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 5 - PHYSICIAN AND PHYSICIAN ASSISTANT SERVICES
Section 354.1061 - Additional Claim Information Requirements

(1) the appropriate identification number of each physician providing a specific service (except pathologists or radiologists in group practices);

(2) place of service;

(3) the type of each diagnostic, treatment, or surgical procedure performed;

(4) the number of miles for which a travel charge is made;

(5) the date on which each service was provided;

(6) the individual charge for each service;

(7) diagnosis(es) of the condition(s) for which treatment and services were provided. With respect to diagnostic or other services furnished at the request of another physician, this requirement may be waived by the health insuring agent if the physician providing the service shows that such information is not available to him or her;

(8) the name, address, and appropriate identification number of the ordering physician or doctor if services were provided by another physician or doctor;

(9) all pertinent supplemental information, including clarification of the diagnoses in terms of the degree or extent of involvement necessary to substantiate the need for the services provided or charges made, or both; and

(10) for medically necessary hysterectomies, a patient's acknowledgment statement must be attached or added to each claim form which states that the person who secured authorization to perform the hysterectomy has informed the individual and her representative, if any, orally and in writing, that the hysterectomy will render the individual permanently incapable of reproducing. The individual or her representative, if any, must sign the written acknowledgment of receipt of that information prior to the actual surgery.