Chapter 30Radiation Therapy Services 30 30.1 Enrollment...................................................... 30-2 30.2 Benefits, Limitations, and Authorization Requirements...................... 30-2 30.2.1 Clinical Brachytherapy......................................... 30-3 30.2.2 Clinical Treatment Planning..................................... 30-4 30.2.3 Intensity Modulated Radiation Therapy (IMRT)........................ 30-4 30.2.4 Medical Radiation Physics, Dosimetry, Treatment Devices, and Special Services............................................. 30-4 30.2.5 Noncovered Radiation Therapy Services............................ 30-5 30.2.6 Procedure Code Limitations..................................... 30-5 30.2.7 Proton-Beam and Neutron-Beam Delivery........................... 30-8 30.2.7.1 Prior Authorization Requirements............................ 30-8 30.2.8 Radiation Treatment Management and Delivery....................... 30-8 30.2.8.1 Radioisotope Therapy.................................... 30-9 30.2.9 Stereotactic Radiosurgery...................................... 30-9 30.2.10 Strontium-89............................................. 30-10 30.2.11 Technetium TC 99M Tetrofosmin............................... 30-10 30.3 Claims Information............................................... 30-10 30.4 Reimbursement................................................. 30-11 30.5 TMHP-CSHCN Services Program Contact Center.......................... 30-11 CPT only copyright 2008 American Medical Association. All rights reserved.
Chapter 30 30.1 Enrollment To enroll and be reimbursed for services in the CSHCN Services Program, radiation therapy services providers must be actively enrolled in Texas Medicaid, have a valid Provider Agreement with the CSHCN Services Program, have completed the CSHCN Services Program enrollment process, and comply with all applicable state and federal laws and requirements. Out-of-state radiation therapy services providers must meet all the above conditions and be located in the United States within 50 miles of the Texas state border. Physicians, physician groups, hospitals, and free-standing radiation treatment centers are eligible to enroll in Texas Medicaid and to receive reimbursement for CSHCN Services Program radiation therapy services. Important: CSHCN Services Program providers are responsible for knowing, understanding, and complying with the laws, administrative rules, and policies of the CSHCN Services Program and Texas Medicaid. By enrolling in the CSHCN Services Program, providers are charged not only with knowledge of the adopted CSHCN Services Program agency rules published in Title 25 Texas Administrative Code (TAC), but also with knowledge of the adopted Medicaid agency rules published in 1 TAC, Part 15, and specifically including the fraud and abuse provisions contained in Chapter 371. CSHCN Services Program providers also are required to comply with all applicable laws, administrative rules, and policies that apply to their professions. Specifically, it is a violation of program rules when a provider fails to provide health-care services or items to recipients in accordance with accepted medical community standards and standards that govern occupations, as explained in 1 TAC 371.1617(a)(6)(A) for Medicaid providers, which also applies to CSHCN Services Program providers as set forth in 25 TAC 38.6(b)(1). Accordingly, CSHCN Services Program providers can be subject to sanctions for failure to, at all times, deliver health-care items and services to recipients in full accordance with all applicable licensure and certification requirements. These include, without limitation, requirements related to documentation and record maintenance, such that a CSHCN Services Program provider can be subject to sanctions for failure to create and maintain all records required by his/her profession, as well as those required by the CSHCN Services Program and Texas Medicaid. Refer to: Section 2.1, Provider Enrollment, on page 2-2 for more detailed information about CSHCN Services Program provider enrollment procedures. 30.2 Benefits, Limitations, and Authorization Requirements The CSHCN Services Program may reimburse radiation therapy services performed by physicians, radiation treatment centers, and inpatient and outpatient hospitals. Radiation therapy services include, but are not limited to, the following: Clinical brachytherapy Clinical treatment planning Intensity modulated radiation therapy (IMRT) (prior authorization required) Medical radiation physics, dosimetry, and treatment devices Proton- or neutron-beam therapy (prior authorization required) Radiation treatment management and delivery Stereotactic radiosurgery Physicians and radiation treatment centers may bill the total component of any laboratory or radiological procedures they actually perform. All drugs given during the course of radiation therapy should be billed separately for appropriate reimbursement. 30 2 CPT only copyright 2008 American Medical Association. All rights reserved.
Radiation Therapy Services All inpatient radiation therapy services must be billed with the appropriate HCPCS procedure codes in addition to the revenue code (333). Note: Outpatient hospital services include those services performed in the emergency room or clinic setting of a hospital. In instances of sudden illness or injury, the client may receive treatment in the emergency room and be discharged, admitted for observation, or admitted for further care as an inpatient. If the client is admitted as an inpatient within 24 hours of treatment in the emergency room or clinic, the emergency room or clinic charges must be submitted as ancillary charges. Refer to: Chapter 22, Hospital, on page 22-1 for more information about inpatient, outpatient, ER, and observation services. If complications occur on the same day as a therapeutic radiology service, or if medical visits are necessary for services unrelated to the radiation treatment, additional care may be reimbursed on appeal with documentation of medical necessity. Normal follow-up care by the same physician on the same day as any therapeutic radiology service will be denied. Any other E/M office visit will not be reimbursed when billed with the same date of service by the same provider as the radiation treatment or a radiation treatment complication. Providers may appeal denied claims using modifier 25 indicating the additional visit was for a separate, distinct service unrelated to the radiation treatment or radiation treatment complication. Documentation that supports the provision of a significant, separately-identifiable E/M service must be maintained in the client s medical record and made available to the CSHCN Services Program upon request. Note: Each provider is responsible for verifying client eligibility. Any services that are provided outside of the client s eligibility period or beyond the limitations of the CSHCN Services Program are not considered for reimbursement. Prior Authorization Requirements Prior authorization is required for stereotactic radiosurgery, proton- or neutron-beam treatment delivery, and IMRT. Prior authorization is not required for all other radiation therapy services. Prior authorization must be obtained before submitting claims for the services. Authorization or prior authorization is a condition for reimbursement; it is not a guarantee of payment. Prior authorization is given only if the client is eligible for CSHCN Services Program benefits when TMHP receives the request. Refer to: Chapter 4, Authorizations and Prior Authorizations, on page 4-1 for more information about authorizations and prior authorizations. 30.2.1 Clinical Brachytherapy The following procedure codes for brachytherapy may be reimbursed: Surgery Procedure Codes 19296 19297 19298 31643 55860* 55862* 55865* 55875 55876 58346 61770* 92974 *Assistant surgeons also reimbursed. Note: Procedure codes 61770 and 92974 are not reimbursed to ASCs. 30 Radiation Therapy Procedure Codes 77750* 77761* 77762* 77763* 77776* 77777* 77778* 77785 77786 77787 77789 77799 *Total component only. Note: Physicians may be reimbursed for the professional components for services performed in inpatient or outpatient hospital settings or radiation treatment centers or as total components when performed in the office. CPT only copyright 2008 American Medical Association. All rights reserved. 30 3
Chapter 30 Clinical brachytherapy services include admission to the hospital, daily care, and same-day office visits. Initial and subsequent hospital care and same-day office visits will be denied when billed with the same date of service as clinical brachytherapy services. Note: Providers may appeal denied claims using modifier 25 indicating the additional visit was for a separate, distinct service unrelated to the radiation treatment or radiation treatment complication. Documentation that supports the provision of a significant, separately-identifiable E/M service must be maintained in the client s medical record and made available to the CSHCN Services Program upon request. 30.2.2 Clinical Treatment Planning Physicians may be reimbursed for the professional components for services performed in inpatient or outpatient hospital settings or radiation treatment centers. Physicians may be reimbursed for the total components when performed in the office. The following procedure codes must be used to bill clinical treatment planning services: Procedure Codes 77261** 77262** 77263** 77280 77285* 77290* 77295* 77299* *Radiation treatment centers, outpatient facilities, and hospitals may be reimbursed for the technical component only. **Total and professional components only. Therapeutic radiology field setting (procedure code 77295) is considered for reimbursement to freestanding therapy facilities and outpatient hospitals. Procedure code 77295 is limited to once per day. An office visit performed on the same day by the same provider as clinical treatment planning and clinical brachytherapy is included in the therapeutic radiology procedure. 30.2.3 Intensity Modulated Radiation Therapy (IMRT) IMRT (procedure code 77418) must be prior-authorized and may be considered after review of documentation of medical necessity along with a review of current literature supporting the requested use. 30.2.4 Medical Radiation Physics, Dosimetry, Treatment Devices, and Special Services Physicians may submit the total component of these procedures when services are provided in the office. Physicians may submit the professional component when services are provided in radiation treatment centers, inpatient hospitals, or outpatient facilities. Radiation treatment centers, outpatient facilities, or inpatient hospitals may submit the technical component only. Procedure codes 77305, 77310, and 77315 are denied when submitted with the same date of service as 77295. The following procedure codes must be used to bill medical radiation physics, dosimetry, treatment devices, and special services: Procedure Codes 77300 77301 77305 77310 77315 77326 77327 77328 77332 77333 77334 77399 30 4 CPT only copyright 2008 American Medical Association. All rights reserved.
Radiation Therapy Services 30.2.5 Noncovered Radiation Therapy Services The following medical radiation services are not benefits of the CSHCN Services Program (this list is not all-inclusive): Procedure Codes 77321* 77331* 77336* 77370* 77470 77600 77605 77610 77615 77620 77790* *Total and professional components only. 30.2.6 Procedure Code Limitations The following procedure codes in Column A will be denied as part of another service when billed with the same date of service by the same provider as procedure codes in Column B. Column A (These procedure codes will be denied...) 36000, 36410, 37202, 51701, 51702, 51703, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 76000, 76942, 76965, 77002, 77012, 77021, 77031, 77032, 96360, 96365, 96372, 96374, 96375 Column B (...when these have been reimbursed.) 19296, 19298 76000, 76942, 76965 19297 77421, G0339, G0340 G0251 77421 G0339 G0340, 77422, 77423, 77435 77371 G0339, G0340, 77422, 77423, 77435 77372, 77373 99201, 99202, 99203, 99204, 99205, 99211, 77371, 77372, 77373, 77750, 77789 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99281, 99282, 99283, 99284, 99285, 99291, 99315, 99316, 99341, 99342, 99343, 99347, 99348, 99349, 99354, 99356 55860 55862 55860, 2/8/F-55862 55865 77750, 77761, 77762, 77763 77785, 77786 77761, 77762, 77763, 77785, 77786 77787 11100, 36000, 96360, 96365, 97022 16000, 16020, 16025, 16030 36410, 37202, 62318, 62319, 64415, 64416, 16000, 16020, 16025, 16030, 36425 64417, 64450, 64470, 64475, 96372, 96374, 96375 01951, 01952, 11040 16020, 16025, 16030 11719 16020 M0064, 36000, 36410, 51701, 51702, 51703, 90804, 90805, 90806, 90807, 90808, 90809, 90816, 90817, 90818, 90819, 90821, 90822, 90862, 97802, 97803, 99201, 99202, 99203, 99204, 99205, 99217, 99218, 99219, 99220, 99221, 99223, 99231, 99232, 99233, 99238 77261, 77262, 77263, 77280, 77285, 77290, 77295, 77300, 77301, 77305, 77310, 77315, 77326, 77327, 77328, 77332, 77333, 77334, 77401, 77402, 77403, 77404, 77406, 77407, 77408, 77409, 77411, 77412, 77413, 77414, 77416, 77417, 77418, 77427, 77431, 77432, 77435 30 CPT only copyright 2008 American Medical Association. All rights reserved. 30 5
Chapter 30 Column A (These procedure codes will be denied...) 90810, 90811, 90812, 90813, 90814, 90815, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99465, 99468, 99469, 99472, 99478, 99479, 99480 Column B (...when these have been reimbursed.) 77261, 77262, 77263, 77280, 77285, 77290, 77295, 77300, 77301, 77305, 77310, 77315, 77326, 77327, 77328, 77332, 77333, 77334, 77401, 77402, 77403, 77404, 77406, 77407, 77408, 77409, 77411, 77412, 77413, 77414, 77416, 77417, 77418, 77427, 77431, 77432 63620, 63621, 90810 77435 99234, 99235, 99236 77261, 77262, 77263, 77280, 77285, 77290, 77300, 77301, 77305, 77310, 77315, 77326, 77327, 77328, 77332, 77333, 77334, 77401, 77402, 77403, 77404, 77406, 77407, 77408, 77409, 77411, 77412, 77413, 77414, 77416, 77417, 77418 99239, 99291, 99292, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99471 77261, 77262, 77263, 77280, 77285, 77290, 77295, 77300, 77301, 77305, 77310, 77315, 77326, 77327, 77328, 77332, 77333, 77334, 77401, 77402, 77403, 77404, 77406, 77407, 77408, 77409, 77411, 77412, 77413, 77414, 77416, 77417, 77418 99471 77427, 77431, 77432 99354, 99356 77261, 77262, 77263, 77280, 77285, 77290, 77295, 77300, 77301, 77305, 77310, 77315, 77326, 77327, 77328, 77332, 77333, 77334, 77401, 77402, 77403, 77404, 77406, 77407, 77408, 77409, 77411, 77412, 77413, 77414, 77417, 77418, 77427, 77431, 77432, 77435 61795, 77261, 90780 77262 77261, 77262 77263 76376, 76377 77280, 77401 76376, 76377, 77280 77285 76376, 76377, 77280, 77285 77290 76376, 76377, 77014, 6/I-77280, 77285, 77295 77290, 99465 70450, 70460, 70470, 70480, 70481, 70482, 77301 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 71250, 71260, 71270, 71275, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72191, 72192, 72193, 72194, 73200, 73201, 73202, 73206, 73700, 73701, 73702, 73706, 74150, 74160, 74170, 74175, 75635, 76376, 76377, 76380, 76950, 77014, 77261, 77262, 77263, 77280, 77285, 77290, 77295, 77305, 77310, 77315, 77326, 77327, 77328, 77332, 77333, 77334, 77401, 77402, 77403, 77404, 77406, 77407, 77408, 77409, 77411, 77412, 77413, 77414, 77416, 77417, 77421, 77422, 77423, 77431, 77432, 77435, 77520, 77522, 77523, 77525 76376, 76377, 77014, 96365 77305 76376, 76377, 77014, 77305 77310 76376, 76377, 77014, 77305, 77310 77315 76376, 76377 77326 76376, 76377, 77326 77327 30 6 CPT only copyright 2008 American Medical Association. All rights reserved.
Radiation Therapy Services Column A (These procedure codes will be denied...) 76376, 76377, 77326, 77327 77328 77332 77333 77332, 77333 77334 76376, 76377, 77401 77402 76376, 76377, 77401, 77402 77403 76376, 76377, 77401, 77402, 77403 77404 76376, 76377, 77401, 77402, 77403, 77404 77406 76376, 76377, 77401, 77402, 77403, 77404, 77407 77406 76376, 76377, 77401, 77402, 77403, 77404, 77408 77406, 77407 76376, 76377, 77401, 77402, 77403, 77404, 77409 77406, 77407, 77408 76376, 76377, 77401, 77402, 77403, 77404, 77411 77406, 77407, 77408, 77409 76376, 76377, 77401, 77402, 77403, 77404, 77412 77406, 77407, 77408, 77409, 77411 76376, 76377, 77401, 77402, 77403, 77404, 77413 77406, 77407, 77408, 77409, 77411, 77412 76376, 76377, 77401, 77402, 77403, 77404, 77414 77406, 77407, 77408, 77409, 77411, 77412, 77413 76376, 76377, 77401, 77402, 77403, 77404, 77416 77406, 77407, 77408, 77409, 77411, 77412, 77413, 77414 G0339, G0340, 76506, 76511, 76512, 76513, 77418 76516, 76519, 76529, 76536, 76604, 76645, 76700, 76705, 76770, 76775, 76800, 76805, 76810, 76815, 76816, 76818, 76819, 76825, 76826, 76827, 76828, 76830, 76831, 76856, 76857, 76870, 76872, 76873, 76880, 76885, 76886, 76930, 76932, 76936, 76941, 76942, 76945, 76946, 76948, 76965, 76970, 76975, 76977, 76998, 77261, 77262, 77263, 77305, 77310, 77315, 77326, 77327, 77328, 77371, 77372, 77373, 77401, 77402, 77403, 77404, 77406, 77407, 77408, 77409, 77411, 77412, 77413, 77414, 77416, 77432, 77435, 77520, 77522, 77523, 77525 96150, 96151, 96152, 96153, 96154, 99183, 77427 99355, 99357 76950, 96150, 96151, 96152, 96153, 96154, 77431 99183, 99355, 99357 61795, 77421, 77431, 96150, 96151, 96152, 77432 96153, 96154, 99183, 99355, 99357 61795, 77421, 77427, 77431, 77432, 96150, 77435 96151, 96152, 96153, 96154, 99183, 99355, 99357 Column B (...when these have been reimbursed.) 30 CPT only copyright 2008 American Medical Association. All rights reserved. 30 7
Chapter 30 30.2.7 Proton-Beam and Neutron-Beam Delivery The following procedure codes may be used to bill proton-beam and neutron-beam treatment delivery services: Proton-Beam Procedure Codes S8030 77520 77522 77523 77525 Neutron-Beam Procedure Codes 77422 77423 Note: Physicians, radiation treatment centers, or outpatient facilities may bill the total component for protonand neutron-beam treatment delivery. 30.2.7.1 Prior Authorization Requirements Prior authorization requirements for proton-beam and neutron-beam treatment delivery may include, but are not limited to, diagnoses indicating one of the following medical conditions: Proton-Beam Treatment Delivery Melanoma of the uveal tract (iris, choroid, ciliary body) Postoperative treatment for chordomas or low grade chondrosarcomas of the skull or cervical spine Prostate cancer Pituitary neoplasms Other central nervous system tumors located near vital structures Neutron-Beam Treatment Delivery Malignant neoplasms of the salivary glands Other diagnoses may be considered for proton-beam and neutron-beam treatment delivery after review of documentation of medical necessity along with a review of current literature supporting the requested therapy. Prior authorization is required for proton-beam therapy (procedure codes 77520, 77522, 77523, and 77525). 30.2.8 Radiation Treatment Management and Delivery The following procedure codes must be used to bill for radiation treatment management and delivery services: Radiation Treatment Management Procedure Codes 77427 77431 77432 77435 77499 Radiation Treatment Delivery/Port Films Procedure Codes 77401* 77402* 77403* 77404* 77406* 77407* 77408* 77409* 77411* 77412* 77413* 77414* 77416* 77417* 77418* 77421 77422** 77423** *Technical component only. **Total component only. Radiation treatment delivery/port films procedure codes may be billed in addition to procedure codes 77427 and 77431 when provided in the office setting. 30 8 CPT only copyright 2008 American Medical Association. All rights reserved.
Radiation Therapy Services 30.2.8.1 Radioisotope Therapy Physicians, radiation treatment centers, outpatient facilities, and hospitals can submit the total component, professional component, or technical component as applicable for radioisotope therapy services. Physicians can submit radioisotope therapy performed in the office setting. Radiation treatment centers and outpatient facilities can submit radioisotope therapy services performed in the outpatient setting. The CSHCN Services Program considers therapeutic radioisotopes separately for reimbursement, but considers diagnostic radioisotopes as part of the diagnostic service. The CSHCN Services Program does not consider the diagnostic radioisotopes separately for reimbursement. 30.2.9 Stereotactic Radiosurgery The following procedure codes must be used to bill stereotactic radiosugery services (SRS): Surgery Procedure Codes 61795 61796 61797 61798 61799 61800 63620 63621 Radiation Therapy Procedure Codes 77371* 77372* 77373* 77421 G0251* G0339* G0340* *Total component only. Procedure code 61796 will not be reimbursed more than once per course of treatment. Procedure code 61796 will be denied if billed with the same date of service as procedure code 61798. Procedure code 61797 must be billed with the same date of service as procedure code 61796 or 61798. Procedure code 61799 must be billed with the same date of service as procedure code 61798. Procedure codes 61797 and 61799 must not be billed more than once per lesion. Any combination of 61797 and 61799 may be billed up to four times for the entire course of treatment, regardless of the number of lesions treated. Procedure code 61800 must be billed with the same date of service as procedure code 61796 or 61798. Procedure code 63620 will not be reimbursed more than once per course of treatment. Procedure code 63621 must be billed with the same date of service as procedure code 63620. Procedure code 63620 will not be reimbursed more than two times for the entire course of treatment, regardless of the number of lesions treated. Stereotactic radiosurgery services (procedure codes 63620 and 63621) will be denied if billed with the same date of service by the same provider as radiation treatment management procedure code 77435. Authorization Requirements Prior authorization requirements for SRS procedure codes may include, but are not limited to, diagnoses indicating one of the following medical conditions: Benign and malignant tumors of the central nervous system Vascular malformations Soft tissue tumors in the chest, abdomen, and pelvis Trigeminal neuralgia refractory to medical management Other diagnoses may be considered after reviewing the documentation of medical necessity. SRS is considered investigational and not a benefit of the CSHCN Services Program for all other indications including, but not limited to, epilepsy and chronic pain. 30 CPT only copyright 2008 American Medical Association. All rights reserved. 30 9
Chapter 30 30.2.10 Strontium-89 Strontium-89 is a benefit of the CSHCN Services Program and is limited to a total of 10 mci, per client, intravenously injected every 90 days by any provider. Procedure code A9600 (per mci) may be used. Reimbursement is limited to hospital facilities, freestanding radiation treatment centers, and the office setting. Strontium-89 provided in the inpatient setting is part of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) reimbursement, and no separate payment is made. The quantity used per mci must appear on the claim. Procedure code A9600 must be submitted with one of the following diagnosis codes to be considered for reimbursement: Diagnosis Code Description 1740 Malignant neoplasm of nipple and areola of female breast 1741 Malignant neoplasm of central portion of female breast 1742 Malignant neoplasm of upper-inner quadrant of female breast 1743 Malignant neoplasm of lower-inner quadrant of female breast 1744 Malignant neoplasm of upper-outer quadrant of female breast 1745 Malignant neoplasm of lower-outer quadrant of female breast 1746 Malignant neoplasm of axillary tail of female breast 1748 Malignant neoplasm of other specified sites of female breast 1749 Malignant neoplasm of breast (female), unspecified site 1750 Malignant neoplasm of male breast; nipple and areola 1759 Malignant neoplasm of male breast; other and unspecified sites 185 Malignant neoplasm of prostate 1985 Secondary malignant neoplasm of bone and bone marrow 30.2.11 Technetium TC 99M Tetrofosmin Procedure codes A9500 and A9502 are benefits, without age restriction, and are considered for reimbursement when performed in the office, inpatient hospital, and outpatient hospital settings and when submitted by physicians, radiation treatment centers, and inpatient and outpatient hospitals. Procedure codes A9500 and A9502 are limited to a quantity of three per day when billed by the same provider. 30.3 Claims Information Claims for radiation therapy services must include the following: The referring provider. Radiologists are required to identify the referring provider by full name and address or CSHCN Services Program provider identifier in Block 17 of the CMS-1500 claim form. Baseline screening or comparison studies are not benefits. Authorization and prior authorization number (as appropriate). All claims must meet all authorization and prior authorization requirements and claim filing and authorization deadlines. Details are given in the description of the services and in more detail in association with services described in this chapter and in Chapter 4, Authorizations and Prior Authorizations, on page 4-1. Radiation therapy services must be submitted to TMHP in an approved electronic format or on the CMS-1500 claim form or the UB-04 CMS-1450 claim form. Providers may purchase CMS-1500 claim forms or UB-04 CMS-1450 claim forms from the vendor of their choice. TMHP does not supply the forms. 30 10 CPT only copyright 2008 American Medical Association. All rights reserved.
Radiation Therapy Services When completing a CMS-1500 claim form or a UB-04 CMS-1450 claim form, all required information must be included on the claim, as information is not keyed from attachments. Superbills, or itemized statements, are not accepted as claim supplements. Refer to: Chapter 36, TMHP Electronic Data Interchange (EDI), on page 36-1 for information about electronic claims submissions. Chapter 5, Claims Filing, Third-Party Resources, and Reimbursement, on page 5-1 for general information about claims filing. Chapter 5, CMS-1500 Claim Form Instructions, on page 5-21 and Instructions for Completing the UB-04 CMS-1450 Claim Form, on page 5-26 for instructions on completing paper claims. Blocks that are not referenced are not required for processing by TMHP and may be left blank. Inpatient and outpatient hospitals must use the UB-04 CMS-1450 claim form to submit charges for covered services. If the client is admitted as an inpatient within 24 hours of treatment in the emergency room or clinic, the emergency room or clinic charges must be submitted on the UB-04 CMS-1450 claim form as an ancillary charge. 30.4 Reimbursement Providers will not be reimbursed for services provided outside the scope of all applicable licenses, certificates, or permits. Physicians and radiation treatment centers may be reimbursed at the lower of the billed amount or the amount allowed by Texas Medicaid. Inpatient and outpatient hospitals may be reimbursed for radiation therapy services at 80 percent of the rate authorized by TEFRA, which is equivalent to the hospital s Medicaid interim rate. 30.5 TMHP-CSHCN Services Program Contact Center The TMHP-CSHCN Services Program Contact Center at 1-800-568-2413 is available Monday through Friday from 7 a.m. to 7 p.m., Central Time, and is the main point of contact for the CSHCN Services Program provider community. 30 CPT only copyright 2008 American Medical Association. All rights reserved. 30 11