Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter I - MEDICAL BILL REPORTING › Section 134.804 - Reporting Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) Insurance
				  carriers shall submit an '00' original medical EDI record for each action
				  (initial processing, request for reconsideration or appeal, or subsequent
				  orders) taken on an individual medical bill. Original medical EDI records shall
				  be reported within 30 days after the date of the action. Each iteration of an
				  '00' original medical EDI record must contain a different unique medical bill
				  identification number. The amount paid on each action related to a medical bill
				  must contain only the amount issued for that event and must not contain a
				  cumulative amount reflecting all events related to an individual medical bill.
				  Original medical EDI records on subsequent actions must contain a
				  Texas-specific claim adjustment reason code of 'W3' to designate the medical
				  EDI record as a reconsideration or appeal. The Texas-specific claim adjustment
				  reason code must be included on the explanation of benefits issued pursuant to
				  §
										133.250
				  of this title (relating to Reconsideration for Payment of Medical
				  Bills).
(b) Insurance carriers
				  shall submit an '01' cancel medical EDI record if the '00' original medical EDI
				  record should not have been sent or contained the incorrect insurance carrier
				  identification number. Cancel medical EDI records shall be reported within 30
				  days after the earliest date the insurance carrier discovered the reporting
				  error. The '01' cancel medical EDI record must contain the same unique bill
				  identification number as the '00' original medical EDI record that was
				  previously submitted and accepted. An '00' original medical EDI record must be
				  accepted by the division before an '01' cancel medical EDI record may be
				  submitted.
(c) Insurance carriers
				  shall submit an '05' replacement medical EDI record when correcting data on a
				  previously submitted medical EDI record. Replacement medical EDI records shall
				  be submitted within 30 days after the earliest date the insurance carrier
				  discovered the reporting error. The '05' replacement medical EDI record must
				  contain the same unique bill identification number as the associated '00'
				  original medical EDI record. An '00' original medical EDI record must be
				  accepted by the division before an '05' replacement medical EDI record may be
				  submitted.
(d) Insurance carriers
				  must submit timely and accurate medical EDI records to the division. For the
				  purpose of this section, a medical EDI record is considered to have been
				  accurately submitted when the record:
(1)
				  received an Application Acknowledgment Code of accepted;
(2) contained accurate medical EDI data;
				  medical EDI data may be obtained from all sources, including the medical bill,
				  explanation of benefits, and insurance carrier's claim file; and
(3) to the extent supported by the format,
				  contained all appropriate modifiers, code qualifiers, and data elements
				  necessary to identify health care services, charges and payments.