Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 21 - TRADE PRACTICES
Subchapter KK - HEALTH CARE REIMBURSEMENT RATE INFORMATION
Section 21.4507 - Data Required
Universal Citation: 28 TX Admin Code § 21.4507
Current through Reg. 50, No. 13; March 28, 2025
(a) Applicable health benefit plans must include the following information as a cover page to each report:
(1) reporting period;
(2) company or plan name;
(3) NAIC number, issued to the company by the
National Association of Insurance Commissioners;
(4) TDI company number;
(5) contact information for the person
designated to discuss the report with TDI staff, including name, telephone
number, and email address;
(6) an
indication of whether the report is for insurance business or HMO business,
consistent with subsection (d) of this section, or "NA" for reports limited to
self-insured business;
(7) an
indication of whether the report includes data on self-insured business,
including data for certain governmental plans required to report under
Insurance Code Chapter 38, Subchapter H; and
(8) a certification that the information
provided is a full and true statement of the data required under this
subchapter.
(b) Applicable health benefit plans must submit the following data, for in-network and out-of-network claims, for each geographic region, as defined by § 21.4503 of this title, for each service identified in subsection (c) of this section, with data columns reported in the following order:
(1) network
status of the claims data, using "IN" to indicate in-network claims and "OON"
to indicate out-of-network claims;
(2) geographic region of the claims data,
using the three-digit ZIP code to indicate the applicable region;
(3) total number of unique claim identifiers
for all claim types;
(4) for
inpatient procedure facility claims, the total number of discharges;
(5) total amount billed;
(6) total amount allowed;
(7) mean amount billed;
(8) mean amount allowed;
(9) median amount billed;
(10) median amount allowed;
(11) maximum amount billed;
(12) maximum amount allowed;
(13) minimum amount billed;
(14) minimum amount allowed;
(15) lower quartile amount billed,
representing the 25th percentile of all amounts billed;
(16) lower quartile amount allowed,
representing the 25th percentile of all amounts allowed;
(17) upper quartile amount billed,
representing the 75th percentile of all amounts billed; and
(18) upper quartile amount allowed,
representing the 75 percentile of all amounts allowed.
(c) Data elements identified in subsection (b) of this section must be reported in the specified manner for each category of services in this subsection.
(1) Inpatient
procedures. Data on inpatient procedure claims must be reported separately for
facility claims and professional claims.
(A)
Facility claims data must be grouped by discharge and only include claims that
occurred in an inpatient hospital.
(B) Professional claims data must be reported
separately for surgical claims, radiology claims, pathology claims, and
anesthesia claims, as applicable, and only include claims for which the
place-of-service code indicates inpatient hospital.
(C) Inpatient procedure claims data must be
reported for the full cost of any claim, or the full cost of any discharge for
facility claims, for the following services, using the medical billing codes
specified by TDI consistent with §
21.4505(b) of
this title:
(i) cesarean section
delivery;
(ii) vaginal
delivery;
(iii)
hysterectomy;
(iv) hip
replacement;
(v) knee
replacement;
(vi) coronary artery
bypass grafting;
(vii) back surgery
- laminectomy;
(viii) inguinal
hernia repair, unilateral;
(ix)
inguinal hernia repair, bilateral;
(x) laparoscopic cholecystectomy;
and
(xi) appendectomy.
(2) Outpatient
procedures. Data on outpatient facility procedure claims must be reported
separately for facility claims and professional claims.
(A) Facility claims data must be reported
separately for outpatient procedures that occurred in an outpatient hospital
and those that occurred in an ambulatory surgical center or freestanding
clinic.
(B) Professional claims
data must only include claims for which the place-of-service code indicates
outpatient hospital or ambulatory surgical center, and be reported separately
for surgical claims, radiology claims, pathology claims, and anesthesia claims,
as applicable.
(C) Data on
outpatient procedure facility claims must be reported for the full cost of any
claim for the following services, using the medical billing codes specified by
TDI, consistent with §
21.4505(b) of
this title:
(i) back surgery -
laminectomy
(ii) inguinal hernia
repair, unilateral;
(iii) inguinal
hernia repair, bilateral;
(iv)
laparoscopic cholecystectomy;
(v)
appendectomy;
(vi)
tonsillectomy;
(vii)
adenoidectomy;
(viii) tonsillectomy
and adenoidectomy;
(ix)
tympanostomy;
(x)
colonoscopy;
(xi) upper GI
endoscopy;
(xii) upper and lower GI
endoscopy;
(xiii) bunion
repair;
(xiv) ACL repair;
(xv) rotator cuff repair;
(xvi) cardiac catheterization,
left;
(xvii) cardiac
catheterization, right;
(xviii)
cardiac catheterization, left and right; and
(xix) percutaneous transluminal coronary
angioplasty.
(3) Emergency services. Data on emergency
room visits must be reported only for professional claims for which the place
of service is an emergency room or outpatient hospital. An emergency room
includes both a hospital emergency room and a freestanding emergency medical
care facility. Data must be reported at the claim-line level for the following
types of emergency room visits, using the medical billing codes specified by
TDI, consistent with §
21.4505(b) of
this title:
(A) emergency department visit,
self-limited or minor problem;
(B)
emergency department visit, low to moderately severe problem;
(C) emergency department visit, moderately
severe problem;
(D) emergency
department visit, problem of high severity; and
(E) emergency department visit, problem with
significant threat to life or function.
(4) Imaging services. Data on imaging
services must be reported separately for facility claims and professional
claims.
(A) Facility claims must include only
claims that occurred in an outpatient hospital, and for which units of service
equal one.
(B) Professional claims
must be reported only for claims for which units of service equal one. Data
must be reported separately for claims billed with CPT code modifiers for the
professional component (26), technical component (TC), and a missing or null
modifier. Data must be reported separately by place-of-service code:
(i) outpatient hospital;
(ii) office; and
(iii) all other place-of-service codes,
excluding office, inpatient hospital, outpatient hospital, and emergency
room.
(C) Data must be
reported at the claim-line level for the following imaging services, using the
medical billing codes specified by TDI, consistent with §
21.4505(b) of
this title:
(i) CT abdomen and
pelvis;
(ii) CT scan
abdomen;
(iii) CT scan
pelvis;
(iv) CT scan
head/brain;
(v) CT scan mouth, jaw,
and neck;
(vi) CT scan soft tissue
neck;
(vii) CT scan
chest;
(viii) CT scan lumbar lower
spine;
(ix) CT scan lower
extremity;
(x) MRI brain;
(xi) MRI head, orbit/face/neck;
(xii) MRI angiography head;
(xiii) MRI neck spine;
(xiv) MRI spine;
(xv) MRI lumbar spine;
(xvi) MRI lower limb;
(xvii) MRI upper limb, other than
joint;
(xviii) MRI lower limb with
joint;
(xix) MRI upper limb with
joint;
(xx) MRI abdomen;
(xxi) MRI one breast;
(xxii) MRI both breasts;
(xxiii) MRI pelvis;
(xxiv) mammogram, analog;
(xxv) mammogram with CAD; and
(xxvi) mammogram, digital.
(5) Pathology services.
Data on pathology services must be reported only for professional claims for
which the place of service is an independent lab.
(A) Data must be reported at the claim-line
level and averaged to reflect the cost per unit of service.
(B) Data must be reported for the following
pathology services, using the medical billing codes consistent with §
21.4505(b) of
this title:
(i) organ or disease
panels;
(ii) evocative suppression
testing;
(iii)
urinalysis;
(iv)
chemistry;
(v)
hematology-coagulation;
(vi)
immunology;
(vii)
microbiology;
(viii) anatomic
pathology;
(ix) screening
cytopathology; and
(x) complete
blood count.
(6) Office visits. Data on office visits must
be reported only for professional claims for which the place of service is an
office or rural health clinic.
(A) For data
elements listed in subparagraph (B) of this paragraph, data must be reported at
the claim-line level and averaged to reflect the cost per unit of
service.
(B) Data must be reported
for the following types of office visits, using the medical billing codes
consistent with §
21.4505(b) of
this title:
(i) office or other outpatient
visit with a new patient, by time or complexity;
(ii) office or other outpatient visit with an
established patient, by time or complexity;
(iii) office consultation, by time or
complexity;
(iv) preventive
medicine evaluation and management, new patient, by age group;
(v) preventive medicine evaluation and
management, established patient, by age group;
(vi) annual gynecological exam, new
patient;
(vii) annual gynecological
exam, established patient;
(viii)
screening pelvic and breast exam;
(ix) screening pap smear; and
(x) cytopathology for pap smear.
(C) Data must be reported for
well-woman exams so that all costs associated with a claim are reported with
respect to the medical billing consistent with §
21.4505(b) of
this title.
(d) In reporting data required under this section, issuers must:
(1) report data
elements according to medical billing codes specified by §
21.4505(b) of
this title;
(2) separately report
data for insurance and HMO and exclude any HMO claims paid through a capitation
agreement;
(3) separately report
data for in-network and out-of-network claims; and
(4) filter claims data to include only:
(A) claims incurred during the 12-month
reporting period. For the 2015 reporting period, limit data for inpatient
procedure claims and outpatient procedure claims to claims incurred before
October 1, 2015, or the date on which the issuer transitioned billing systems
to use ICD-10 procedure codes;
(B)
claims for which adjudication is final; exclude pending or denied
claims;
(C) claims for which the
issuer is the primary plan responsible for payment; exclude claims for which
issuer is the secondary plan; and
(D) claims with an allowed amount greater
than zero.
Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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