© 2002, 2004 American Dental Association

MISSING TEETH INFORMATION

34. (Place an 'X' on each missing tooth)

35. Remarks

J515 (Same as ADA Dental Claim Form – J516, J517, J518, J519)

1 2 3 4 5 6 7 8

32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

9 10 11 12 13 14 15 16 A B C D E F G H I J

T S R Q P O N M L K

Permanent Primary 32. Other Fee(s)

33.Total Fee

24. Procedure Date(MM/DD/CCYY)

25. Area of Oral Cavity

26.ToothSystem

27. Tooth Number(s)or Letter(s)

28. ToothSurface

29. ProcedureCode 30. Description 31. Fee

fold

RECORD OF SERVICES PROVIDED

TREATING DENTIST AND TREATMENT LOCATION INFORMATIONBILLING DENTIST OR DENTAL ENTITY (Leave blank if dentist or dental entity is not submitting claim on behalf of the patient or insured/subscriber)

PATIENT INFORMATION

18. Relationship to Primary Insured (Check applicable box) 19. Student Status

Self Spouse Dependent Child Other

20. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code

21. Date of Birth (MM/DD/CCYY) 23. Patient ID/Account # (Assigned by Dentist)22. Gender

M F

PRIMARY PAYER INFORMATION

3. Name, Address, City, State, Zip Code

5. Other Insured’s Name (Last, First, Middle Initial, Suffix)

11. Other Carrier Name, Address, City, State, Zip Code

4. Other Dental or Medical Coverage?

48. Name, Address, City, State, Zip Code

56. Address, City, State, Zip Code

54. Provider ID 55. License Number

49. Provider ID

52. Phone Number ( ) – 57. Phone Number ( ) –

50. License Number 51. SSN or TIN

Yes (Complete 5-11)No (Skip 5-11)

53. I hereby certify that the procedures as indicated by date are in progress (for procedures that require multiple visits) or have been completed and that the fees submitted are the actual fees I have charged and intend to collect for those procedures.

Signed (Treating Dentist) DateX

fold

fold

fold

2. Predetermination / Preauthorization Number

ANCILLARY CLAIM/TREATMENT INFORMATION

41. Date Appliance Placed (MM/DD/CCYY)

44. Date Prior Placement (MM/DD/CCYY)42. Months of Treatment Remaining

No Yes (Complete 44)

38. Place of Treatment (Check applicable box)

43. Replacement of Prosthesis?

39. Number of Enclosures (00 to 99)Radiograph(s) Oral Image(s) Model(s)

Yes (Complete 41-42)No (Skip 41-42)

40. Is Treatment for Orthodontics?

Provider’s Office Hospital ECF Other

45. Treatment Resulting from (Check applicable box)

47. Auto Accident State46. Date of Accident (MM/DD/CCYY)

Occupational illness/ injury Auto accident Other accident

AUTHORIZATIONS36. I have been informed of the treatment plan and associated fees. I agree to be responsible for allcharges for dental services and materials not paid by my dental benefit plan, unless prohibited by law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure of my protected health information to carry out payment activities in connection with this claim.

DatePatient /Guardian signatureX

37. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the below named dentist or dental entity.

DateSubscriber signatureX

58. Treating Provider Specialty

FTS PTS

1

2

3

4

5

6

7

8

9

10

6. Date of Birth (MM/DD/CCYY) 8. Subscriber Identifier (SSN or ID#)7. Gender

M F

9. Plan/Group Number 10. Patient’ s Relationship to Other Insured (Check applicable box)

Self Spouse Dependent Other

PRIMARY INSURED INFORMATION

12. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code

13. Date of Birth (MM/DD/CCYY) 15. Subscriber Identifier (SSN or ID#)14. Gender

M F

16. Plan/Group Number 17. Employer Name

C–19

Appendix C

C.7 Instructions for Completing the Physician/Dentist Assessment Form

Instructions for Completing thePhysician/Dentist Assessment Form (PAF) for the

Children with Special Health Care Needs Program CSHCN

Dear Doctor,Thank you for helping this family to apply for benefits from the Children with Special

Health Care Needs Program (CSHCN). The Physician/Dentist Assessment Form (or “PAF”) is akey part of the application process. The PAF is just two pages long, with a block that identifiesthe applicant plus six other short sections for you to complete. Please fill in the applicant’sidentifying information and then go on to Part 1.

1) DIAGNOSIS AND EVALUATION SERVICES (screening exam): Please complete Part 1 onlyif you need to do a workup or further examinations or tests to determine if the applicant meetsthe CSHCN “medical certification definition” (see Part 2). Please note that whenever CSHCNhas a waiting list, applicants cannot get diagnosis and evaluation services. To find out ifCSHCN currently has a waiting list, call 1-800-252-8023.

2) MEDICAL CERTIFICATION DEFINITION: Please pay particular attention to Part 2. Itcontains the definition of a child with special health care needs for CSHCN purposes. Theprimary diagnosis should reflect a chronic illness or disability that affects the child and meetsthe definition. The form has spaces to add as many as three additional diagnoses.

3) QUESTIONS FOR INITIAL APPLICATION TO CSHCN: Complete Part 3 only if this is thefirst time the applicant has ever applied to CSHCN. If the client is renewing his or herCSHCN application, please leave Part 3 blank.

4) DETERMINATION OF URGENT NEED FOR SERVICES: Part 4 is very important,especially when CSHCN has a waiting list. Your answers to Part 4 help CSHCN physiciansdetermine which children need health care services most urgently. This information is a factor indetermining the order in which to remove clients from the waiting list whenever available fundsmake it possible to do so. If you answer “yes” to Part 4a and/or 4b, your explanation is required.When answering 4a, please base your answer on what would happen if the applicant had noresources to pay for health care.

5) FUNCTIONAL NEEDS: The Texas Legislature requires CSHCN to collect this information.Please check all appropriate boxes.

6) SERVICES NEEDED: Please talk with the family and then check the blocks for any and allservices the client/applicant may require. This information will help CSHCN plan for effectiveservices now and in the future. It will not affect the applicant’s eligibility for services.

7) PHYSICIAN/DENTIST DATA: Part 7 must be filled out completely. Phone numbers areespecially important. Remember that to process the application, we must have your signatureand the date.

Thank you again for all you do to help the clients and families of CSHCN!

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C

C.8 CSHCN Physician/Dentist Assessment Form

CSHCN Physician/Dentist Assessment Form(For Application to CSHCN)

Please complete and sign this form for the person applying for the Children with Special Health Care NeedsProgram (CSHCN). If you need more copies or have questions, please refer to the instruction sheet or call1-800-252-8023. Send the completed form to the parent or guardian or to the client’s local CSHCN office.

Client/Applicant’s Name (Last, First, Middle): CSHCN Case No. (if known): Date of Birth:

Address (Street, City, State, Zip):

Parent/Guardian Name: Telephone No.: ( )

1) DIAGNOSIS AND EVALUATION SERVICES (screening exam): Is this a request for Diagnosis andEvaluation Services to determine whether the client/applicant has a chronic physical or developmentalcondition? (Please check the box.)

Yes Please indicate the appropriate V-Code: and go to the “Physician/DentistData” section on the reverse side. (Only CSHCN-enrolled providers will be reimbursed for Diagnosis and Evaluation Services.)

No Please complete the remainder of this form.

2) MEDICAL CERTIFICATION DEFINITION:

The client/applicant must be either:2a) A person younger than 21 years of age who has a chronic physical or developmental condition that:

• Will last or is expected to last for at least 12 months; and• Results or, if not treated, may result in limits to one or more major life activities; and• Requires health and related services of a type or amount beyond those required by children generally; and• Has a physical (body, bodily tissue or organ) manifestation; and• May exist with accompanying developmental, mental, behavioral, or emotional conditions; but• Is not solely a delay in intellectual development or solely a mental, behavioral, and/or emotional condition.

OR

2b) A person of any age who has cystic fibrosis.

I certify that the client/applicant meets the above definition. Yes No

PRIMARY DIAGNOSIS (must meet 2a or 2b above): ICD-9-CM Code & Descriptor (required):

________________________________________________________

Other Diagnoses and Conditions:

ICD-9-CM code: __________________________ Descriptor: _____________________________



3) QUESTIONS FOR INITIAL APPLICATION TO CSHCN: (If renewing, go to the next section)

Is the applicant’s condition a result of a traumatic injury or accident? Yes NoIf yes, date of trauma or accident? ___________________________If hospitalized, date of discharge home? ___________________________Date of admission to rehab. facility? ___________________________

For applicants less than 1 year old: Was the child born before 36 weeks gestation? Yes NoIf yes, date of discharge home after birth? _____________________________Has the child spent 14 consecutive days out of the hospital? Yes No

NOT VALID WITHOUT A PHYSICIAN OR DENTIST SIGNATURE ON PAGE 2

Page 1 of 2

C–21

Appendix C

CSHCN Physician/Dentist Assessment Form (Continued)

CLIENT/APPLICANT’S NAME: ___________________________________________________________

CSHCN #: DOB: / /

4) DETERMINATION OF URGENT NEED FOR SERVICES:

4a) Would an inability to get healthcare services cause a permanent increase in disability, intense painor suffering, or death? Please base your answer on what would happen if the applicant had noresources to pay for health care.

Yes NoIf Yes, explanation required: ________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4b) Is the family or client/applicant actively planning to move the client/applicant to a nursing home,group home, or similar institution in the next 6 months?

Yes NoIf Yes, explanation required: ________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4c) If there is additional information related to the complexity or severity of the client’s/applicant’scondition or need for care that the CSHCN Program should know, please indicate below or attachadditional narrative.

5) FUNCTIONAL NEEDS: Check appropriate blocks indicating the client/applicant’s functional needs or limitations

Physical Developmental Behavioral Emotional

6) SERVICES NEEDED: Check all blocks that apply for services the client/applicant may require.Data is for CSHCN Program planning purposes and does not affect eligibility.

7) PHYSICIAN/DENTIST DATA – Must Be Completed for All Applications

Physician/Dentist’s Name: (type or print) TPI#: Tax ID#: Specialty:

Mailing Address: (Street, City, State, Zip)

Contact Person’s Name: (type or print) Phone: ( ) Fax: ( )

PHYSICIAN/DENTIST SIGNATURE: DATE:

bone marrow transplantcase managementdental servicesdrugsdurable medical equipmentexpendable medical suppliesfamily support servicesgrowth hormone

help with drug co-payments hemophilia blood factor productshome health/nursing servicesinpatient hospital Insurance Premium Payment Assistancemental health servicesoutpatient services (including PT, OT & SLP)physician services

pulmozymerenal dialysis/renal transplantinhaled tobramycintotal parenteral nutrition transportation/meals/lodgingvision servicesother _________________________________________

C–22


C

C.9 Prior Authorization Request for Inpatient Hospital Admission

Prior Authorization Request for Inpatient Hospital Admission

Complete the following form and submit to the TMHP-CSHCN Authorization Department at12357-B Riata Trace Parkway MC-A11, Austin TX 78727 or fax to 1-512-514-4222.

For help completing this form, call TMHP-CSHCN Customer Service at 1-800-568-2413.

All inpatient hospital stays and extensions of inpatient stays must be PRIOR authorized. Refer to the CSHCN Provider Manual Part I for information regarding prior authorization requirements for emergency admissions. Please print or type requested information below.

Client Information: First name: Last name: CSHCN number: 9- -00

Date of birth: Diagnoses (ICD-9-CM):

Address/City/ZIP:

Procedure Information: Surgical procedure(s) requested (per ICD-9-CM vol. 3):

Surgeon’s name: Surgeon’s CSHCN TPI:

Number of days requested: Inpatient Extension

Date of admission: Anticipated date of discharge:

Facility name: Facility CSHCN TPI number:

Attending physician’s name: Attending physician’s CSHCN TPI:

Other insurance information(check EACH that applies) None Yes If Yes: Private Medicare Medicaid

Insurance Type/Carrier: Insurance ID number:

Medical Necessity Information: Document medical necessity by indicating items listed below that pertain to this hospital stay, including additional comments as necessary. (For bone marrow/stem cell transplants, refer to the CSHCN Provider Manual Part I for specific criteria that must accompany EACH request.)

Surgical admit Transfusions (excluding bone marrow/stem cell transplants)

Chemotherapy Diagnostics

ER admit Lab

Intensive care Radiology

IV fluids Persistent symptoms (e.g., seizures, fever)

IV medications Post-operative complications

Additional comments:

Provider Required Signature and Information:Provider name: CSHCN TPI number:

Provider contact name (if any):

Telephone number: Fax number:

Address/City/ZIP:

Provider signature: Date:

C–23

Appendix C

C.10 Prior Authorization Request for Inpatient Rehabilitation Admission

Page 1 of 2

Prior Authorization Request for Inpatient Rehabilitation Admission



All inpatient rehabilitation stays and extensions of rehabilitation stays must be PRIOR authorized. Please print or type requested information below.



Address/City/ZIP:

Procedure Information: Number of days requested: Initial Rehabilitation Rehabilitation Extension

Date of admission: Anticipated date of discharge:


Attending physician’s name: Attending physician’s CSHCN TPI:

Other insurance information (check each that applies) None Yes If Yes: Private Medicare Medicaid


Information Required for INITIAL Rehabilitation Admission Authorization: Name of team physician: Date of onset of condition:

Is the patient sufficiently alert to participate with the rehabilitation team?

In setting own treatment goals (n/a for patients less than 4 years old) Yes No

In therapeutic activities (must complete for patient of all ages) Yes No

Has the patient received inpatient rehabilitation at an earlier date? Yes No

If Yes, explain why needed now?

Has the patient lost previous level of attained functional independence through complications or recurrent illness, and re-attainment of functional independence is feasible?

Yes No

If child is under 4 years of age, will parent/caregiver be present during inpatient rehabilitation stay and participate in setting treatment goals? Yes No

If the patient has a congenital condition, what recent change in medical and functional status warrants inpatient rehabilitation? (If there has been no recent change, justification for inpatient rehabilitation must be sent in addition to this request form)

An initial authorization of up to 14 days is requested to determine the patient’s ability to progress toward treatment goals as a result of inpatient rehabilitation. Yes No

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C

Page 2 of 2

Prior Authorization Request for Inpatient Rehabilitation Admission


Information Required for Authorization Extension:This request is for an extension after a 14-day authorization.

Using the key provided, describe the patient’s Functional Level and Progress in the chart below.

Key for Functional Levels

A. Needs no assistance to independently perform activity.

B. Needs only standby assistance to independently perform activity.

C. Needs minimal assistance to independently perform activity.

D. Needs moderate assistance to independently perform activity.

E. Needs maximum assistance to independently perform activity.

F. Needs total care–unable to perform activity independently.

Functional Level and Progress

Functional Activity Functional Level on Initial Evaluation

(Give Dates)

Anticipated Functional Level

(Give Projected Dates)

Present Functional Level

(Give Current Date)

e.g. w/c mobility D 01/06/0606 A 02/15/06 C 01/29/06

Provider Signature and Information (Required for ALL Authorizations):I certify the treatment goals cannot be net through outpatient rehabilitation services and significant progress can be attained in cognitive and/or mobility and self care activities:

Provider name: CSHCN TPI number:



Address/City/ZIP:


C–25

Appendix C

C.11 Prior Authorization Request for Bone Marrow/Stem Cell or Renal Transplant

Prior Authorization Request for Bone Marrow/Stem Cell orRenal Transplant


For help completing this form, call the TMHP-CSHCN Contact Center at 1-800-568-2413.

The transplant center/coordinator or surgeon must complete this form. Remember that inpatient hospital admissions also must be prior authorized by or on behalf of the hospital using the Prior Authorization Request for Inpatient Hospital Admission.

Please print or type information depending upon the type of transplant requested.

Client Information (complete for both transplant types): First name: Last name: CSHCN number: 9- -00

Date of birth: Diagnosis (ICD-9-CM):

Address/City/ZIP:

Bone Marrow/Stem Cell Transplant Information: Lead surgeon’s name: Surgeon’s CSHCN TPI number:

Transplant facility name: Facility CSHCN TPI number:

Has this client had a previous bone marrow/stem cell transplant? No Yes

Number of times the client previously has been in remission:

Transplant CPT procedure code(s):

Client status, statement of medical necessity for transplant, and long-term prognosis (attach additional pages as needed):

Renal Transplant Information: Lead Surgeon’s name: Surgeon’s CSHCN TPI number:

Transplant facility name: Facility CSHCN TPI number:

Type of transplant: Living-Related Cadaveric Type of dialysis: Hemodialysis Peritoneal

Transplant CPT procedure code(s):

Client status, statement of medical necessity for transplant, and long-term prognosis (attach additional pages as needed):

Facility/Hospital Required Signature and Information:I/we certify that the client meets the institutional guidelines for the transplant protocol and the policy requirements for the transplant requested, and that a Medicaid-approved team will perform the transplant in an approved Texas Medicaid transplant facility that is also enrolled as a CSHCN provider.

Provider name: CSHCN TPI number:



Address/City/ZIP:


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C.12 Authorization Request for Surgery

Authorization Request for Surgery



Please print or type requested information below.



Address/City/ZIP:

Procedure Information: Surgical procedure(s) requested (per ICD-9-CM vol. 3):

Surgeon’s name: Surgeon’s CSHCN TPI number:

Inpatient surgery? No YesIf yes, the admitting facility must obtain prior authorization for an inpatient stay. Some surgery procedures have specialty team requirements.

Outpatient surgery? No YesSome outpatient surgery procedures have specialty team requirements. Contact CSHCN or refer to the CSHCN Provider Manual—Part I for more information.

Anticipated date of surgery:


Other insurance information(check each that applies) None Yes If Yes: Private Medicare Medicaid


Freestanding Surgical Center Information: If freestanding surgical center, indicate patient’s physical status (ASA level) below.

ASA I/P1 Normal healthy patient

ASA II/P2 Patient with mild systemic disease

If the patient’s condition is P3, P4, P5, or P6, services may not be authorized in a freestanding surgical center.Descriptions follow.

ASA III/P3 Patient with severe systemic disease

ASA IV/P4 Patient with severe systemic disease which is a constant threat to life

ASA V/P5 Moribund patient who is not expected to survive without the operation

ASA VI/P6 Declared brain-dead patient whose organs are being removed for donor purposes

Please include additional information as applicable (documentation for procedures, medical necessity, etc.).For rhizotomy, craniectomy for anterior temporal lobectomy, and bone marrow/stem cell transplant, see theProvider Manual—Part I for specific criteria that must accompany the request for any of these procedures.




Address/City/ZIP:


C–27

Appendix C

C.13 Request for Dental Authorization or Orthodontia Prior Authorization

Request for Dental Authorization or Orthodontia Prior Authorization






Address/City/ZIP:

Dental Procedures: CDT Code(s) TID SID POS

Anticipated date of service:

Orthodontia Procedures: (Summarize the Orthodontia Treatment Plan and attach a copy of the completed and scored HLD Index calculation.)CDT code(s) for each orthodontic procedure:

Estimated month of placement for each appliance:

Estimated number of adjustments for each appliance:


Provider contact name:


Address/City/ZIP:


Revisions to initial treatment plans must be submitted to TMHP-CSHCN at the address listed at the top of this form.

C–28


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C.14 Authorization Request for Durable Medical Equipment (DME)

Page 1 of 3

Authorization Request for Durable Medical Equipment (DME)



Please note this is a 3-page form. For specialized seating or custom wheelchair purchase requests, also complete the 5-page TMHP CSHCN Wheelchair Seating Evaluation Form.


Client Information

First name: Last name: CSHCN number: 9- -00


Address/City/ZIP:

Part I – Statement of Medical Necessity -- Required for ALL equipment requests.

Item is to be: Purchased Modified Repaired Rented and if rental, Service Date: .

Client’s Height: Client’s Weight:

Description of Item:

Equipment needed for: Lifetime < 6 months > 6 months > 1 year Other: .

I certify that the patient’s medical condition is such that all equipment requested above is medically necessary. (Some items may require additional medical justification.)

Type or print Physician’s Name:

Physician’s Signature: Date signed:

Part 2 – Vendor Information

Must be completed and signed by the VENDOR. The equipment description and pricing information indicated below must be complete. For custom DME requests, attach manufacturer’s price sheet(s) for each item.

Equipment Description Pricing Information

Brand Name or HCPCS Code

Model # Item Description HCPCSPrice or

Cost/Retail Price

CSHCNPrice

Total

Provider Information Type or print Orthotist/Prosthetist name: CSHCN TPI number:

Supplier/Provider name: CSHCN TPI number:


Address/City/ZIP:

Signature of DME Provider: Date:

C–29

Appendix C

Page 2 of 3

Authorization Request Form for DME (page 2 of 3)

Submit this page (in addition to page 1) if requesting authorization for gait trainers or standers. Include a plan for training the caretakers and/or family on the correct, safe use of the equipment and monitoring the client’s need for increases or decreases in time using the equipment at home. Also include the name of the therapist that is coordinating and/or monitoring the school and/or home standing program

Client InformationFirst name: Last name: CSHCN number: 9- -00


Address/City/ZIP:

Additional Information for Gait Trainer Requests: Child’s condition/functional level:

Is the child expected to be ambulatory, and if so, when?

Specify the time, frequency, and location where the gait trainer will be used:

Specify the length of time the gait trainer is expected to be needed:

Specify the growth potential of the equipment:

Therapist’s name typed or printed:


Therapist’s signature: Date:

Additional Information for Prone or Supine Stander Requests: Child’s condition/functional level:

Specify anticipated benefits expected from the stander:

Frequency and amount of time of the child’s standing program (e.g., 45 minutes, 3 x daily):

Frequency the stander will be used at home:

Length of time the stander is expected to be needed (growth potential):

Therapist’s name typed or printed:



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Page 3 of 3

Authorization Request Form for DME (page 3 of 3)

Submit this page (in addition to page 1) if requesting authorization for car seats, bathroom equipment, or hospital cribs/enclosed beds.

Client InformationFirst name: Last name: CSHCN number: 9- -00


Address/City/ZIP:

Additional Information for Special Needs Car Seat or Travel Restraint Requests:

Head Control: Good Fair Poor

Trunk Control: Good Fair Poor

Equipment Requested:

Name of Certified Installer:

Name of Person Completing Form: Telephone number:

Additional Information for Hygiene Equipment Requests: Equipment Requested:

Is this replacement equipment? Yes No

If yes, why existing equipment cannot be used:

Tone: High Low Fluctuating Absent

Head Control: Good Fair Poor

Trunk Control: Good Fair Poor

Upper Extremity: Good Fair Poor

Lower Extremity: Good Fair Poor

Transfers: Dependent Independent

Name of Person Completing Form: Telephone number:

Additional Information for Hospital Crib/Enclosed Bed Requests: Medical needs, developmental level, and functional skills:

Describe any other less-restrictive devices which have been used, the length of time used, and why ineffective:

Describe why a regular child’s crib, regular bed, or standard hospital bed cannot be used:

Name of Therapist or Doctor typed or printed:


Signature of Therapist/Doctor: Date:

C–31

Appendix C

C.15 Wheelchair Seating Evaluation Form

Page 1 of 5

CSHCN Wheelchair SeatingEvaluation Form



This is a 5-page form. This form is used to supplement information supplied on the 3-page CSHCN Authorization Request for Durable Medical Equipment (DME).


ATTENTION: A current wheelchair seating assessment, conducted by a physical or occupational therapist, must be completed for purchase of or modifications (including new seating systems) to a customized wheelchair. Attach manufacturer information, descriptions and an itemized list of retail prices for all additions not included in base model price.Requests for customized manual and power wheelchairs must include a complete description of the specific base, any attached seating system components and any attached accessories not included in the base price, as well as the retail prices for the individual components, including justification for components that would be considered part of the wheelchair.

Client Information



Address/City/ZIP:

Client’s height: Client’s weight:

Complete Parts I-VI for manual wheelchairs. Complete Parts I-VII for power wheelchairs.

Part I – Neurological Factors

Indicate client’s muscle tone: Hypertonic Absent Fluctuating Other

If other, describe client’s muscle tone:

Describe active movements affected by muscle tone:

Describe passive movements affected by muscle tone:

Describe reflexes present:

Part II – Postural Control

Head control: Good Fair Poor None

Trunk control: Good Fair Poor None

Upper extremity: Good Fair Poor None

Lower extremity: Good Fair Poor None

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Page 2 of 5

Wheelchair Seating Evaluation Form (page 2 of 5)

Part III – Medical/Surgical History and Plans

Is there a history of decubitus/skin breakdown? Yes No

If yes, explain:

Describe orthopedic conditions and/or range of motion limitations requiring special consideration (i.e., contractures, spinal curvature):

Describe other physical limitations or concerns (i.e., respiratory problem):

Describe any recent or expected changes in medical/physical/functional status:

If surgery is anticipated, indicate the procedure and expected date:

Part IV – Functional Assessment

Ambulatory Status: Non-ambulatory With assistance

Short distances only Community ambulatory

Indicate client’s ambulation potential: Not expected Expected within one year

Expected in future within ____ years

Is client totally dependent upon wheelchair? Yes No

If no, explain:

Indicate the client’s transfer capabilities: Maximum assistance • Moderate assistance

Minimum assistance Independent

Feeding: Maximum assistance Moderate assistance


Is the client tube fed? Yes No

If yes, explain:

Dressing: Maximum assistance Moderate assistance


Describe other activities performed while in wheelchair:

C–33

Appendix C

Page 3 of 5


Part V – Environmental AssessmentDescribe where client resides:

Is the home accessible to the wheelchair? Yes No

Are ramps available in the home setting? Yes No

Describe the client’s educational/vocational setting:

Is the school accessible to the wheelchair? Yes No

Are ramps available in the school setting? Yes No

If client is in school, has a school therapist been involved in the assessment? Yes No

Name of school:

Name of school therapist: School therapist’s telephone number:

Describe how the wheelchair will be transported:

Describe where the wheelchair will be stored:

Describe other types of equipment that interface with the wheelchair:

Part VI – Requested EquipmentDescribe client’s current seating system, including the mobility base and the age of the seating system:

Wheelchair type:

Serial number: Date of purchase:

Describe why current seating system is not meeting the client’s needs:

Describe the equipment requested:

Describe the medical necessity for mobility base requested:

Describe the medical necessity for the seating system requested:

Describe the growth potential of equipment requested in number of years:

Describe any anticipated modifications/changes to the equipment within the next three years:

Therapist’s name: Therapist’s title:

Therapist’s telephone: Therapist’s fax:


Therapist’s employer:

Address/City/ZIP:

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Page 4 of 5


Part VII – Power Wheelchairs (Also complete this part when requesting a power wheelchair)Describe the medical necessity for power vs. manual wheelchair and justify any accessories, such as power tilt or recline:

Is client unable to operate manual chair even when adapted? Yes No

Is self-propulsion possible, but activity is extremely labored? Yes No

If yes, please explain:

Is self-propulsion possible, but contrary to treatment regimen? Yes No

If yes, please explain:

How will the power wheelchair be operated? (e.g., hand, chin, etc.)

Is the client physically and mentally capable of operating power wheelchair safely and with respect to others? Yes No

Is the caregiver capable of caring for power wheelchair and understanding how it operates? Yes No

How will training for the power equipment be accomplished?

Therapist’s name: Therapist’s title:

Therapist’s telephone: Therapist’s fax:


Therapist’s employer:

Address/City/ZIP:

C–35

Appendix C

Page 5 of 5


MEASURING WORKSHEET

Client Information


Date when measured:

Print or type measurer’s name:

Measurer’s telephone:

Client Measurements

Description Measure Description Measure

1. Top of head to bottom of buttocks 7. Head width

2. Top of shoulder to bottom of buttocks 8. Shoulder width

3. Arm pit to bottom of buttocks 9. Arm pit to arm pit

4. Elbow to bottom of buttocks 10. Hip width

5. Back of buttocks to back of knee 11. Left leg popliteal to heel

6. Foot length 12. Right leg popliteal to heel

Additional Comments

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C.16 Documentation of Receipt for Durable Medical Equipment (DME)

Documentation of Receipt for Durable Medical Equipment (DME)

This form must be kept in the client’s file for ALL Durable Medical Equipment, Orthotics and Prosthetics, and Prescription Shoes. DO NOT SUBMIT THIS FORM WITH YOUR CLAIM.





Address/City/ZIP:

Equipment Information:

Item NumberReceived

Description(Include Model Number for DME)

Manufacturer’s Serial Number (for DME only)

Certification:I certify that on (mm/dd/yyyy):

The client received the equipment as prescribed by the physician.

The equipment has been properly fitted to the client and/or meets the client’s needs.

The client, the parent or guardian of the client, and/or the primary caregiver of the client has received training and instruction regarding the proper use and maintenance of the equipment.

Print or type Receiver’s name:

Signature of client, parent or client representative: Date:

Print or type Supplier/Provider name:

Signature of DME Supplier/Provider: Date:

THE RECEIVING PARTY AND DME SUPPLIER MUST SIGN AND DATE THIS FORM AT THE TIME THE EQUIPMENT IS ACTUALLY RECEIVED/DELIVERED.

Refer to the CSHCN Provider Manual–Part I for instructions on completing this form.

C–37

Appendix C

C.17 Authorization Form for Diapers or Nutritional Counseling

Authorization Form for Diapers or Nutritional Counseling






Address/City/ZIP:

Diapers Product Information: This is a statement of medical necessity for diapers/pull-ups/briefs. TMHP-CSHCN may approve diapers for a client if the client is incontinent, is over 4 years of age, and has a CSHCN diagnosis approved for diapers. See the CSHCN Provider Manual—Part I for a list of diagnoses. Any combination of diapers, pull-ups, or briefs may not exceed a quantity of 300 per month.

Procedure code: Number of diapers needed/month:

Supplier/provider name: CSHCN TPI number:


Address/City/ZIP:

Signature: Date:

Nutritional Counseling and Assessment Information: This is a statement of medical necessity for nutritional counseling and/or assessment and to request prior authorization. Check the appropriate box and document medical necessity below.

More than 2 nutritional assessments per calendar year More than 4 nutritional counseling visits per calendar year

Dietitian name: CSHCN TPI number:


Address/City/ZIP:

Signature: Date:

Attending Physician Required Signature and Information:Physician name (printed or typed):


Signature: Date:

This form is valid for 12 months from the date signed by the physician.

C–38


C

C.18 Authorization Request for Initial Outpatient Therapy (TP1)

Authorization Request for Initial Outpatient Therapy (TP1)



NOTE: This form is only for INITIAL authorization of physical, occupational, or speech-language therapy. Use the TP2 form to request an extension of therapy services.


Client Information



Address/City/ZIP:

Evaluation Summary:

Has the child received therapy in the last year from the public school system? If yes, a copy of the child’s Individualized Education Program (IEP) must be attached. Yes No

Date of evaluation: (A copy of the initial evaluation must be attached.)

Type of evaluation: Physical Therapy (PT) Occupational Therapy (OT) Speech Language Pathology (SLP)

Comments:

Service Request:

Indicate procedure code(s), type of service (PT, OT, or SLP), the dates of service, and the frequency per week or month. Dates of service cannot exceed six months. If possible, end requested date(s) of service on the last day of a month.

Procedure Code TOS From Date To Date Frequency/Week Frequency/Month

Physician Name: Physician Signature: Date:

PT Name: PT Signature: Date:

OT Name: OT Signature: Date:

SLP Name: SLP Signature: Date:


Provider contact name: 5-digit local number:


Address/City/ZIP:

Signature of provider: Date:

C–39

Appendix C

C.19 Authorization Request for Extension of Outpatient Therapy (TP2)

Page 1 of 2

Authorization Request for Extension of Outpatient Therapy (TP2)



NOTE: This form is for the EXTENSION of an authorization for physical, occupational, or speech-language therapy. Use the TP1 form to request an initial authorization.

This is a 2-page form. Complete both pages and print or type requested information below.

Client Information



Address/City/ZIP:

Evaluation Summary:

Has the child received therapy in the last year from the public school system? If yes, a copy of the child’s Individualized Education Program (IEP) must be attached. Yes No

Date of evaluation: (A copy of the initial evaluation must be attached.)

Type of evaluation: Physical Therapy (PT) Occupational Therapy (OT) Speech Language Pathology (SLP)

Comments:

Service Request:

Indicate procedure code(s), type of service (PT, OT, or SLP), the dates of service, and the frequency per week or month. Dates of service cannot exceed six months. If possible, end requested date(s) of service on the last day of a month.

Procedure Code TOS From Date To Date Frequency/Week Frequency/Month

Physician Name: Physician Signature: Date:

PT Name: PT Signature: Date:

OT Name: OT Signature: Date:

SLP Name: SLP Signature: Date:


Provider contact name: 5-digit local number:


Address/City/ZIP:

Signature of provider: Date:

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Page 2 of 2

Authorization Request for Extension of Outpatient Therapy (TP2) (Page 2 of 2)


Functional Status, Goals, and Treatment Summary:

Current functional status:

New treatment goals:

Prior dates of service: From date: To date:

Prior functional status:

Prior treatment goals:

Prior treatment provided:

Additional Comments:

C–41

Appendix C

C.20 Home Health (Skilled Nursing) Plan of Care Form

Page 1 of 2

Home Health (Skilled Nursing) Plan of Care



This is a 2-page form. Complete and submit both pages. Please print or type requested information below.



Address/City/ZIP:

Requested Services: Start of care date (mm/dd/yy): End of care date (mm/dd/yy):

Request status: New Extension Revision

Type of Service Hours/Day x Days/Week x Number of Weeks = Total Hours

Skilled nursing (RN) hours

Skilled nursing (LVN) hours

Sum of total hours requested:

Additional Comments:

If hours from a previous authorization were not used, complete the following:

Service dates affected:

Original number of hours requested for the service dates:

Actual number of hours used for these service dates:

Reason hours were not used:

RN/LVN Name: RN/LVN Signature:

Date: Telephone number:

Provider Required Signature and Information:Provider Name: CSHCN TPI number:

Other Contact Name (if any):


Address/City/ZIP:

Provider Signature: Date:

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Page 2 of 2

Home Health (Skilled Nursing) Plan of Care Referral and Treatment Plan (page 2 of 2)


Physician Information: The following information must be completed by a physician.

Recent health history:

Brief statement of medical necessity for in-home skilled nursing services:

Treatments ordered:

Medications (primary):

Nutritional requirements:

Safety of precautionary measures:

Developmental/functional status:

Prognosis:

Date last seen:

Progress summary:

I conclude that the client named above requires care as requested on this referral and treatment plan for home health (skilled nursing) services.

Physician Name (typed or printed): Telephone number:

Physician Signature: Date:

C–43

Appendix C

C.21 Authorization Request for Apnea Monitor Rental

Authorization Request for Apnea Monitor Rental




Client Information



Address/City/ZIP:

Statement of Medical Necessity

HCPCS Number Service Description

Initial rental for two months (includes all accessories and supplies)

Additional two months’ rental (includes all accessories and supplies)

Purchase wires/leads for client owned monitor

Narrative – Describe client’s condition and discuss: (1) Why client needs apnea monitor (if not one of the approved diagnoses); or (2) Why client over the age of two months requires apnea monitor; and (3) How long the apnea monitor will be needed.

If ordering only wires and leads, I certify that the client owns their apnea monitor. I certify that the patient’s medical condition is such that all equipment requested above is medically necessary.

Type or print Physician’s Name: Telephone:


Provider Information

Provider name: Provider CSHCN TPI:

Contact person:


Address/City/ZIP:


C–44


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C.22 Authorization Request for Chest Physiotherapy Devices

Authorization Request for Chest Physiotherapy Devices




Client Information



Address/City/ZIP:

Statement of Medical Necessity -- Required for ALL equipment requests.

Item is to be: Rented for 6 month’s trial (HFCWCS) Rented for 3 months (IPV/Coffalator) Purchased

Device requested: HFCWCS (ThAIRapy®) IPV Coffalator®

Number of respiratory illnesses requiring hospitalization or IV antibiotics in past year:

Is the client absent school or work-days, or unable to participate in extracurricular activities due to problems related to respiratory condition? Yes No

Did school or work attendance or activity levels change after the 6-month trial with the physiotherapy device? Yes No

Narrative – Describe client’s condition and discuss: (1) other methods of chest physiotherapy tried and why they were not adequate and (2) results of pulmonary function tests done in last 6 months or during a 6 month’s trial, if requesting purchase.

I certify that the patient’s medical condition is such that all equipment requested above is medically necessary.





Contact person:


Address/City/ZIP:


C–45

Appendix C

C.23 Authorization Request for Pulse Oximeter Devices

Authorization Request for Pulse Oximeter Devices




Client Information



Address/City/ZIP:

Statement of Medical Necessity -- Required for ALL equipment requests.

Item is to be: Rented for 6 months Rented for additional 6 months beyond initial rental Purchased

Device requested: Name: HCPCS #: Modifier:

Client is dependent upon: Ventilator hours/day and/or Oxygen hours/day

Client is weaning from: Ventilator and/or Oxygen

Will spot checks meet the client’s needs? Yes No (explain in narrative section)

Who in the home has been trained to respond to the alarms? Describe the home plan and the medical need for continuous monitoring in the narrative section.

Narrative – Describe client’s condition and discuss the home plan and the medical need for continuous monitoring. Discuss why spot check monitoring does not meet the client’s needs.

I certify that the patient’s medical condition is such that all equipment requested above is medically necessary.





Contact person:


Address/City/ZIP:


C–46


C

C.24 Authorization Request for Omalizumab

Authorization Request for Omalizumab




Client Information


Date of birth: (Client must be age 12 or older)

Diagnosis (ICD-9-CM):

Address/City/ZIP:

Statement of Medical Necessity

Indicate dose and frequency of administration for Omalizumab:

Request period: Initial 3 months Additional 3 months (document compliance & efficacy in narrative)

Documentation includes: Positive skin test and date: or RAST test and date:______________

and Total IgE level: and date: ,

and Requires 660 mcg or more of inhaled steroid treatment

and Client is compliant with asthma treatment

and Client has: Significantly declining PFT’s or Frequent hospitalizations for exacerbations or

Client has dependence on continuous systemic steroids or

Maximal inhaled steroid regimen with frequent systemic steroid pulses

and Client has: Been on daily therapy for persistent asthma 12 months with daily use of a beta agonist or

FEV 1.0 is < 80% predicted with a FEV 1.0/FVCratio < 0.7

and Client has: A 12% or greater post-bronchodilator improvement of FEV 1.0 or

Document in narrative why client is unable to perform PFT’s

Is client currently pregnant or breastfeeding? Yes No Does client currently smoke? Yes No

Narrative:-

I certify that the patient’s medical condition is such that the medication requested is medically necessary.

Type or print physician’s name: Telephone:

Physician’s signature: Date signed:



Contact person:


Address/City/ZIP:


C–47

Appendix C

C.25 Authorization Request for Hemophilia Blood Factor Products

Authorization Request for Hemophilia Blood Factor Products






Address/City/ZIP:

Product Information: Product name:

Product manufacturer:

National Drug Code (NDC):

HCPCS code:

Product quantity (per I.U.):

Prescribing Physician Information: I certify that the patient’s medical condition is such that the treatment requested above is medically necessary.

Physician name: Telephone number:

Physician signature: Date:




Address/City/ZIP:


C–48


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C.26 Transportation of the Remains of Deceased Clients Reimbursement Request

Transportation of the Remains of Deceased Clients Reimbursement RequestSolicitud para el reembolso del gasto de transportación de un difunto

Dates billed: from to Periodo que se está cobrando: del al

Client Information (Información del cliente):Client Name: Nombre del cliente:

CSHCN number:Núm. del cliente:

9- -00

Date of birth: FDN del cliente:

Date of death:FDN de la muerte:

Describe the services for which you are requesting reimbursement. Include the mode of transportation.Describe los servicios por lo cuales tú ides reembolso (inclusivo, el tipo de transportación).

Estimated one-way mileage (if driving): Cantidad aproximada de millas por viaje de ida (si manejó):

City starting from:Ciudad de partida:

City & State (not payable beyond Texas border) ending: Ciudad a donde llegó:

Number of receipts attached: Número de recibos adjuntos:

Total amount requested:Cantidad total que solicita:

$

Certification (Certificación):I certify the information on this form is correct. I have paid in advance for these costs or traveled as described above as a result of transporting the deceased client. I am requesting reimbursement for the transportation cost(s) that were incurred for the above-mentioned deceased CSHCN eligible client, and I certify that I am financially unable to pay for these costs without CSHCN assistance. Yo certifico que la información de este formulario es correcto. He pagado por adelantado para estos gastos o he viajado como se describió anteriormente para transportar al difunto cliente. Solicito reembolso por los gastos de transportación incurridos debido al cliente difunto mencionado anteriormente elegible para CSHCN y certifico que económicamente no puedo pagar estos gastos sin la ayuda de CSHCN.

Parent/Guardian Signature: Firma del padre o tutor:

Date:Fecha:

The following information is required for payment (please print): La información siguiente se necesita para el pago (por favor, escriba en letra de molde): Pay to: Hágase pagadero a:

Relationship to deceased: Parentesco con el difunto:

Address:Dirección:City, State, Zip: Ciudad, Estado, ZIP:

Telephone number: Número del teléfono:

Mail to: (Envíe a): TMHP CSHCN P O Box 200855 Austin, TX 78720-0855

FOR USE BY TMHP ONLY (SOLAMENTE PARA EL USO DE TMHP MICR #: .Amount paid: .Initials: .

Please paper-clip (do not staple) a copy of all the receipts for above request to this form. Haga el favor de adjuntar (no grapar) detrás de este formulario una copia de todos los recibos para la solicitud mencionada.

C–49

Appendix C

C.27 Instructions for Completing the Provider Information Change Form

Instructions for Completing the Provider Information Change Form

Signatures:The provider’s signature is required on the Provider Information Change Form for any and all changes requested for individual provider numbers. A signature by the authorized representative of a group or facility is acceptable for requested changes to group or facility provider numbers.

Address:Performing providers (physicians performing services within a group) may not change accounting information. For Traditional Medicaid, changes to the accounting or mailing address require a copy of the W9 form. For Traditional Medicaid, a change in ZIP code requires copy of the Medicare letter.

Tax Identification Number (TIN): TIN changes for individual practitioner provider numbers can only be made by the individual to whom the number is assigned. Performing providers cannot change the TIN.

General:Forms will be returned unprocessed if the nine-digit provider number is not indicated on the Provider Information Change Form. The W-9 form is required for all name and TIN changes. Mail or fax the completed form to:

Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment MC-B05 PO Box 200795 Austin, TX 78720-0795

Fax: 1-512-514-4214

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C.28 Provider Information Change Form

Provider Information Change Form Traditional Medicaid, Children with Special Health Care Needs (CSHCN), and Primary Care Case Management (PCCM) providers can complete and submit this form to update their provider enrollment file. Print or type all of the information on this form. Mail or fax the completed form and any additional documentation to the address at the bottom of the page.

Check the box to indicate a PCCM Provider Date:

9-digit Texas Provider Identifier (TPI): Provider Name:

List any additional TPIs that use the same provider information:

TPI:______________________ TPI:______________________ TPI:______________________

TPI:______________________ TPI:______________________ TPI:______________________

Physical Address* Accounting/Mailing Address** Secondary Address

City: City: City:

State: ZIP: State: ZIP: State: ZIP:

Phone: ( ) Phone: ( ) Phone: ( ) Fax: Fax: Fax:

Email: Email: Email:

Type of Change: (Check the appropriate box below.)

Change of physical address, telephone, and/or fax number Change of billing/mailing address, telephone, and/or fax number Change/Add secondary address, telephone, and/or fax number Change of provider status (e.g., termination from plan, moved out of area, specialist) Explain in the Comments field Other (e.g., panel closing, capacity changes, and age acceptance)

Comments:

Tax Information—Tax Identification (ID) Number and Name for the Internal Revenue Service (IRS)

Tax ID Number: Effective Date:

Exact name reported to the IRS for this Tax ID:

The signature and date are required or the form will not be processed.

Provider Signature: Date:

Mail or fax the completed form to:

Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment MC-B05 PO Box 200795 Austin, TX 78720-0795

Fax: 1-512-514-4214

* The physical address cannot be a PO Box. Traditional Medicaid providers who change their ZIP code must submit a copy of the Medicare letter along with this form.

** All providers who make changes to the Accounting/Mailing address must submit a copy of the W-9 Form along with this form.

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Appendix C

C.29 Electronic Funds Transfer (EFT) Information and Authorization Agreement

Electronic Funds Transfer (EFT) Information

Electronic Funds Transfer (EFT) is a payment method to deposit funds for claims approved for payment directly into a provider’s bank account. These funds can be credited to either checking or savings accounts, provided the bank selected accepts Automated Clearinghouse (ACH) transactions. EFT also avoids the risks associated with mailing and handling paper checks, ensuring funds are directly deposited into a specified account.

The following items are specific to EFT:

• Applications are processed within five workdays of receipt. • Pre–notification to your bank takes place on the cycle following the application

processing.• Future deposits are received electronically after pre–notification. • The Remittance and Status (R&S) report furnishes the details of individual credits

made to the provider’s account during the weekly cycle. • Specific deposits and associated R&S reports are cross–referenced by both Texas

Provider Identifier (TPI) and R&S number. • EFT funds are released by TMHP to depository financial institutions each Friday. • The availability of R&S reports is unaffected by EFT and they continue to arrive in

the same manner and time frame as currently received.

TMHP must provide the following notification according to ACH guidelines:

Most receiving depository financial institutions receive credit entries on the day before the effective date, and these funds are routinely made available to their depositors as of the opening of business on the effective date. Please contact your financial institution regarding posting time if funds are not available on the release date.

However, due to geographic factors, some receiving depository financial institutions do not receive their credit entries until the morning of the effective day and the internal records of these financial institutions will not be updated. As a result, tellers, bookkeepers, or automated teller machines (ATMs) may not be aware of the deposit and the customer’s withdrawal request may be refused. When this occurs, the customer or company should discuss the situation with the ACH coordinator of their institution who, in turn should work out the best way to serve their customer’s needs.

In all cases, credits received should be posted to the customer’s account on the effective date and thus be made available to cover checks or debits that are presented for payment on the effective date.

To enroll in the EFT program, complete the attached Electronic Funds Transfer Authorization Agreement. You must return a voided check or deposit slip with the agreement to the TMHP address indicated on the form.

Call the TMHP Contact Center at 1–800–925–9126 for assistance.

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Electronic Funds Transfer (EFT) Authorization Agreement Enter ONE Texas Provider Identifier (TPI) per Form

NOTE: Complete all sections below and attach a voided check or a photocopy of your deposit slip.

Type of Authorization: NEW CHANGE

Provider Name Nine–Character Billing TPI

Provider Accounting Address Provider Phone Number

( ) ext.

Bank Name ABA/Transit Number

Bank Phone Number Account Number

Bank Address Type Account (check one)

Checking Savings

I (we) hereby authorize Texas Medicaid & Healthcare Partnership (TMHP) to present credit entries into the bank account referenced above and the depository named above to credit the same to such account. I (we) understand that I (we) am responsible for the validity of the information on this form. If the company erroneously deposits funds into my (our) account, I (we) authorize the company to initiate the necessary debit entries, not to exceed the total of the original amount credited for the current pay period.

I (we) agree to comply with all certification requirements of the applicable program regulations, rules, handbooks, bulletins, standards, and guidelines published by the Texas Health and Human Services Commission (HHSC) or its health insuring contractor. I (we) understand that payment of claims will be from federal and state funds, and that any falsification or concealment of a material fact may be prosecuted under federal and state laws.

I (we) will continue to maintain the confidentiality of records and other information relating to clients in accordance with applicable state and federal laws, rules, and regulations.

Authorized Signature Date

Title Email Address (if applicable)

Contact Name Phone

Return this form to: Texas Medicaid & Healthcare Partnership

ATTN: Provider Enrollment PO Box 200795

Austin TX 78720–0795

DO NOT WRITE IN THIS AREA — For Office Use

Input By: Input Date:

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Appendix C

C.30 Claim Status Inquiry (CSI) Authorization

This form is for ACUTE CARE providers only. If you are a Long Term Care provider, contact TMHP’s EDI Help Desk at 888-863-3638 to request the correct form.

The following information MUST be completed before you can be granted Claim Status Inquiry (CSI) access.

1. Enter your Production User ID:

2. Enter your Production User ID Password:

The TMHP Production User ID (Submitter ID) is the electronic mailbox ID used for downloading your Claim Status Inquiry reports. For assistance with identifying and using your Production User ID and password, contact your software vendor or clearinghouse.

3. Select Action:A Add Claim Status Inquiry Privileges

B Revoke Claim Status Inquiry Privileges

4. Enter organization information:

List the billing Texas Provider Identifier (TPI) number(s) you choose to access using the Production User ID given above. Submit additional copies of this form if you need to add more TPI numbers.

Provider Name Must be the name associated with the TPI Base number listed at right.

7–Digit BILLING TPI Base Number The first 7 digits of the 9 digit TPI number.*

*Note: Performing TPI numbers do not have Claim Status Inquiry access. Enter only BILLING TPI numbers.

5. Enter Requestor Information:

Name:

Title:

Signature:

Telephone Number: ext.

Fax Number: ext.

6. Return this form to: Texas Medicaid & Healthcare Partnership Attention: EDI Help Desk, MC–B14

PO Box 204270 Austin, TX 78720-4270

Or Fax to 512-514-4228 or 512-514-4230


Input By: Input Date: Mailbox ID:

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C.31 Electronic Remittance and Status (ER&S) AgreementBefore your ER&S Agreement* can be processed, you MUST choose ONE of the following:

* These changes affect ONLY the ELECTRONIC version of the Remittance & Status Report. To make

changes to the PAPER version of the R&S report, contact TMHP Provider Enrollment.

Set up INITIALLY (first time). Use Production User ID*: (9 digits)

CHANGE Production User ID FROM: (9 digits)

TO: (9 digits)

REMOVE Production ID Remove: (9 digits)

** The TMHP Production User ID (Submitter ID) is the electronic mailbox ID used for downloading your Electronic Remittance & Status (ER&S) reports. For assistance with identifying and using your Production User ID and password, contact your software vendor or clearinghouse.

This information MUST be completed before your request can be processed.

Provider Name (must match TPI number) BILLING TPI Number Provider Tax ID Number

Provider’s Physical Address Provider Phone Number

Provider Contact Name (if other than provider) Provider Contact Title Contact Phone Number

Do not complete this block UNLESS the ER&S will be downloaded by anyone OTHER than the provider.

Name of Business Organization to Receive ER&S Business Organization Phone Number

Business Organization Contact Name Business Organization Contact Phone No.

Business Organization Address Business Organization Tax ID

Check each box after reading and understanding the following statements.If you are unsure about anything that is stated below, contact the TMHP EDI Help Desk at (888) 863-3638.All three statements must be checked before we can process your Electronic Remittance & Status Agreement.

I (we) request to receive Electronic Remittance and Status information and authorize the information to be deposited in the electronic mailbox as indicated above. I (we) accept financial responsibility for costs associated with receipt of Electronic R&S information.

I (we) understand that paper–formatted R&S information will continue to be sent to my (our) accounting address as maintained at TMHP until I (we) submit an Electronic R&S Certification Request form.

I (we) will continue to maintain the confidentiality of records and other information relating to recipients in accordance with applicable state and federal laws, rules, and regulations.

Provider Signature Date

Title Email Address (if applicable)


Input By: Input Date: Mailbox ID:

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Appendix C

ER&S Agreement — Submission Instructions

Before faxing or mailing this agreement, ensure that all required information is completely filled out, and that the agreement is signed.

Incomplete agreements cannot be processed.

Mail to: Texas Medicaid & Healthcare PartnershipAttention: EDI Help Desk MC–B14

PO Box 204270Austin, TX 78720-4270

Fax to: (512) 514-4228= OR =

(512) 514-4230

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C.32 TDHconnect Order FormTDHconnect is the versatile, reliable, and free Windows-based claims submission software provided by TMHP. Technical support, upgrades, and training for TDHconnect are also available free from TMHP. Providers can use the software to submit claims, eligibility requests, claim status inquiries, adjustments, appeals, and to retrieve Electronic Remittance and Status (ER&S) reports. TDHconnecttraining can be obtained through the Provider Relations workshops. Information about these workshops and other classes related toMedicaid billing can be found at www.tmhp.com\Providers under TMHP Provider Services Representatives and TMHP Provider Workshops. Technical support for TDHconnect is available weekdays from 7a.m. to 7p.m. through the Electronic Data Interchange (EDI) Helpdesk at 1-888-863-3638. Technical support, software updates, and training are provided free of charge.

Mailing Information

Provider or Organization Name Provider Number

Contact Name Contact Number

Address

City State Zip Code

The TDHconnect software and Quick Start Guide should arrive within 15 business days of TMHP’s receipt of the order form. Overnight and 2nd Day services are available through UPS at the expense of the person(s) ordering TDHconnect. Orders received without a valid UPS account number or for any other package service will be sent through standard U.S. Mail. A signature is required for all UPS orders.

Standard mail delivery

UPS Overnight at provider’s expense

UPS 2nd

Day Air at provider’s expense

UPS Account Number:

Authorized Signature Title

Date Telephone

Fax Number: 1-512-514-4228 or 1-512-514-4230

Mailing Address: Texas Medicaid & Healthcare Partnership Attention: EDI Helpdesk MC-B14

P.O. Box 204270

Austin, TX 78720-4270

Hardware and Software Requirements for TDHconnect

400 MHz or greater processor is recommended with 256MB of RAM Platforms

Windows 98, Windows ME, Windows XP Home, Windows XP Pro, Windows NT 4.0 with Service Pack 5 or later, and Windows 2000 Pro

Hard Drive Free space of 100MB for installation and 50MB per database

CD-ROM Drive Any speed

Display 800 X 600 VGA, 256 or more colors

Peripherals

Connectivity 9600bps minimum dial-up modem or Internet connection

Software Adobe Acrobat Reader—latest version ( Version 4.05 is included on the TDHconnect installation disk)

Internet Explorer—Version 6.0 or later

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