TMHP Electronic Claims Submission

TMHP Electronic Claims Submission: Acceptance And Rejection

TMHP Electronic Claims submission requires the HIPAA-compliant American National Standards Institute (ANSI) ASC X12 5010 file format through secure socket layer (SSL) and virtual private networking (VPN) connections for maximum security. Providers must retain all claim and file transmission records. They may be required to submit them for pending research on missing claims or appeals.

Electronic Claim Acceptance

Providers should verify that their electronic claims were accepted by Texas Medicaid for payment consideration by referring to their Claim Response report, which is in the 27S batch response file (e.g., file name E085LDS1.27S). Providers should also check their Accepted and Rejected reports in the rej and acc batch response files (e.g., E085LDS1.REJ and E085LDS1.ACC) for additional information. Only claims that have been accepted on the Claim Response report (27S file) will be considered for payment and made available for claim status inquiry. Claims that are rejected must be corrected and resubmitted for payment consideration.

Electronic Rejections

The most common reasons for electronic professional claim rejections are:

  • Client information does not match. Client information does not match the PCN on the TMHP eligibility file. The name, date of birth, sex, and nine-digit Medicaid identification number must be an exact match with the client’s identification number on TMHP’s eligibility record. A lack of complete client eligibility information causes a rejection and possibly delayed payment.
  • Referring/Ordering Physician field blank or invalid. The referring physician’s NPI must be present when billing for consultations, laboratory, or radiology. Consult the software vendor for this field’s location on the electronic claims entry form.
  • Performing Physician ID field blank or invalid. When the billing provider identifier is a group practice, the performing provider identifier for the physician who performed the service must be entered. Consult the software vendor for this field’s location on the electronic claim form.
  • Facility Provider field blank or invalid. When place of service (POS) is anywhere other than home or office, the facility’s provider identifier must be present. If the provider identifier is not known, enter the name and address of the facility.
  • Invalid Type of Service or Invalid Type of Service/Procedure code combination. In certain cases some procedure codes will require a modifier to denote the procedure’s type of service (TOS). The C21 claims processing system can accept only 40 characters (including spaces) in the Comments section of electronic submissions for ambulance and dental claims. If providers include more than 40 characters in that field, C21 will accept only the first 40 characters; the other characters will not be imported into C21. Providers must ensure that all of the information that is required for the claim to process appropriately is included in the first 40 characters.

To learn more about Health Care Claims submission and become a certified  EDI Professional please visit our course schedule page.

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