Texas Administrative Code
Title 28 - INSURANCE
Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION
Chapter 133 - GENERAL MEDICAL PROVISIONS
Subchapter G - ELECTRONIC MEDICAL BILLING, REIMBURSEMENT, AND DOCUMENTATION
Section 133.501 - Electronic Medical Bill Processing
Universal Citation: 28 TX Admin Code ยง 133.501
Current through Reg. 49, No. 38; September 20, 2024
(a) Applicability.
(1) This section applies to
the exchange of electronic medical bill data in accordance with §
133.500
of this title (relating to Electronic Formats for Electronic Medical Bill
Processing) for professional, institutional/hospital, pharmacy, and dental
services. This section applies to all electronic medical bill processing,
including transactions for medical services rendered under the provisions of
Insurance Code Chapter 1305 or rendered to political subdivisions with
contractual relationships under Labor Code §
504.053(b)(2).
(2) Insurance carriers shall accept
electronic medical bills from health care providers transmitted in accordance
with §
133.500
of this title unless the insurance carrier is exempt from the process in
accordance with subsection (b) of this section.
(3) Health care providers shall submit
electronic medical bills to insurance carriers in accordance with §
133.500
of this title unless the health care provider or the billed insurance carrier
is exempt from the process in accordance with subsection (b) of this
section.
(b) Exemptions.
(1) A health care provider is exempt from the
requirement to submit medical bills electronically to an insurance carrier if:
(A) the health care provider employs fewer
than 10 full time employees;
(B)
the health care provider provided services to 32 or fewer injured employees
during the preceding calendar year; or
(C) the health care provider can sufficiently
demonstrate electronic medical bill implementation will create an unreasonable
financial hardship and can provide supporting documentation such as financial
statements and other documentation which reflect the cost of
implementation.
(2) A
health care provider who asserts an exemption under this section must provide
all supporting documentation to the division within 15 days of a division
request for documentation.
(3) An
insurance carrier is exempt from the requirement to receive medical bills
electronically from health care providers if:
(A) the insurance carrier is placed in
receivership;
(B) the insurance
carrier was issued an initial license to write workers' compensation insurance
by the Texas Department of Insurance during the current or preceding calendar
year;
(C) the insurance carrier had
less than 32 workers' compensation claims for which income or medical benefits
were paid during the preceding calendar year;
(D) the insurance carrier no longer writes
workers' compensation insurance in Texas and is only handling runoff
claims;
(E) the insurance carrier
was a certified self-insured employer under Labor Code, Chapter 407, or a
self-insured group under Labor Code, Chapter 407A, which has withdrawn from the
certified self-insurance program or group self-insurance; or
(F) the insurance carrier submits a request
to the division with supporting documentation such as financial statements and
other documents which reflect cost of implementation and sufficiently
demonstrates that electronic medical bill implementation will create an
unreasonable financial hardship and the Commissioner approves the
request.
(4) An
insurance carrier who asserts an exemption under this subsection must provide
all supporting documentation to the division within 15 days of a division
request for documentation.
(5)
Insurance carriers shall submit notification to the division prior to the
beginning of each calendar year for which they will assert an exemption to the
electronic medical bill processing requirements. The required notification must
include:
(A) federal tax identification number
of the insurance carrier;
(B)
contact information, including but not limited to the name, physical address,
and telephone number; and
(C) a
description regarding facts related to the exemption under paragraph (3) of
this subsection asserted by the insurance carrier.
(c) Agents. Health care providers and insurance carriers may contract with other entities for electronic medical bill processing. Insurance carriers and health care providers are responsible for the acts or omissions of their agents executed in the performance of services for the insurance carrier or health care provider.
(d) Electronic medical bill.
(1) An electronic medical bill is a medical
bill submitted electronically by a health care provider or its agent.
(2) An insurance carrier shall take final
action not later than the 45th day after the date the insurance carrier
received a complete electronic medical bill.
(e) Acknowledgment.
(1) An insurance carrier must acknowledge
receipt of an electronic medical bill by returning an acknowledgment within two
working days of receipt of the electronic submission. The time frame for
returning an incomplete medical bill contained in §
133.200
of this title (relating to Insurance Carrier Receipt of Medical Bills from
Health Care Providers) does not apply to an electronic medical bill.
(A) Notification of a rejection is
transmitted in an acknowledgment when an electronic medical bill does not meet
the definition of a complete electronic medical bill or does not meet the edits
defined in the applicable standard.
(B) A health care provider may not submit a
duplicate electronic medical bill earlier than 45 days from the date submitted
if an insurance carrier acknowledged receipt of the original complete
electronic medical bill. A health care provider may submit a corrected medical
bill electronically to the insurance carrier after receiving notification of a
rejection. The corrected medical bill is submitted as a new, original
bill.
(2) Acknowledgment
of a medical bill is not an admission of liability by the insurance carrier.
The insurance carrier may subsequently deny a medical bill for liability or
other issues within the 45-day medical bill processing timeframe contained in
Labor Code §
408.027.
(f) Electronic remittance notification.
(1) An electronic remittance
notification is an explanation of benefits (EOB), submitted electronically
regarding payment or denial of a medical bill, recoupment request, or receipt
of a refund.
(2) An insurance
carrier must provide an electronic remittance notification no later than 45
days after receipt of a complete electronic medical bill or within 5 days of
generating a payment. This requirement applies only to the date the electronic
remittance is sent and does not modify the medical bill processing timeframes
contained in Labor Code §
408.027.
(g) Electronic documentation. Electronic documentation consists of medical documentation submitted electronically that is related to an electronic medical bill.
(h) This section is effective August 1, 2011.
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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