| (L) procedure code (ADA 2006 Dental Claim Form/field
29) is required;
(M) fee (ADA 2006 Dental Claim Form/field 31) is required;
(N) total fee (ADA 2006 Dental Claim Form/field 33)
is required;
(O) place of treatment (ADA 2006 Dental Claim Form/field
38) is required;
(P) treatment resulting from (ADA 2006 Dental Claim
Form/field 45) is required, the provider shall check the box for occupational
illness/injury;
(Q) date of injury (ADA 2006 Dental Claim Form/field
46) is required;
(R) billing provider's name and address (ADA 2006 Dental
Claim Form/field 48) is required;
(S) billing provider's NPI number (ADA 2006 Dental
Claim Form/field 49) is required if the billing provider is eligible
for an NPI number;
(T) billing provider's state license number (ADA 2006
Dental Claim Form/field 50) is required when the billing provider
is a licensed health care provider; the billing provider shall enter
the license type, license number, and jurisdiction code (for example,
'DS1234TX');
(U) billing provider's federal tax ID number (ADA 2006
Dental Claim Form/field 51) is required;
(V) rendering dentist's NPI number (ADA 2006 Dental
Claim Form/field 54) is required when different than the billing provider's
NPI number (ADA 2006 Dental Claim Form/field 49) and the rendering
dentist is eligible for an NPI number;
(W) rendering dentist's state license number (ADA 2006
Dental Claim Form/field 55) is required when different than the billing
provider's state license number (ADA 2006 Dental Claim Form/field
50), the billing provider shall enter the license type, license number,
and jurisdiction code (for example, 'MDF1234TX'); and
(X) rendering provider's and treatment location address
(ADA 2006 Dental Claim Form/field 56) is required when different from
the billing provider's address (ADA Dental Claim Form/field 48).
(g) If the injured employee does not have a Social
Security Number as required in subsection (f) of this section, the
health care provider must leave the field blank.
(h) Except for facility state license numbers, state
license numbers submitted under subsection (f) of this section must
be in the following format: license type, license number, and jurisdiction
state code (for example 'MDF1234TX').
(i) In reporting the state license number under subsection
(f) of this section, health care providers should select the license
type that most appropriately reflects the type of medical services
they provided to the injured employees. When a health care provider
does not have a state license number, the field is submitted with
only the license type and jurisdiction code (for example, DMTX). The
license types used in the state license format must be one of the
following:
(1) AC for Acupuncturist;
(2) AM for Ambulance Services;
(3) AS for Ambulatory Surgery Center;
(4) AU for Audiologist;
(5) CN for Clinical Nurse Specialist;
(6) CP for Clinical Psychologist;
(7) CR for Certified Registered Nurse Anesthetist;
(8) CS for Clinical Social Worker;
(9) DC for Doctor of Chiropractic;
(10) DM for Durable Medical Equipment Supplier;
(11) DO for Doctor of Osteopathy;
(12) DP for Doctor of Podiatric Medicine;
(13) DS for Dentist;
(14) IL for Independent Laboratory;
(15) LP for Licensed Professional Counselor;
(16) LS for Licensed Surgical Assistant;
(17) MD for Doctor of Medicine;
(18) MS for Licensed Master Social Worker;
(19) MT for Massage Therapist;
(20) NF for Nurse First Assistant;
(21) OD for Doctor of Optometry;
(22) OP for Orthotist/Prosthetist;
(23) OT for Occupational Therapist;
(24) PA for Physician Assistant;
(25) PM for Pain Management Clinic;
(26) PS for Psychologist;
(27) PT for Physical Therapist;
(28) RA for Radiology Facility; or
(29) RN for Registered Nurse.
(j) When resubmitting a medical bill under subsection
(f) of this section, a resubmission condition code may be reported.
In reporting a resubmission condition code, the following definitions
apply to the resubmission condition codes established by the Uniform
National Billing Committee:
(1) W3 - Level 1 Appeal means a request for reconsideration
under §133.250 of this title (relating to Reconsideration for
Payment of Medical Bills) or an appeal of an adverse determination
under Chapter 19, Subchapter U of this title (relating to Utilization
Reviews for Health Care Provided Under Workers' Compensation Insurance
Coverage);
(2) W4 - Level 2 Appeal means a request for reimbursement
as a result of a decision issued by the division, an Independent Review
Organization, or a Network complaint process; and
(3) W5 - Level 3 Appeal means a request for reimbursement
as a result of a decision issued by an administrative law judge or
judicial review.
(k) The inclusion of the appropriate resubmission condition
code and the original reference number is sufficient to identify a
resubmitted medical bill as a request for reconsideration under §133.250
of this title or an appeal of an adverse determination under Chapter
19, Subchapter U of this title provided the resubmitted medical bill
complies with the other requirements contained in the appropriate
section.
(l) This section is effective for medical bills submitted
on or after April 1, 2014.
|
| Source Note: The provisions of this §133.10 adopted to be effective May 2, 2006, 31 TexReg 3544; amended to be effective December 24, 2006, 31 TexReg 10097; amended to be effective May 1, 2008, 33 TexReg 3443; amended to be effective August 1, 2011, 36 TexReg 929; amended to be effective April 1, 2014, 38 TexReg 9594 |
