Transcription of Crossover Professional Claim Type 30 - TMHP
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Crossover Professional Claim Type 30 - TMHP
Crossover Professional Claim Type 30 tmhp Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Template Instructions F00041 Effective 02012016 / Revised 09072016 Providers that bill Professional services on the CMS-1500 paper Claim form may submit the Crossover Professional Claim Type 30 template with a copy of a completed Claim form. The MAP explanation of benefits (EOB) document is required when submitting the Crossover Professional Claim Type 30 template. All fields (excluding Medicaid information fields) on the form must be completed using the MAP EOB. Important: All details from the MAP EOB must be included in the template even if a deductible or coinsurance is not due.
Enter the National Provider Identifier (NPI) for the billing provider. 2 . Billing Provider TPI ; Enter the Medicaid Texas Provider Identifier (TPI) number of the billing provider.
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