Get Tx Tmhp F00041 2021-2025

Filling out the TX TMHP F00041 form is a straightforward process when done online. This guide provides comprehensive instructions to assist users in accurately completing the form for the Crossover Professional Claim Type 30.

Follow the steps to fill out the TX TMHP F00041 form online.

1. Press the ‘Get Form’ button to obtain the form and open it in your chosen editor.
2. Indicate that the client has a MAP, Part C Medicare by checking the box in field 0.
3. Enter the National Provider Identifier (NPI) for the billing provider in field 1.
4. Fill in the billing provider’s taxonomy in field 2.
5. Provide the billing provider's Benefit Code in field 3.
6. Complete the billing provider's address, including street, city, state, and ZIP + 4 Code in field 4.
7. Input the client’s nine-digit Medicaid number from the Medicaid identification form in field 5.
8. Record the Medicare Paid Date listed on the MAP EOB in field 6.
9. Enter the client’s last name, as listed on the MAP EOB, in field 7.
10. Input the client’s first name listed on the MAP EOB in field 8.
11. Provide the Medicare Internal Control Number (ICN) from the MAP EOB in field 9.
12. Enter the patient’s Medicare Health Insurance Claim (HIC) number in field 10.
13. Fill in the detail information from field 11 with all relevant details as listed on the MAP EOB, ensuring to enter the correct coding and service dates.
14. Calculate and enter all totals required in section 12, ensuring accuracy with the MAP EOB.
15. Verify that all information matches the MAP EOB before finalizing and submitting your form.
16. Once completed, you can save changes, download, print, or share the form as needed.

Begin filling out your documents online today to streamline your submission process.