Current through Reg. 49, No. 38; September 20, 2024
(a) For electronic transactions conducted
before January 1, 2012, the division adopts by reference the following
electronic medical bill processing standards as adopted by the United States
Department of Health and Human Services in
45
CFR §162.1102(b) and
§
162.1602(b):
(1) Professional Billing--the ASC X12N 837,
Health Care Claim: Professional, Volumes 1 and 2, Version 004010, May 2000,
Washington Publishing Company, 004010X098 and Addenda to Health Care Claim:
Professional, Volumes 1 and 2, Version 4010, October 2002, Washington
Publishing Company, 004010X098A1.
(2) Institutional/Hospital Billing--the ASC
X12N 837, Health Care Claim: Institutional, Volumes 1 and 2, Version 004010,
May 2000, Washington Publishing Company, 004010X096 and Addenda to Health Care
Claim: Institutional, Volumes 1 and 2, Version 4010, October 2002, Washington
Publishing Company, 004010X096A1.
(3) Dental Billing--the ASC X12N 837, Health
Care Claim: Dental, Version 004010, May 2000, Washington Publishing Company,
004010X097 and Addenda to Health Care Claim: Dental, Version 4010, October
2002, Washington Publishing Company, 004010X097A1.
(4) Retail Pharmacy Billing--the
Telecommunication Standard Implementation Guide Version 5, Release 1 (Version
5.1), September 1999, National Council for Prescription Drug Programs and the
Batch Standard Batch Implementation Guide, Version 1, Release 1 (Version 1.1),
January 2000, supporting Telecommunication Standard Implementation Guide,
Version 5, Release 1 (Version 5.1) for the NCPDP Data Record in the Detail Data
Record, National Council for Prescription Drug Programs.
(5) Remittance--the ASC X12N 835, Health Care
Claim Payment/Advice, Version 004010, May 2000, Washington Publishing Company,
004010X091, and Addenda to Health Care Claim Payment/Advice, Version 4010,
October 2002, Washington Publishing Company, 004010X091A1.
(b) For electronic transactions conducted
before January 1, 2012, the division adopts by reference the following
electronic medical bill processing standards:
(1) Acknowledgment:
(A) Electronic responses to ASC X12N 837
transactions:
(i) the TA1 Interchange
Acknowledgment contained in the standards adopted under subsection (a) of this
section;
(ii) the 997 Functional
Acknowledgment contained in the standards adopted under subsection (a) of this
section; and
(iii) the ASC X12N
824--Application Advice, Version 004010, February 2006, Washington Publishing
Company, 004010X161.
(B)
Electronic responses to National Council for Prescription Drug Programs (NCPDP)
transactions, the Response contained in the standards adopted under subsection
(a) of this section.
(2)
Documentation submitted with an electronic medical bill: ASC X12N
275--Additional Information to Support a Health Claim or Encounter, Version
004050, May 2004, Washington Publishing Company, 004050X151.
(c) For electronic transactions
conducted on or after January 1, 2012, the division adopts by reference the
following electronic medical bill processing standards as adopted by the United
States Department of Health and Human Services in
45
CFR §162.1102(c) and
§
162.1602(c):
(1) Professional Billing--the ASC X12
Standards for Electronic Data Interchange Technical Report Type 3, Health Care
Claim: Professional (837), May 2006, ASC X12, 005010X222 and Type 3 Errata to
Health Care Claim: Professional (837), June 2010, ASC X12,
005010X222A1.
(2)
Institutional/Hospital Billing--the ASC X12 Standards for Electronic Data
Interchange Technical Report Type 3, Health Care Claim: Institutional (837),
May 2006, ASC X12, 005010X223, Type 1 Errata to Health Care Claim:
Institutional (837), ASC X12 Standards for Electronic Data Interchange
Technical Report Type 3, October 2007, ASC X12, 005010X223A1, and Type 3 Errata
to Health Care Claim: Institutional (837), June 2010, ASC X12,
005010X223A2.
(3) Dental
Billing--the ASC X12 Standards for Electronic Data Interchange Technical Report
Type 3, Health Care Claim: Dental (837), May 2006, ASC X12, 005010X224, Type 1
Errata to Health Care Claim: Dental (837), ASC X12 Standards for Electronic
Data Interchange Technical Report Type 3, October 2007, ASC X12, 005010X224A1,
and Type 3 Errata to Health Care Claim: Dental (837), June 2010, ASC X12,
005010X224A2.
(4) Retail Pharmacy
Billing--the Telecommunication Standard Implementation Guide, Version D,
Release 0 (Version D.0), August 2007, National Council for Prescription Drug
Programs and the Batch Standard Batch Implementation Guide, Version 1, Release
2 (Version 1.2), January 2006, National Council for Prescription Drug
Programs.
(5) Remittance--the ASC
X12 Standards for Electronic Data Interchange Technical Report Type 3, Health
Care Claim Payment/Advice (835), April 2006, ASC X12, 005010X221, and Type 3
Errata to Health Care Claim Payment/Advice (835), June 2010, ASC X12,
005010X221A1.
(d) For
electronic transactions conducted on or after January 1, 2012, the division
adopts by reference the following electronic medical bill processing standards:
(1) Acknowledgment:
(A) Electronic responses to ASC X12N 837
transactions:
(i) the ASC X12 Standards for
Electronic Data Interchange TA1 Interchange Acknowledgment contained in the
standards adopted under subsection (c) of this section;
(ii) the ASC X12 Standards for Electronic
Data Interchange Technical Report Type 3, Implementation Acknowledgment for
Health Care Insurance (999), June 2007, ASC X12, 005010X231; and
(iii) the ASC X12 Standards for Electronic
Data Interchange Technical Report Type 3, Health Care Claim Acknowledgment
(277CA), January 2007, ASC X12, 005010X214.
(B) Electronic responses to NCPDP
transactions, the Response contained in the standards adopted under subsection
(c) of this section.
(2)
Documentation submitted with an electronic medical bill: ASC X12N 275 -
Additional Information to Support a Health Claim or Encounter, Version 005010,
February 2008, Washington Publishing Company, 005010X210.
(e) Electronic medical billing transactions
must:
(1) contain all fields required in the
applicable standard as set forth in subsection (a) or (c) of this section and
the data requirements contained in §
133.502
of this title (relating to Electronic Medical Billing Supplemental Data
Requirements); and
(2) be populated
with current and valid values defined in the applicable standard as set forth
in subsection (a) or (c) of this section, Chapter 134 of this title (relating
to Benefits--Guidelines for Medical Services, Charges, and Payments), and the
data requirements contained in §
133.502
of this title.
(f)
Insurance carriers and health care providers may exchange electronic data in a
non-prescribed format by mutual agreement. All data elements required in the
division prescribed formats must be present in a mutually agreed upon
format.
(g) The implementation
specifications for the ASC X12N and the ASC X12 Standards for Electronic Data
Interchange may be obtained from the ASC X12, 7600 Leesburg Pike, Suite 430,
Falls Church, VA 22043; Telephone (703) 970-4480; and FAX (703) 970-4488. They
are also available through the internet at http://www.X12.org. A fee is charged
for all implementation specifications.
(h) The implementation specifications for the
retail pharmacy standards may be obtained from the National Council for
Prescription Drug Programs, 9240 East Raintree Drive, Scottsdale, AZ 85260.
Telephone (480) 477-1000; FAX (480) 767-1042. They are also available through
the Internet at http://www.ncpdp.org. A fee is charged for all implementation
specifications.
(i) The electronic
medical bill processing standards adopted in this section are available for
inspection at the main office of the Texas Department of Insurance, Division of
Workers' Compensation, 7551 Metro Center Drive, Suite 100, Austin, TX 78744 or
any subsequent address of the division's main office.
(j) This section is effective August 1,
2011.
