| (RR) other procedure codes (UB-92, field 81) are required as an extension of subparagraph (QQ) of this paragraph if additional surgical procedures were performed; (SS) attending physician ID (UB-92, field 82) is required; (TT) signature of provider representative, electronic signature or notation that the signature is on file with the HMO or preferred provider carrier (UB-92, field 85) is required; and (UU) date bill submitted (UB-92, field 86) is required. (c) Required data elements-dental claims. The data elements described in this subsection are required as indicated and must be completed or provided in accordance with the special instructions applicable to the data elements for non-electronic clean claims filed by dental providers with HMOs. (1) Patient's name is required; (2) Patient's address is required; (3) Patient's date of birth is required; (4) Patient's gender is required; (5) Patient's relationship to subscriber is required; (6) Subscriber's name is required; (7) Subscriber's address is required, but provider may enter "same" if the subscriber's address is the same as the patient's address required by paragraph (2) of this subsection; (8) Subscriber's date of birth is required, if shown on the patient's ID card; (9) Subscriber's gender is required; (10) Subscriber's identification number is required, if shown on the patient's ID card; (11) Subscriber's plan/group number is required, if shown on the patient's ID card; (12) HMO's name is required; (13) HMO's address is required; (14) Disclosure of any other plan providing dental benefits is required and shall include a "no" if the patient is not covered by another plan providing dental benefits. If the patient does have other coverage, the provider shall indicate "yes" and the elements in paragraphs (15) - (20) of this subsection are required unless the provider submits with the claim documented proof to the HMO that the provider has made a good faith but unsuccessful attempt to obtain from the enrollee any of the information needed to complete the data elements; (15) Other insured's or enrollee's name is required in accordance with the response to and requirements of paragraph (14) of this subsection; (16) Other insured's or enrollee's date of birth is required in accordance with the response to and requirements of the element in paragraph (15) of this subsection; (17) Other insured's or enrollee's gender is required in accordance with the response to and requirements of the element in paragraph (15) of this subsection; (18) Other insured's or enrollee's identification number is required in accordance with the response to and requirements of the element in paragraph (15) of this subsection; (19) Patient's relationship to other insured or enrollee is required in accordance with the response to and requirements of the element in paragraph (15) of this subsection; (20) Name of other HMO or insurer is required in accordance with the response to and requirements of the element in paragraph (15) of this subsection; (21) Verification or preauthorization number is required, if a verification or preauthorization number was issued by an HMO to the provider; (22) Date(s) of service(s) or procedure(s) is required; (23) Area of oral cavity is required, if applicable; (24) Tooth system is required, if applicable; (25) Tooth number(s) or letter(s) are required, if applicable; (26) Tooth surface is required, if applicable; (27) Procedure code for each service is required; (28) Description of procedure for each service is required, if applicable; (29) Charge for each listed service is required; (30) Total charge for the claim is required; (31) Missing teeth information is required, if a prosthesis constitutes part of the claim. A provider that provides information for this element shall include the tooth number(s) or letter(s) of the missing teeth; (32) Notification of whether the services were for orthodontic treatment is required. If the services were for orthodontic treatment, the elements in paragraphs (34) and (35) of this subsection are required; (33) Date of orthodontic appliance placement is required, if applicable; (34) Months of orthodontic treatment remaining is required, if applicable; (35) Notification of placement of prosthesis is required, if applicable. If the services included placement of a prosthesis, the element in paragraph (36) of this subsection is required; (36) Date of prior prosthesis placement is required, if applicable; (37) Name of billing provider is required; (38) Address of billing provider is required; (39) Billing provider's provider identification number is required, if applicable; (40) Billing provider's license number is required; (41) Billing provider's social security number or federal tax identification number is required; (42) Billing provider's telephone number is required; and (43) Treating provider's name and license number are required if the treating provider is not the billing provider. (d) Coordination of benefits or non-duplication of benefits. If a claim is submitted for covered services or benefits in which coordination of benefits pursuant to §§3.3501 - 3.3511 of this title (relating to Group Coordination of Benefits) and §11.511(1) of this title (relating to Optional Provisions) is necessary, the amount paid as a covered claim by the primary plan is a required element of a clean claim for purposes of the secondary plan's processing of the claim and CMS-1500 (08/05), field 29; CMS-1500 (12/90), field 29; UB-04, field 54; or UB-92, field 54, as applicable, must be completed pursuant to subsection (b)(1)(KK), (2)(II), (3)(BB), and (4)(GG) of this section. If a claim is submitted for covered services or benefits in which non-duplication of benefits pursuant to §3.3053 of this title (relating to Non-duplication of Benefits Provision) is an issue, the amounts paid as a covered claim by all other valid coverage is a required element of a clean claim and CMS-1500 (08/05), field 29; CMS-1500 (12/90), field 29; UB-04, field 54; or UB-92, field 54, as applicable, must be completed pursuant to subsection (b)(1)(KK), (2)(II), (3)(BB), and (4)(GG) of this section. If a claim is submitted for covered services or benefits and the policy contains a variable deductible provision as set forth in §3.3074(a)(4) of this title (relating to Minimum Standards for Major Medical Expense Coverage), the amount paid as a covered claim by all other health insurance coverages, except for amounts paid by individually underwritten and issued hospital confinement indemnity, specified disease, or limited benefit plans of coverage, is a required element of a clean claim and CMS-1500 (08/05), field 29; CMS-1500 (12/90), field 29; UB-04, field 54; or UB-92, field 54, as applicable, must be completed pursuant to subsection (b)(1)(KK), (2)(II), (3)(BB), and (4)(GG) of this section. Notwithstanding these requirements, an HMO or preferred provider carrier may not require a physician or provider to investigate coordination of other health benefit plan coverage. (e) A physician or provider submits an electronic clean claim by submitting a claim using the applicable format that complies with all applicable federal laws related to electronic health care claims, including applicable implementation guides, companion guides and trading partner agreements. (f) If a physician or provider submits an electronic clean claim that requires coordination of benefits pursuant to §§3.3501 - 3.3511 of this title (relating to Group Coordination of Benefits) or §11.511(1) of this title (relating to Optional Provisions), the HMO or preferred provider carrier processing the claim as a secondary payor shall rely on the primary payor information submitted on the claim by the physician or provider. The primary payor may submit primary payor information electronically to the secondary payor using the ASC X12N 837 format and in compliance with federal laws related to electronic health care claims, including applicable implementation guides, companion guides and trading partner agreements. (g) Format of elements. The elements of a clean claim set forth in subsections (b), (c), (d), (e) and (f), if applicable, of this section must be complete, legible and accurate. (h) Additional data elements or information. The submission of data elements or information on or with a claim form by a physician or provider in addition to those required for a clean claim under this section shall not render such claim deficient. |
| Source Note: The provisions of this §21.2803 adopted to be effective May 23, 2000, 25 TexReg 4543; amended to be effective February 14, 2001, 26 TexReg 1341; amended to be effective October 2, 2001, 26 TexReg 7542; amended to be effective October 5, 2003, 28 TexReg 8647; amended to be effective February 1, 2004, 29 TexReg 1001; amended to be effective July 11, 2007, 32 TexReg 4215 |
