Current through Reg. 49, No. 38; September 20, 2024
(a) Facilities shall submit event files
electronically in the file format for emergency visit bills defined by ANSI,
commonly known as the ANSI ASC X12N form 837 Health Care Claims transaction for
institutional claims. ANSI updates these formats from time to time by issuing
new versions and the United States Department of Health and Human Services
adopts regulations regarding HIPAA that update the version allowed for claim
submissions.
(b) DSHS will make
detailed specifications for these data elements available to submitters and to
the public.
(c) In addition to the
data elements contained in the ANSI 837 Institutional Guide, DSHS has specified
the location where additional data elements shall be reported in the ANSI 837
Institutional Guide format. These are specified in §
421.67(c)
of this title (relating to Event Files--Records, Data Fields and
Codes.)
(d) Facilities shall submit
the required minimum data set in the following modified ANSI 837 Institutional
Guide format for all patients that are uninsured or considered self-pay or
covered by third party payers in which the payer requires the claim be
submitted in an ANSI 837 Institutional Guide format for which an event claim is
required by this subchapter. The required minimum data set for the modified (as
specified in subsection (c) of this section) ANSI 837 Institutional Guide
format includes the following data elements as listed in this subsection:
(1) Patient Name:
(A) Patient Last Name;
(B) Patient First Name; and
(C) Patient Middle Initial.
(2) Patient Address:
(A) Patient Address Line 1;
(B) Patient Address Line 2 (if
applicable);
(C) Patient
City;
(D) Patient State;
(E) Patient ZIP; and
(F) Patient Country (if address is not in
United States of America, or one of its territories).
(3) Patient Birth Date;
(4) Patient Sex;
(5) Patient Race;
(6) Patient Ethnicity;
(7) Patient Social Security Number;
(8) Patient Account Number;
(9) Patient Medical Record Number;
(10) Claim Filing Indicator Code (primary and
secondary);
(11) Payer Name -
Primary and secondary (if applicable, for both);
(12) National Plan Identifier - for primary
and secondary (if applicable) payers (National Health Plan Identification
number, if applicable and when assigned by the Federal Government);
(13) Type of Bill (Facility Type Code plus
Claim Frequency Code);
(14)
Statement Dates;
(15) Principal
Diagnosis;
(16) Patient's Reason
for Visit;
(17) External Cause of
Injury (E-Code) up to 10 occurrences (if applicable);
(18) Other Diagnosis Codes - up to 24
occurrences (all applicable);
(19)
Occurrence Code - up to 24 occurrences (if applicable);
(20) Occurrence Code Associated Date - up to
24 occurrences (if applicable);
(21) Value Code - up to 24 occurrences (if
applicable);
(22) Value Code
Associated Amount - up to 24 occurrences (if applicable);
(23) Condition Code - up to 24 occurrences
(if applicable);
(24) Related Cause
Code - up to 3 occurrences (if applicable);
(25) Attending Physician or Attending
Practitioner Name (if applicable):
(A)
Attending Practitioner Last Name;
(B) Attending Practitioner First Name;
and
(C) Attending Practitioner
Middle Initial.
(26)
Attending Practitioner Primary Identifier (National Provider Identifier) (if
applicable);
(27) Attending
Practitioner Secondary Identifier (Texas state license number) (if
applicable);
(28) Operating
Physician or Other Health Professional Name (if applicable):
(A) Operating Physician or Other Health
Professional Last Name;
(B)
Operating Physician or Other Health Professional First Name; and
(C) Operating Physician or Other Health
Professional Middle Initial.
(29) Operating Physician or Other Health
Professional Primary Identifier (National Provider Identifier) (if
applicable);
(30) Operating
Physician or Other Health Professional Secondary Identifier (Texas state
license number) (if applicable);
(31) Total Claim Charges;
(32) Revenue Service Line Details (up to 999
service lines) (all applicable);
(A) Revenue
Code;
(B) Procedure Code;
(C) HCPCS Procedure Modifier 1 (applicable to
each submitted Procedure code);
(D)
HCPCS Procedure Modifier 2 (applicable to each submitted Procedure
code);
(E) HCPCS Procedure Modifier
3 (applicable to each submitted Procedure code);
(F) HCPCS Procedure Modifier 4 (applicable to
each submitted Procedure code);
(G)
Charge Amount;
(H) Unit
Code;
(I) Unit Quantity;
(J) Unit Rate; and
(K) Non-covered Charge Amount.
(33) Service Line Date;
(34) Service Provider Name;
(35) Service Provider Primary Identifier -
Provider Federal Tax ID (EIN) or National Provider Identifier;
(36) Service Provider Address:
(A) Service Provider Address Line
1;
(B) Service Provider Address
Line 2 (if applicable);
(C) Service
Provider City;
(D) Service Provider
State; and
(E) Service Provider
ZIP; and
(37) Service
Provider Secondary Identifier - THCIC 6-digit facility ID assigned to each
facility;
(38) Point of Origin
(Source of Admission); and
(39)
Patient Status.
(e)
Facilities shall submit the required minimum data set to DSHS for each patient
who has one or more of the following revenue codes in this subsection.
Facilities operating in the State of Texas shall submit the required data
elements as specified in subsection (d) of this section relating to the revenue
codes in this subsection.
(1) 0450 Emergency
Room--General Classification;
(2)
0451 Emergency Room--EMTALA Emergency Medical Screening;
(3) 0452 Emergency Room--Emergency Room
beyond EMTALA;
(4) 0456 Emergency
Room--Urgent Care; and
(5) 0459
Emergency Room--Other Emergency Room;
(f) This section is effective 90 calendar
days after being published in the Texas Register.
