| (a) Eligible providers are required to provide separate
claim information for each eligible recipient. Claims must be complete,
accurate, and as specified by the Texas Health and Human Services
Commission (HHSC) or its designee.
(b) Required information includes the following:
(1) name, address, and appropriate Texas provider identification
number of the provider of services or supplies or both;
(2) the date of the claim;
(3) the name, address, identification number, and date
of birth of the individual who received services or supplies or both;
(4) the type of such services or supplies or both provided;
(5) the date(s) each service or supplies or both were
provided;
(6) the amounts of each charge for the various types
of services or supplies or both;
(7) the total charge for services or supplies or both;
(8) credits for any payments made at the time of submission
of the claim, including payments made by private health insurance
and under Medicare;
(9) indication that the eligible recipient has health,
accident, or other insurance policies, or is covered by private or
governmental benefit systems, or other third party liability, when
reported, known, or suspected;
(10) the date of the eligible recipient's death, if
applicable; and
(11) the name and associated national provider identifier
of:
(A) the eligible billing provider;
(B) the ordering or referring provider or other professional,
if services or supplies, or both, are ordered or referred; and
(C) the supervising and supervised provider, except
for pharmacy claims, if:
(i) the services or supplies, or both, were provided
due to a referral or ordered by a provider;
(ii) the referring or ordering provider is acting at
the direction or under the supervision of another provider; and
(iii) the referral or order is based on the supervised
provider's evaluation of the recipient or enrollee.
(c) If the eligible billing provider is a physician
supervising the performance of eligible services by a Physician Assistant
or an Advanced Practice Registered Nurse (Nurse Practitioner, Clinical
Nurse Specialist, or Certified Nurse-Midwife) and the supervising
physician did not make a decision regarding the patient's care or
treatment on the same date of service as the billable medical visit,
the physician must note on the claim, in accordance with standards
set by HHSC, that the services were performed by the supervisee.
|
| Source Note: The provisions of this §354.1001 adopted to be effective May 30, 1977, 2 TexReg 1929; 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 January 8, 2013, 38 TexReg 19; amended to be effective January 1, 2015, 39 TexReg 9881 |
