Form 1290, Long Term Care Claim

Instructions

Updated: 1/2010

Purpose

For long term care providers that submit paper claims to the Texas Medicaid and Healthcare Partnership (TMHP) for processing in the Claims Management System (CMS).

Procedures

CMS. To ensure quality imaging, TMHP recommends only using black ink. Printing the completed claim using computer software or a typewriter is preferred.

Providers may submit the following types of claims on Form 1290:

• New
• Dental
• Nurse Aide Training (NAT)
• Adjustment

Form 1290 only allows billing for one individual per claim. For example, if billing for 25 individuals, 25 individual forms must be completed, one for each individual. A single claim form may contain up to 17 line items for one individual.

Process

The following is a brief summary of the TMHP paper claims process:

1. Receive claim.
2. Sort claim.
3. Image claim for tracking and archiving purposes.
4. CMS.

Note: Information is entered into CMS exactly as it appears on the claim form. No editing or corrections are performed.

Once the claim is received by TMHP, normal processing averages seven to 10 days. The amount of time may be impacted by:

• Suspension, awaiting manual or system review
• Provider on hold
• Ineligible data
• Form filled out incorrectly

Guidelines

Providers should use the following guidelines when using Form 1290:

• Print legibly.
• Do not write in cursive.
• If data is typed, use a font large enough to distinguish between characters.
• Complete all required fields.
• Sign each form.
  • Copies or stamped signatures are not accepted.
  • An original signature is required on each form.
• Use the latest LTC Bill Code Crosswalk.
• Review the form for accuracy before submitting.

After the claim is data-entered, CMS edits the claim for validity and acceptance requirements. TMHP pays, denies or suspends the claim according to business requirements.

Mail Form 1290 to the following address:

Texas Medicaid and Healthcare Partnership
Attention: Long Term Care MC-B02
P.O. Box 200105
Austin, TX 78720-0105

Note: Delivery to TMHP could take three to five business days. Allow seven business days for the claim to appear in the system.

Send overnight mail to:

Texas Medicaid and Healthcare Partnership
Attention: Long Term Care, MC-B02
12357-B Riata Trace Parkway
Austin, TX 78727

Note: To avoid processing delays when sending overnight mail, be sure to include "Attention: Long Term Care, MC-B02." Delivery to TMHP could take an additional day, depending on the time of day the claim is mailed. Allow two to three days for the overnighted claim to appear in the system. Have your overnight mail tracking number available when calling to check status.

For assistance completing Form 1290, call the LTC Call Center/Help Desk (Option 1) at the following telephone numbers: 1-800-626-4117, or in Austin at 1-512-335-4729.

http://www.dads.state.tx.us/forms/1290/, or by contacting your contract manager.

Form Retention

The original Form 1290 must be submitted to TMHP. Retain a copy according to the LTC program's retention requirements.

Detailed Instructions

Claims

Claims must contain the provider's complete name, address and nine-digit provider/contract number. All required items on Form 1290 must be completed.

The following instructions describe the information providers must enter in each item of Form 1290. TMHP will not process a claim without the required information.

Important: The LTC Bill Code Crosswalk will be referenced throughout this manual for instructions about completing Form 1290. The LTC Bill Code Crosswalk is a cross-referenced code set used to match the National Standard Codes (procedure and revenue codes) to the Texas LTC local codes (i.e., bill codes). When billing for LTC services, use information on the LTC Bill Code Crosswalk associated with the bill code that reflects the service. The LTC Bill Code Crosswalk includes codes necessary when billing services (i.e., revenue codes, procedure codes qualifiers, and HCFA Common Procedural Coding System [HCPCS]). A copy of the LTC Bill Code Crosswalk is found in Appendix B, LTC Bill Code Crosswalk, of the Long Term Care User Manual for Paper Submitters. The LTC Bill Code Crosswalk is updated quarterly. Always use the latest LTC Bill Code Crosswalk. The most current version of the LTC Bill Code Crosswalk may be found at the following website addresses:

• http://www.dads.state.tx.us/providers/hipaa/billcodes/index.html (PDF format or Excel spreadsheet).
• http://www.tmhp.com/LTC%20Programs/default.aspx, under News; Updated Long Term Care Reference Codes (download executable file).

Using the LTC Bill Code Crosswalk

• Identify the Service Group/Service Code (SG/SC) to be billed.
• Go to the Bill Code Crosswalk table and find the same SG/SC.
• Continue on the same line to find the corresponding information to complete the applicable items on the form. (for example, bill codes, HCPCS and revenue codes).

Section A — Header Information

1. NPI No. — This item is required. Enter the National Provider Identifier (NPI) number or, for atypical providers, the nine-digit contract number preceded by alpha letter D.

Example: D106321123

2. Contract No. — This item is required. Enter the provider's contract number.

3. Provider Name — This item is required. Enter the provider's name as it appears on the contract.

4. Address — This item is required. Enter the provider's address as it appears on the contract.

5. Area Code and Telephone No. — Enter the provider's telephone number as it appears on the contract.

6. Client/Medicaid No. — This item is required for all claims except Nurse Aide Training (NAT) claims. Enter the individual's nine-digit number.

7. Patient Account No. — Enter the provider's internal patient account number.

8. Client Last Name — This item is required. Enter the individual's last name. For NAT, enter the trainee's last name.

9. Client First Name — Enter the individual's first name. For NAT, enter the trainee's first name.

10. Client Middle Initial — Enter the individual's middle initial. For NAT, enter the trainee's middle initial.

11. Client Suffix Name — Enter the individual's suffix name (for example, Jr., Sr.).

Note: Complete Item 12 when billing for a Veteran Affairs (VA) individual residing in a VA facility.

12. VA Indicator — This item is applicable only to service groups (SGs) 1 and 8. Enter "VA" if the individual is residing in a VA facility.

Note: Complete Item 13 when billing for an individual who requires Applied Income (AI)/copay.

13. Billed Applied Income/Copay — Enter the dollar amount of the individual's income contributed to the individual's care or the individual's assessed copay amount.

Do not use Items 14 through 18

Section B — Complete for Nurse Aide Training (NAT) Only

Only complete Section B or C. Do not complete both sections.

19. NAT SSN — This item is required. Enter the trainee's nine-digit Social Security number.

20. Service Group — This item is required. Enter up to five characters for the service group identification as it appears on the provider's service authorization. Refer to the Service Group column in Appendix B, LTC Bill Code Crosswalk, of the Long Term Care User Manual for Paper Submitters.

21. Bill Code — This item is required. Enter the five-character code for the specific service provided to the individual. Refer to the Bill Code column in Appendix B, LTC Bill Code Crosswalk, of the Long Term Care User Manual for Paper Submitters.

22. Patient Days % — This item is required. One or all of the subtypes can be completed. The sum of all three types must equal 100.0. This percentage should consist of a maximum of three leading digits before and one digit after the decimal point (for example, 100.0).

23. Begin Date — This item is required. Enter the eight-digit service begin date (mm/dd/yyyy) for the line item (for example, 05/01/2007).

24. End Date — This item is required. Enter the eight-digit service end date (mm/dd/yyyy) for the line item (for example, 05/31/2007).

25. Training Hours — This item is required. Enter the number of training hours completed. Include one digit after the decimal point (for example, 79.5).

26. Number of Units — This item is required. Enter the number of service units provided to the individual. The line item should include one digit after the decimal point (for example, 139.0).

27. Unit Rate — This item is required. Enter the unit rate for the service provided. The line item should include two digits after the decimal point (for example, 33.00).

28. Line Item Total — This item is required. Enter the line item total by calculating the information entered in Item 26 and Item 27. The line item should include two digits after the decimal point.

Section C — Line Item Information

29. Begin Date — This item is required. Enter the eight-digit service begin date (mm/dd/yyyy) for the line item (for example, 05/01/2007).

30. End Date — This item is required. Enter the eight-digit service end date (mm/dd/yyyy) for the line item (for example, 05/31/2007).

31. Rev Code — This item is required for some services. Revenue codes are used to classify types of services. To determine if a revenue code is required for the service to be billed, refer to the Revenue Code column in Appendix B, LTC Bill Code Crosswalk, of the Long Term Care User Manual for Paper Submitters.

32. Proc Code Qual. — This item is required when a procedure code is used. The Procedure Code Qualifier describes the source of the procedure code entered in Item 32. To determine the Procedure Code Qualifier to enter when billing for a particular service, refer to the Procedure Code Qualifier column in Appendix B, LTC Bill Code Crosswalk, found in the Long Term Care User Manual for Paper Submitters. There are three types of procedure code qualifiers:

• ZZ = Texas LTC Local Codes (usually referred to as a bill code)
• HC = HCFA Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT)
• AD = American Dental Association Codes

33. Proc/Item Code — This item is required for some services. The Procedure/Item Code uniquely identifies a procedure, product or the service provided to the individual. Services provided are described by codes. To determine the procedure/item codes to use when billing for a particular service, refer to the Bill Code, HCPCS or CPT Codes columns in Appendix B, LTC Bill Code Crosswalk, found in the Long Term Care User Manual for Paper Submitters. There are four types of procedure codes:

• Bill (local) codes
• HCPCS
• CPT
• AD

Complete this item as follows:

• If "ZZ" is entered in Item 32, Proc/Item Code Qual, enter a local/bill code.
• If "HC" is entered in Item 32, Proc/Item Code Qual, enter a HCPCS or CPT code.
• If "AD" is entered in Item 32, Proc/Item Code Qual, enter a dental code.

34. Modifiers — Modifiers are two-digit codes used to further define a service and/or assist in determining what to pay during the claims adjudication process. There are four modifier fields on Form 1290. Refer to the modifier columns in Appendix B, LTC Bill Code Crosswalk, found in the Long Term Care User Manual for Paper Submitters, and the information following, to determine if a modifier should be billed for a particular service(s). A copy of the Modifier table may be found in Appendix E, Modifiers, in the same manual. The Modifier table may be updated at any time. The most current version of the Modifier table can be found at the following website:
https://hhs.texas.gov/sites/default/files/documents/laws-regulations/legal-information/ltcbillcodecrosswalk.pdf.

Note: Modifiers 1 and 2 used to provide contract-specific information are not included in the Bill Code Crosswalk (for example, service group and budget number). To determine if a modifier should be included when billing for a particular service, refer to the following Modifiers 1 and 2 examples.

Modifier Field 1 is used only if you:

• have a single contract with multiple service groups. Use Modifier 1 to indicate the service group of the individual for whom you are billing services; and
• are a hospice provider billing for an ICF/IID individual. Use Modifier 1 to indicate the service group of the individual before entering hospice.

Modifier Field 2 is used:

• if shown on the crosswalk; or
• to specify a budget when billing a service if required by contract.

Modifier Field 3 is used only if shown on the crosswalk.

Modifier Field 4 is used only if shown on the crosswalk.

Important information about Modifiers 1 and 2

Modifier 1

Complete Modifier 1 if the contract includes more than one SG.

Example: SG3 (CBA AL/RC) and SG7 (CCAD RC)

Modifier	Service Group
U3	SG 3
U7	SG 7

A hospice provider is billing for an SG 4, 5 or 6 ICF/IID individual.

Example: Provider billing for an SG 4 MHMR individual (shown below):

Modifier	Service Group
U4	04

Modifier 2

Use Modifier 2 if the contract requires a Budget 1 or 2 or if indicated on the crosswalk (most contracts include only one budget). For example, use Modifier 2 when billing for Personal Assistance Services (PAS), Emergency Response Services (ERS) and meals, etc.

Example:

Modifier	Budget
U1	Budget 1
U2	Budget 2

35. POS Code — This code is not required. The Place of Service (POS) Code identifies the location, such as a nursing facility, individual's home, assisted living/residential care facility or dentist's office where the service was provided (for example, daily care, personal assistance services (PAS), emergency response services (ERS), assisted living/residential care (AL/RC) and dental. A table containing POS codes and descriptions can be found at the following website: https://hhs.texas.gov/sites/default/files/documents/laws-regulations/legal-information/ltcbillcodecrosswalk.pdf.

Examples:

Service	Place of Service	Place of Service Code
PAS/ERS	Home	12
Dental Care	Office or other POS	11 or 99
DAHS	Other POS	99
Assisted Living/Residential Care	Assisted Living Facility	13

36. TID — Tooth ID. Complete this item if you are billing for services for an individual receiving dental services/treatment by a licensed dentist. Enter up to a two-digit number that identifies the tooth on which the service was performed. For a list of Tooth IDs, refer to Appendix F, Tooth ID, found in the Long Term Care User Manual for Paper Submitters.

37. Rendering Provider Name — This item is required if the service billed is a skilled/professional service and was provided by someone other than the provider agency, such as a dentist, therapist or other licensed professional. The rendering provider name identifies the person who provided the service to the individual. This item does not apply to unskilled/nonprofessional services delivered by the provider agency (for example, meals, personal attendant services, day activity and health services). Refer to the following table for examples of rendering provider names.

Examples:

Skilled/Professional Service Provided	Name of Rendering Provider
Dental Services	David Dental
Physical Therapy	Patty Therapist
Nursing Services	Nadine Service

38. Number of Units — This item is required. Enter the number of units of service provided to the individual. The units are based on the bill code, not the procedure code.

The line item should include one digit after the decimal point (for example, 139.0).

Note: If the unit rate for the services you are billing is hourly and you are billing for less than one hour of service, enter the unit in quarter-hour increments (15 minutes). For example, if 25 hours and 30 minutes of service was provided, enter 25.50 in the Number of Units field.

39. Unit Rate — This item is required. Enter the unit rate for the service provided. The line item should include two digits after the decimal point (for example, 33.00).

40. Line Item Total — This item is required. Enter the line item total by calculating the information entered in Item 38 and Item 39 and (if appropriate), Item 13, Billed Applied Income/Copay.

41. Claim Total — This item is required. Enter the claim total. The claim total is the sum of all line items. The line item must include two-digits after the decimal point (for example, 33.00).

42. Signature — This item is required. Sign each form. Each claim Form 1290 must have an original signature.

43. Date — Enter the date the claim is submitted.

Line Item Adjustments

Line item adjustments are submitted to change a previously paid claim. Line items should contain the original claim's information exactly as shown on the R&S report. TMHP matches line item information to the original claim detail line item using data that includes (but not limited to) service dates, units paid and dollar amount paid codes (revenue, bill and procedure/item).

The line item adjustments must contain one or more negative line items. The negative line items cancel applicable line items listed on the original claim to be adjusted. To submit an adjustment in Section C of Form 1290, enter the line item to be adjusted as it appears on the original claim, except that the units and line item total are entered in negative (-) amounts.

More than one line item for a claim may be adjusted. Each line item adjusted must be credited back before any corrections are made. The credit appears on the adjusted line item as a negative number of units on the R&S report. Not all negative line items (credited line items) have a corresponding positive line item (adjusted charge) adjustment associated with it.

Line item adjustments for dates of service before Oct. 16, 2003

Unless the item adjustment falls under the exceptions category, use the "ZZ" qualifier and the appropriate local/bill code originally used when the original claim was processed.

Line item adjustments for dates of service after Oct. 16, 2003

Use the appropriate local/national code or revenue code used when the original claim was processed.