28 Tex. Admin. Code § 133.502 - Electronic Medical Billing Supplemental Data Requirements
(a) In addition to the
data requirements and standards adopted under §
133.500(a) of
this title (relating to Electronic Formats for Electronic Medical Bill
Processing), all professional, institutional or hospital, and dental electronic
medical bills submitted before January 1, 2012, must contain:
(1) the telephone number of the
submitter;
(2) the workers'
compensation claim number assigned by the insurance carrier or, if that number
is not known by the health care provider, a default value of
"UNKNOWN";
(3) the injured
employee's Social Security number as the subscriber member identification
number;
(4) the injured employee's
date of injury;
(5) the rendering
health care provider's state provider license number;
(6) the referring health care provider's
state provider license number;
(7)
the billing provider's state provider license number, if the billing provider
has a state provider license number;
(8) the attending physician's state medical
license number, when applicable;
(9) the operating physician's state medical
license number, when applicable;
(10) the claim supplemental information, when
electronic documentation is submitted with an electronic medical bill;
and
(11) the resubmission condition
code, when the electronic medical bill is a duplicate, request for
reconsideration, or other resubmission.
(b) In reporting the injured employee Social
Security number and the state license numbers under subsection (a) of this
section, health care providers must follow the data content and format
requirements contained in §
133.10 of this title (relating to
Required Billing Forms/Formats).
(c) In addition to the data requirements
contained in the standards adopted under §
133.500(c) of
this title, all professional, institutional or hospital, and dental electronic
medical bills submitted on or after January 1, 2012, must contain:
(1) the telephone number of the
submitter;
(2) the workers'
compensation claim number assigned by the insurance carrier or, if that number
is not known by the health care provider, a default value of
"UNKNOWN";
(3) the injured
employee's date of injury;
(4) the
claim supplemental information, when electronic documentation is submitted with
an electronic medical bill;
(5) the
resubmission condition code, when the electronic medical bill is a duplicate,
request for reconsideration, or other resubmission; and
(6) for a designated doctor and a health care
provider performing a test or evaluation as a result of a designated doctor's
referral, the assignment number in the prior authorization field.
(d) In addition to the data
requirements contained in the standards adopted under §
133.500 of this title, all
pharmacy electronic medical bills must contain:
(1) the dispensing pharmacy's National
Provider Identification number;
(2)
the prescribing doctor's National Provider Identification number; and
(3) for a health care provider performing a
test or evaluation as a result of a designated doctor's referral, the
assignment number in the prior authorization field.
(e) In reporting the resubmission condition
code under this section, the resubmission condition codes must have the
definitions specified in §
133.10(j) of
this title.
(f) This section does
not apply to paper medical bills submitted for payment under §
133.10(b) of
this title.
(g) This section is
effective for medical bills submitted on or after June 1, 2024, including
medical bills submitted as a result of an examination that was ordered or
referred as the result of an order issued on or after June 1, 2024.
Notes
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