| (O) patient discharge status (UB-04/field 17) is required;
(P) condition codes (UB-04/fields 18 - 28) are required
when there is a condition code that applies to the medical bill;
(Q) occurrence codes and dates (UB-04/fields 31 - 34)
are required when there is an occurrence code that applies to the
medical bill;
(R) occurrence span codes and dates (UB-04/fields 35
and 36) are required when there is an occurrence span code that applies
to the medical bill;
(S) value codes and amounts (UB-04/fields 39 - 41)
are required when there is a value code that applies to the medical
bill;
(T) revenue codes (UB-04/field 42) are required;
(U) revenue description (UB-04/field 43) is required;
(V) HCPCS/Rates (UB-04/field 44):
(i) HCPCS codes are required when billing for outpatient
services and an appropriate HCPCS code exists for the service line
item; and
(ii) accommodation rates are required when a room and
board revenue code is reported;
(W) service date (UB-04/field 45) is required when
billing for outpatient services;
(X) service units (UB-04/field 46) is required;
(Y) total charge (UB-04/field 47) is required;
(Z) date bill submitted, page numbers, and total charges
(UB-04/field 45/line 23) is required;
(AA) insurance carrier name (UB-04/field 50) is required;
(BB) billing provider NPI number (UB-04/field 56) is
required when the billing provider is eligible to receive an NPI number;
(CC) billing provider's state license number (UB-04/field
57) is required when the billing provider has a state license number;
the billing provider shall enter the license number and jurisdiction
code (for example, '123TX');
(DD) employer's name (UB-04/field 58) is required;
(EE) patient's relationship to subscriber (UB-04/field
59) is required;
(FF) patient's Social Security Number (UB-04/field
60) is required;
(GG) workers' compensation claim number assigned by
the insurance carrier (UB-04/field 62) is required when known, the
billing provider shall leave the field blank if the workers' compensation
claim number is not known by the billing provider;
(HH) preauthorization number (UB-04/field 63) is required
when preauthorization, concurrent review or voluntary certification
was approved and the insurance carrier provided an approval number
to the health care provider;
(II) principal diagnosis code and present on admission
indicator (UB-04/field 67) are required;
(JJ) other diagnosis codes (UB-04/field 67A - 67Q)
are required when there conditions exist or subsequently develop during
the patient's treatment;
(KK) admitting diagnosis code (UB-04/field 69) is required
when the medical bill involves an inpatient admission;
(LL) patient's reason for visit (UB-04/field 70) is
required when submitting an outpatient medical bill for an unscheduled
outpatient visit;
(MM) principal procedure code and date (UB-04/field
74) is required when submitting an inpatient medical bill and a procedure
was performed;
(NN) other procedure codes and dates (UB-04/fields
74A - 74E) are required when submitting an inpatient medical bill
and other procedures were performed;
(OO) attending provider's name and identifiers (UB-04/field
76) are required for any services other than nonscheduled transportation
services, the billing provider shall report the NPI number for an
attending provider eligible for an NPI number and the state license
number by entering the '0B' qualifier and the license type, license
number, and jurisdiction code (for example, 'MDF1234TX');
(PP) operating physician's name and identifiers (UB-04/field
77) are required when a surgical procedure code is included on the
medical bill, the billing provider shall report the NPI number for
an operating physician eligible for an NPI number and the state license
number by entering the '0B' qualifier and the license type, license
number, and jurisdiction code (for example, 'MDF1234TX'); and
(QQ) remarks (UB-04/field 80) is required when separate
reimbursement for surgically implanted devices is requested.
(3) The following data content or data elements are
required for a complete pharmacy medical bill related to Texas workers'
compensation health care:
(A) dispensing pharmacy's name and address (DWC-066/field
1) is required;
(B) date of billing (DWC-066/field 2) is required;
(C) dispensing pharmacy's National Provider Identification
(NPI) number (DWC-066/field 3) is required;
(D) billing pharmacy's or pharmacy processing agent's
name and address (DWC-066/field 4) is required when different from
the dispensing pharmacy (DWC-066/field 1);
(E) invoice number (DWC-066/field 5) is required;
(F) payee's federal employer identification number
(DWC-066/field 6) is required;
(G) insurance carrier's name (DWC-066/field 7) is required;
(H) employer's name and address (DWC-066/field 8) is
required;
(I) injured employee's name and address (DWC-066/field
9) is required;
(J) injured employee's Social Security Number (DWC-066/field
10) is required;
(K) date of injury (DWC-066/field 11) is required;
(L) injured employee's date of birth (DWC-066/field
12) is required;
(M) prescribing doctor's name and address (DWC-066/field
13) is required;
(N) prescribing doctor's NPI number (DWC-066/field
14) is required;
(O) workers' compensation claim number assigned by
the insurance carrier (DWC-066/field 15) is required when known, the
billing provider shall leave the field blank if the workers' compensation
claim number is not known by the billing provider;
(P) dispensed as written code (DWC-066/field 19) is
required;
(Q) date filled (DWC-066/field 20) is required;
(R) generic National Drug Code (NDC) code (DWC-066/field
21) is required when a generic drug was dispensed or if dispensed
as written code '2' is reported in DWC-066/field 19;
(S) name brand NDC code (DWC-066/field 22) is required
when a name brand drug is dispensed;
(T) quantity (DWC-066/field 23) is required;
(U) days supply (DWC-066/field 24) is required;
(V) amount paid by the injured employee (DWC-066/field
26) is required if applicable;
(W) drug name and strength (DWC-066/field 27) is required;
(X) prescription number (DWC-066/field 28) is required;
(Y) amount billed (DWC-066/field 29) is required;
(Z) preauthorization number (DWC-066/field 30) is required
when preauthorization, voluntary certification, or an agreement was
approved and the insurance carrier provided an approval number to
the requesting health care provider; and
(AA) for billing of compound drugs refer to the requirements
in §134.502 of this title (relating to Pharmaceutical Services).
(4) The following data content or data elements are
required for a complete dental medical bill related to Texas workers'
compensation health care:
(A) type of transaction (ADA 2006 Dental Claim Form/field
1);
(B) preauthorization number (ADA 2006 Dental Claim
Form/field 2) is required when preauthorization, concurrent review
or voluntary certification was approved and the insurance carrier
provided an approval number to the health care provider;
(C) insurance carrier name and address (ADA 2006 Dental
Claim Form/field 3) is required;
(D) employer's name and address (ADA 2006 Dental Claim
Form/field 12) is required;
(E) workers' compensation claim number assigned by
the insurance carrier (ADA 2006 Dental Claim Form/field 15) is required
when known, the billing provider shall leave the field blank if the
workers' compensation claim number is not known by the billing provider;
(F) patient's name and address (ADA 2006 Dental Claim
Form/field 20) is required;
(G) patient's date of birth (ADA 2006 Dental Claim
Form/field 21) is required;
(H) patient's gender (ADA 2006 Dental Claim Form/field
22) is required;
(I) patient's Social Security Number (ADA 2006 Dental
Claim Form/field 23) is required;
(J) procedure date (ADA 2006 Dental Claim Form/field
24) is required;
(K) tooth number(s) or letter(s) (ADA 2006 Dental Claim
Form/field 27) is required;
Cont'd... |
