Get Texas Medicaid Refund Information Form.fm - Tmhp

Filling out the Texas Medicaid Refund Information Form is an essential step for providers seeking reimbursement. This guide will walk you through the process of completing the form online, ensuring that all necessary information is provided accurately.

Follow the steps to complete your Texas Medicaid Refund Information Form.

1. Click the ‘Get Form’ button to obtain the Texas Medicaid Refund Information Form and open it in your preferred editing tool.
2. Fill in the date field with the current date. Next, enter the refunding provider’s name in the designated area. Ensure this corresponds with your records.
3. Provide the provider's TPI in the specified field. This is a unique identifier for billing purposes.
4. In the provider contact name section, enter the name of the individual who can be reached regarding this form.
5. Complete the provider's telephone number with the necessary extension for direct contact. Include all required digits for clarity.
6. Input the provider's email address in the designated section for electronic communication regarding the form.
7. Enter the provider’s NPI and taxonomy, ensuring accurate representation of your provider status.
8. Locate the claim information section and provide the Medicaid claim number from the Remittance and Status report that this refund relates to.
9. Add the patient’s name and Medicaid number accurately in their respective fields.
10. Specify the date(s) of service for which the refund is requested.
11. Indicate the reason for the refund by selecting the appropriate checkbox. If applicable, provide additional details as instructed, including insurance company information if required.
12. Review all entered information for accuracy. Ensure that all necessary attachments, including the EOB where needed, are prepared.
13. Once the form is fully completed, save your changes. You can then opt to download, print, or share the form as necessary.

Complete your Texas Medicaid Refund Information Form online today for efficient processing.