In addition to the general requirements in §354.1001 of
this title (relating to Claim Information Requirements), the following
information is required on claims for physician services:
(1) the appropriate identification number of each physician
providing a specific service (except pathologists or radiologists
in group practices);
(2) place of service;
(3) the type of each diagnostic, treatment, or surgical
procedure performed;
(4) the number of miles for which a travel charge is
made;
(5) the date on which each service was provided;
(6) the individual charge for each service;
(7) diagnosis(es) of the condition(s) for which treatment
and services were provided. With respect to diagnostic or other services
furnished at the request of another physician, this requirement may
be waived by the health insuring agent if the physician providing
the service shows that such information is not available to him or
her;
(8) the name, address, and appropriate identification
number of the ordering physician or doctor if services were provided
by another physician or doctor;
(9) all pertinent supplemental information, including
clarification of the diagnoses in terms of the degree or extent of
involvement necessary to substantiate the need for the services provided
or charges made, or both; and
(10) for medically necessary hysterectomies, a patient's
acknowledgment statement must be attached or added to each claim form
which states that the person who secured authorization to perform
the hysterectomy has informed the individual and her representative,
if any, orally and in writing, that the hysterectomy will render the
individual permanently incapable of reproducing. The individual or
her representative, if any, must sign the written acknowledgment of
receipt of that information prior to the actual surgery.
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Source Note: The provisions of this §354.1061 adopted to be effective May 30, 1977, 2 TexReg 1929; amended to be effective February 6, 1979, 4 TexReg 478; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective August 6, 2013, 38 TexReg 4885 |