Clinics and Other Outpatient Facility Services Handbook - TMHP

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TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 - JANUARY 2013 OP.4 Family Planning Claim Form Family Planning 2017 Claim Form V 1. Family Planning Program: XIX XX 1a. Full Pay Title X Partial Pay Only No Pay 3. Provider Name 4. Eligibility Date (V or XX ) Joe Smith (MM/DD/CCYY) 01/02/2012 2a. Billing Provider TPI 1234567-89 2b. Billing Provider NPI 9870654321 5. Family Planning No. (Medicaid PCN if XIX) 6. Patient’s Name (Last Name, First Name, Middle Initial) 7. Address (Street, City, State) 7a. ZIP code Doe, Jane 341 Tosca Way, Houston, TX 77485 8. County of Residence 9. Date of Birth 10. Sex 11. Patient Status 12. Patient's Social Security Number (MM/DD/CCYY) F M New Patient Established Patient Harris X 123 - 45 - 6789 02/02/1971 X 13. Race (Code #) 13a. Ethnicity 14. Marital Status White (1) Black (2) 1 AmIndian/AlaskaNat (4) Asian (5) 0 3 Unk/NotRep (6) NatHawaii/PacIsland (7) More than one race (8) Hispanic (5) Non-Hispanic (0) (1) Married (2) Never Married (3) Formerly Married 15. Family Income (All) 15a. Family Size $ 1 2 16. Number Times Pregnant 17. Number Live Births 18. Number Living Children 1 1 1 19. Primary Birth Control Method Before Initial Visit a=Oral Contraceptive f= Hormonal Implant k=Intrauterine device (IUD) p=Other method G b=1-Month hormonal injection g=Male condom l=Vaginal ring q=Method unknown 20. Primary Birth Control Method c=3-Month hormonal injection h=Female condom m=Fertility awareness method (FAM) r=No method (if used at End of This Visit d=Cervical cap/diaphragm i=Hormonal/Contraceptive patch n=Sterilization for #20, must A e=Abstinence j=Spermicide (used alone) o=Contraceptive sponge complete #21) 21. If No Method Used at End of This Visit, Give Reason (Required only if #20 = r) a=Refused b=Pregnant c=Inconclusive Preg Test d=Seeking Preg e=Infertile f=Rely on Partner g=Medical 22. Is There Other Insurance Available? 23. Other Insurance Name and Address Y N If Y, Complete Items 23 – 25a 24a. Insured’s Policy/Group No. 24b. Benefit Code 25. Other Insurance Pd. Amt. 25a. Date of Notification $ 26. Name of Referring Provider 27a. Referring Other ID 27b. Referring NPI 28. Level of Practitioner Physician Nurse Mid Level Other 29. Diagnosis Code (Relate Items 1,2,3,or 4 to Item 32D by Line # in 32E) 1. ______________._________ V25 09 3. ______________._________ 30. Authorization Number 31. Date of Occurrence (MM / DD / CCYY) 2. ______________._________ 4. ______________._________ 32. A B C D E F G H Dates of Service Place Type Procedures, Services, or Dx. Units or Days $ Charges Performing Provider # From To of of Supplies Ref. (Quantity) Service Service CPT/HCPCS Modifier (29) No. of Participants MM DD CCYY MM DD CCYY (Teen Counseling) TPI 1 01 02 2012 01 02 2012 1 1 99203 FP 1 1 $48 27 NPI TPI 2 NPI 3 NPI 4 NPI 5 NPI 33. Federal Tax ID Number/EIN 34. Patient’s Account No. (optional) 35. Patient Co-Pay Assessed (V, X or XX) $ 37. Signature of Physician or Supplier Date: 01/02/2012 Signed: Joe Smith 38. Name and Address of Facility Where Services Were Rendered (If Other Than Home or Office) 38a. NPI 38b. Other ID TPI TPI TPI 36. Total Charges $48.27 39. Physician’s, Supplier’s Billing Name, Address, Zip Code & Phone No. Joe Smith 1234 Oak Drive Houston, Texas 77485 (281)123-4567 OP-48 CPT ONLY - COPYRIGHT 2012 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.
CLINICS AND OTHER OUTPATIENT FACILITY SERVICES HANDBOOK OP.5 Family Planning Services for Hospitals, FQHCs 1 2 3a PAT. 4 TYPE CNTL # 12345678 OF BILL b. MED. REC. # 987651234 Federally Qualified Health 1242 Medical Drive The Colony, Texas 75321 5 FED. TAX NO. 6 STATEMENT COVERS PERIOD FROM THROUGH 7 0731 8 PATIENT NAME a 9 PATIENT ADDRESS a b Doe, Jane L. 1234 Bartland Way, Plano, Texas 75011 b c d 10 BIRTHDATE 11 SEX ADMISSION CONDITION CODES 12 DATE 13 HR 14 TYPE 15 SRC 16 DHR 29 ACDT 30 17 STAT 18 19 20 21 22 23 24 25 26 27 28 STATE 02141977 F 01012012 11 31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37 CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH e a a b b 38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES CODE AMOUNT CODE AMOUNT CODE AMOUNT a b c d 42 REV. CD. 43 DESCRIPTION 44 HCPCS / RATE / HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49 1 1 2 3 4 5 6 520 Annual Family Planning Exam 1-99203 FP 01012012 1 47 57 307 Urinalysis 5-81015 FP 01012012 1 4 31 2 3 4 5 6 7 7 8 8 9 9 10 11 12 Total Charges 51 88 10 11 12 13 13 14 14 15 15 16 16 17 17 18 18 19 19 20 20 21 21 22 22 23 50 PAYER NAME A Medicaid B PAGE OF 51 HEALTH PLAN ID CREATION DATE TOTALS 52 REL. 53 ASG. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI INFO BEN. 57 OTHER 1324650879 9876543-21 23 A B C PRV ID C A B 58 INSURED’S NAME 59 P.REL 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO. Doe, Jane L. 123456789 A B C C A B 63 TREATMENT AUTHORIZATION CODES 1234567890 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME A B C 66 DX 67 A B C D E F G H I J K L M N O P Q V2509 69 ADMIT 70 PATIENT 71 PPS 72 73 DX REASON DX a b c CODE ECI a b c 74 PRINCIPAL PROCEDURE a. OTHER PROCEDURE b. OTHER PROCEDURE 75 CODE DATE CODE DATE CODE DATE 76 ATTENDING NPI QUAL LAST FIRST c. OTHER PROCEDURE d. OTHER PROCEDURE e. OTHER PROCEDURE CODE DATE CODE DATE CODE DATE 77 OPERATING LAST NPI QUAL FIRST 80 REMARKS 81CC a 78 OTHER NPI QUAL Annual Family Planning Exam b LAST FIRST c 79 OTHER NPI QUAL 68 C UB-04 CMS-1450 APPROVED OMB NO. 0938-0997 d LAST FIRST National Uniform NUBC Billing Committee THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF. OP-49 CPT ONLY - COPYRIGHT 2012 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.
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