Form 1595, Billing Resolutions Request

Instructions

Updated: 10/2012

Purpose

Contractors complete this form to request assistance from the Texas Health and Human Services (HHS) for billing rejections, denials, or both, for the following HHS programs or services:

• Adult Foster Care;
• Community Attendant Services;
• Day Activity and Health Services;
• Emergency Response Services;
• Family Care;
• Home Delivered Meals;
• Medically Dependent Children Program;
• Primary Home Care;
• Residential Care;
• Special Services to Persons with Disabilities; and
• Targeted Case Management.

Procedure

When to Prepare

Contractors complete this form when requesting assistance with billing rejections, denials, or both.

Transmittal

The contractor faxes or mails the completed Form 1595 to the appropriate Claims Management Services (CMS) coordinator with appropriate supportive documentation.

Detailed Instructions

Contractor Name — Enter the contractor's legal or "doing business as" (DBA) name.

Contract No. — Enter the HHS contract number that applies to this billing resolution request.

Date — Enter the date the form is being completed.

Contractor Contact Person/Contact's Telephone No. — Enter the name and telephone number of the contractor's contact person the CMS coordinator can contact regarding the billing resolution request.

Contact's Mailing Address — Enter the full mailing address to which the CMS coordinator can mail the billing resolution response.

Contact's Fax No. — Enter the telephone number to which the billing resolution response can be faxed.

Name of Individual Receiving Services — Enter the individual's name. (Last, First, MI)

Individual No. — Enter the individual's identification number. This is the Medicaid number, individual number assigned through the Texas Integrated Eligibility Redesign System (TIERS) or the Service Authorization System (SAS).

Name of HHS Case Manager (if known) — Enter the HHS case manager's name, if known. Local authorities leave blank.

Service Group — Enter the service group identified on your Remittance and Status (R&S) report or a populated TexMedConnect claim template for the claim which pertains to this billing resolution request.

Service Code — Enter the service code identified on your R&S report or a populated TexMedConnect claim template for the claim which pertains to the billing resolution request.

Service Dates (From and To) — Enter the service dates that pertain to the billing resolution (each service month should be listed on a separate line.)

Error Code Number — Enter the non-Health Insurance Portability and Accounting Act (HIPAA) EOB (Explanation of Benefits) code regarding the rejection or denial. (These are the EOB's used before the implementation of HIPAA. TexMedConnect provides the contractor with both the HIPAA compliant and non-HIPAA compliant codes.)

Units — Enter the number of units billed that were denied or rejected. (This field is not optional.)

Amount — Enter the dollar amount of the claim that was denied or rejected. (This field is not optional.)

Comments — Enter appropriate comments that may assist the CMS coordinator in processing the billing resolution request.

Signature – Contractor Representative — A contractor representative signs this form.

Signature Date — Enter the date the form was signed and sent to the CMS coordinator.

HHS Use Only — This section is for the use of the CMS coordinator only. Contractors should not enter any information in this section.

Date Received by CMS Coordinator — Enter the date the CMS coordinator received Form 1595.

Date Billing Resolution was Communicated to the Contractor — Enter the date the CMS coordinator communicated the billing resolution to the contractor.

Comments — Enter any comments regarding the billing resolution request, if applicable.

Signature – CMS Coordinator — The CMS coordinator signs upon completion of Form 1595.