Long Term Care Coding Scenarios: Mastering Texas Medicaid Form 1290

Navigating the complexities of healthcare billing can be daunting, especially for long-term care providers. In Texas, for providers submitting paper claims to the Texas Medicaid and Healthcare Partnership (TMHP), Form 1290 is the key to accessing the Claims Management System (CMS). This guide breaks down the essential instructions and procedures for accurately completing Form 1290, ensuring smooth processing and timely reimbursements for your long term care services. Understanding the nuances of Long Term Care Coding Scenarios within this form is crucial for efficient claim submissions.

Understanding Form 1290: Purpose and Who Should Use It

Form 1290 is specifically designed for long term care providers in Texas who are required to submit paper claims to TMHP. This form acts as the conduit to the Claims Management System (CMS), where your claims are processed. It is important to note that electronic claim submissions may have different procedures, so this guide focuses exclusively on paper submissions using Form 1290.

Providers can utilize Form 1290 for various types of claims, including:

• New Claims: Initial submissions for services rendered.
• Dental Claims: Specifically for dental services provided to long term care residents.
• Nurse Aide Training (NAT) Claims: For reimbursement related to Nurse Aide training programs.
• Adjustment Claims: To correct or modify previously submitted claims.

A critical aspect to remember is the “one individual per claim” rule. Each Form 1290 can only accommodate billing for a single patient. Therefore, if you are billing for multiple individuals, you must complete a separate Form 1290 for each one. However, within a single Form 1290, you can include up to 17 line items, allowing for a comprehensive billing of services for that individual.

Navigating the Paper Claim Process at TMHP

Understanding the journey of your paper claim after submission can provide valuable context and help manage expectations. Here’s a simplified overview of the TMHP paper claims process:

1. Claim Receipt: TMHP receives your completed Form 1290.

2. Claim Sorting: The claim is sorted and categorized for processing.

3. Claim Imaging: For tracking and archival purposes, each claim is imaged, creating a digital record.

   Alt text: Image showing a visual representation of the Form 1290 claim process, from submission to processing in the CMS system.

4. Claims Management System (CMS) Entry: The information from your Form 1290 is meticulously entered into the CMS. It is crucial to understand that data is entered exactly as it appears on the form, without any editing or corrections. This emphasizes the importance of accuracy and legibility when completing Form 1290.

Once your claim is in the system, normal processing typically takes between seven to 10 business days. However, several factors can impact this timeframe:

• Suspension: Claims may be suspended pending manual or system review for various reasons.
• Provider on Hold: Issues related to the provider’s account can cause delays.
• Ineligible Data: Incorrect or invalid information on the form can lead to processing delays.
• Incorrectly Filled Form: Errors or omissions in completing Form 1290 are a primary cause of delays.

Key Guidelines for Completing Form 1290

To minimize processing delays and ensure your claims are handled efficiently, adhering to specific guidelines when completing Form 1290 is paramount. These guidelines focus on clarity, accuracy, and completeness:

• Print Legibly: Ensure all information is printed clearly. Illegible handwriting can cause significant delays.

• Avoid Cursive Writing: Do not use cursive handwriting. Print all information.

• Typed Data Preferred: Using computer software or a typewriter to complete the form is highly recommended for optimal legibility. If typing, use a font size large enough to ensure clear distinction between characters.

• Complete All Required Fields: Every field marked as “required” must be filled in accurately. Missing information will lead to claim rejection or delays.

• Sign Each Form with an Original Signature: An original signature is mandatory on each submitted Form 1290. Copies or stamped signatures are not accepted.

  Alt text: Detail view highlighting the signature section on Form 1290, emphasizing the requirement for an original, handwritten signature for claim validation.

• Utilize the Latest LTC Bill Code Crosswalk: The LTC Bill Code Crosswalk is a critical reference document. Always use the most current version to ensure you are using the correct codes for billing long term care services. This crosswalk is updated quarterly and is essential for accurate coding scenarios.

• Review for Accuracy: Before submitting, meticulously review the entire form for any errors or omissions. Accuracy is key to preventing delays and denials.

After data entry, the CMS edits the claim for validity and acceptance. TMHP then processes the claim according to business requirements, resulting in payment, denial, or suspension.

Submitting Form 1290:

Mail your completed 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

Important Mailing Notes:

• Allow 3 to 5 business days for delivery to TMHP when using standard mail.
• It may take up to 7 business days for the claim to appear in the TMHP system after mailing.

Overnight Mail Option:

For expedited delivery, you can use overnight mail:

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

Overnight Mail Notes:

• Include “Attention: Long Term Care, MC-B02” to avoid processing delays.
• Delivery may take an additional day depending on mailing time.
• Allow 2 to 3 business days for overnighted claims to appear in the system.
• Keep your overnight mail tracking number handy for status inquiries.

Need Assistance?

For help completing Form 1290, contact the LTC Call Center/Help Desk (Option 1) at:

• 1-800-626-4117
• 1-512-335-4729 (in Austin)

Form Retention:

Remember to retain a copy of the original Form 1290 for your records, adhering to LTC program retention requirements. Only the original form should be submitted to TMHP.

Detailed Instructions: Section by Section Breakdown

Form 1290 is divided into sections to organize the necessary information for claim processing. Let’s delve into each section with detailed instructions:

Section A — Header Information

This section gathers essential provider and patient details.

1. NPI No.: (Required) Enter your National Provider Identifier (NPI) number. Atypical providers should enter their nine-digit contract number preceded by the letter “D” (e.g., D106321123).
2. Contract No.: (Required) Provide your provider contract number.
3. Provider Name: (Required) Enter the legal name of your provider organization as it is registered under the contract.
4. Address: (Required) Enter the provider’s official address as it appears on the contract.
5. Area Code and Telephone No.: Provide the provider’s phone number, including area code, as listed on the contract.
6. Client/Medicaid No.: (Required, except for NAT claims) Enter the nine-digit Medicaid number of the individual receiving services.
7. Patient Account No.: This is for your internal record-keeping. Enter your internal patient account number, if applicable.
8. Client Last Name: (Required) Enter the last name of the individual receiving services. For NAT claims, enter the trainee’s last name.
9. Client First Name: Enter the first name of the individual. For NAT claims, use the trainee’s first name.
10. Client Middle Initial: Enter the individual’s middle initial, if available. For NAT, use the trainee’s middle initial.
11. Client Suffix Name: Include any suffix to the individual’s name (e.g., Jr., Sr.).
12. VA Indicator: (Conditional – for Service Groups 1 & 8 only) If billing for a Veteran Affairs (VA) individual residing in a VA facility and the Service Group is 1 or 8, enter “VA”.
13. Billed Applied Income/Copay: (Conditional – for AI/copay cases) If applicable, enter the dollar amount of the individual’s applied income or assessed copay.
    14-18. Do not use Items 14 through 18. These items are reserved and should be left blank.

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

Section B is exclusively for Nurse Aide Training (NAT) claims. Complete either Section B or Section C, but not both.

19. NAT SSN: (Required for NAT claims) Enter the trainee’s nine-digit Social Security Number.
20. Service Group: (Required for NAT claims) Enter the service group identification code (up to five characters) as it appears on your service authorization. Refer to the Service Group column in the LTC Bill Code Crosswalk.
21. Bill Code: (Required for NAT claims) Enter the five-character bill code for the specific NAT service provided. Consult the Bill Code column in the LTC Bill Code Crosswalk.
22. Patient Days %: (Required for NAT claims) Provide the percentage of filled beds in your facility, broken down by payer type. The sum of Medicaid, Medicare, and Private percentages must equal 100.0%.
    • Medicaid: Percentage of beds filled by Medicaid residents (e.g., 30.0).
    • Medicare: Percentage of beds filled by Medicare residents (e.g., 30.0).
    • Private: Percentage of beds filled by private pay residents (e.g., 40.0).
23. Begin Date: (Required for NAT claims) Enter the service begin date (mm/dd/yyyy) for this line item (e.g., 05/01/2007).
24. End Date: (Required for NAT claims) Enter the service end date (mm/dd/yyyy) for this line item (e.g., 05/31/2007).
25. Training Hours: (Required for NAT claims) Enter the total training hours completed, including one decimal place (e.g., 79.5).
26. Number of Units: (Required for NAT claims) Enter the number of service units provided, including one decimal place (e.g., 139.0).
27. Unit Rate: (Required for NAT claims) Enter the unit rate for the NAT service, including two decimal places (e.g., 33.00).
28. Line Item Total: (Required for NAT claims) Calculate and enter the line item total (Number of Units x Unit Rate), including two decimal places.

Section C — Line Item Information

Section C is used for detailing the specific services provided for all claim types (except NAT, which uses Section B). You can include up to 17 line items per Form 1290 in this section, allowing for comprehensive long term care coding scenarios.

29. Begin Date: (Required) Enter the service begin date (mm/dd/yyyy) for this line item (e.g., 05/01/2007).

30. End Date: (Required) Enter the service end date (mm/dd/yyyy) for this line item (e.g., 05/31/2007).

31. Rev Code: (Conditional – required for some services) Revenue codes classify the type of service provided. Consult the Revenue Code column in the LTC Bill Code Crosswalk to determine if a revenue code is required for the specific service you are billing.

32. Proc Code Qual.: (Conditional – required when a procedure code is used) The Procedure Code Qualifier specifies the source of the procedure code. Refer to the Procedure Code Qualifier column in the LTC Bill Code Crosswalk. Common qualifiers include:

    • ZZ: Texas LTC Local Codes (Bill Codes)
    • HC: HCPCS and CPT Codes
    • AD: American Dental Association Codes

33. Proc/Item Code: (Conditional – required for some services) This code uniquely identifies the procedure, product, or service. Refer to the Bill Code, HCPCS, or CPT Codes columns in the LTC Bill Code Crosswalk. The code type depends on the Procedure Code Qualifier (Item 32):

    • If “ZZ” is in Item 32, use a local/bill code.
    • If “HC” is in Item 32, use a HCPCS or CPT code.
    • If “AD” is in Item 32, use a dental code.

    Alt text: Snippet of the LTC Bill Code Crosswalk, illustrating the cross-reference between Service Codes and various billing codes needed for Form 1290 completion.

34. Modifiers: (Conditional – refer to LTC Bill Code Crosswalk and Modifier Table) Modifiers are two-digit codes that provide further detail about a service. Up to four modifiers can be used per line item. Consult the Modifier columns in the LTC Bill Code Crosswalk and Appendix E (Modifiers) of the Long Term Care User Manual for Paper Submitters to determine if modifiers are necessary.

    • Modifier Field 1: Used if your contract has multiple service groups or if you are a hospice provider billing for an ICF/IID individual. Use to specify the service group. Examples: “U3” for SG 3, “U7” for SG 7, “U4” for SG 4 (MHMR individual in hospice).
    • Modifier Field 2: Used if indicated in the crosswalk or to specify a budget (Budget 1 or 2) if required by your contract (common for PAS, ERS, meals). Examples: “U1” for Budget 1, “U2” for Budget 2.
    • Modifier Fields 3 & 4: Used only if specified in the crosswalk.

35. POS Code: (Optional) Place of Service (POS) codes identify the location where the service was provided. Refer to the POS code table (available at https://hhs.texas.gov/sites/default/files/documents/laws-regulations/legal-information/ltcbillcodecrosswalk.pdf). Examples:

    • Home: 12 (for PAS/ERS)
    • Office: 11 or 99 (for Dental Care)
    • Assisted Living Facility: 13 (for AL/RC)

36. TID: (Conditional – for dental services) Tooth ID. If billing for dental services, enter the tooth number (up to two digits) where the service was performed. Refer to Appendix F (Tooth ID) in the Long Term Care User Manual for Paper Submitters for a list of Tooth IDs.

37. Rendering Provider Name: (Conditional – for skilled/professional services) If the service was provided by someone other than your provider agency (e.g., dentist, therapist), enter the rendering provider’s name. This is not required for unskilled services (e.g., meals, personal attendant services). Examples: “David Dental” for dental services, “Patty Therapist” for physical therapy.

38. Number of Units: (Required) Enter the number of service units provided. Units are based on the bill code, not the procedure code. Include one decimal place (e.g., 139.0). For hourly services billed in less than one-hour increments, use quarter-hour (15-minute) units (e.g., 25 hours and 30 minutes = 25.50 units).

39. Unit Rate: (Required) Enter the unit rate for the service, including two decimal places (e.g., 33.00).

40. Line Item Total: (Required) Calculate and enter the line item total (Number of Units x Unit Rate, potentially adjusted for Applied Income/Copay), including two decimal places.

41. Claim Total: (Required) Enter the total claim amount, which is the sum of all line item totals. Include two decimal places (e.g., 33.00).

42. Signature: (Required) Sign the Form 1290 with an original signature.

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

Handling Line Item Adjustments

Line item adjustments are used to modify previously processed claims. When submitting adjustments, accuracy is crucial for proper matching to the original claim.

• Matching Original Claim: Line item adjustments must contain the original claim’s information exactly as it appeared on the Remittance and Status (R&S) report. TMHP uses various data points to match adjustments to the original line item, including service dates, units paid, and dollar amounts.
• Negative Line Items: Adjustments require at least one negative line item to cancel out the incorrect item from the original claim.
• Adjustment Process: To adjust a line item in Section C, enter the line item information exactly as it appeared on the original claim, but input the units and line item total as negative amounts (-).
• Multiple Adjustments: You can adjust multiple line items on a single claim. Each adjusted line item must first be credited (negative entry) before any corrections are made (positive entry if applicable).
• R&S Report: Credited line items (negative entries) will appear on the R&S report with negative units. Not all negative line items will have a corresponding positive adjustment.

Dates of Service Considerations for Adjustments:

• Before Oct. 16, 2003: For dates of service before this date, use the “ZZ” qualifier and the original local/bill code used on the initial claim (unless exceptions apply).
• After Oct. 16, 2003: Use the local/national code or revenue code that was used when the original claim was processed.

By meticulously following these detailed instructions and guidelines, long term care providers can confidently navigate the complexities of Form 1290 and ensure accurate claim submissions for their services. Remember to always refer to the most current LTC Bill Code Crosswalk and other TMHP resources for the latest coding and billing information, optimizing your long term care coding scenarios for successful reimbursement.