Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 354 - MEDICAID HEALTH SERVICES
Subchapter A - PURCHASED HEALTH SERVICES
Division 1 - MEDICAID PROCEDURES FOR PROVIDERS
Section 354.1001 - Claim Information Requirements

Universal Citation: 1 TX Admin Code § 354.1001

Current through Reg. 50, No. 13; March 28, 2025

(a) Eligible providers are required to provide separate claim information for each eligible recipient. Claims must be complete, accurate, and as specified by the Texas Health and Human Services Commission (HHSC) or its designee.

(b) Required information includes the following:

(1) name, address, and appropriate Texas provider identification number of the provider of services or supplies or both;

(2) the date of the claim;

(3) the name, address, identification number, and date of birth of the individual who received services or supplies or both;

(4) the type of such services or supplies or both provided;

(5) the date(s) each service or supplies or both were provided;

(6) the amounts of each charge for the various types of services or supplies or both;

(7) the total charge for services or supplies or both;

(8) credits for any payments made at the time of submission of the claim, including payments made by private health insurance and under Medicare;

(9) indication that the eligible recipient has health, accident, or other insurance policies, or is covered by private or governmental benefit systems, or other third party liability, when reported, known, or suspected;

(10) the date of the eligible recipient's death, if applicable; and

(11) the name and associated national provider identifier of:
(A) the eligible billing provider;

(B) the ordering or referring provider or other professional, if services or supplies, or both, are ordered or referred; and

(C) the supervising and supervised provider, except for pharmacy claims, if:
(i) the services or supplies, or both, were provided due to a referral or ordered by a provider;

(ii) the referring or ordering provider is acting at the direction or under the supervision of another provider; and

(iii) the referral or order is based on the supervised provider's evaluation of the recipient or enrollee.

(c) If the eligible billing provider is a physician supervising the performance of eligible services by a Physician Assistant or an Advanced Practice Registered Nurse (Nurse Practitioner, Clinical Nurse Specialist, or Certified Nurse-Midwife) and the supervising physician did not make a decision regarding the patient's care or treatment on the same date of service as the billable medical visit, the physician must note on the claim, in accordance with standards set by HHSC, that the services were performed by the supervisee.

Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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