| (a) Facilities shall submit event files electronically
in the file format for emergency visit bills defined by ANSI, commonly
known as the ANSI ASC X12N form 837 Health Care Claims transaction
for institutional claims. ANSI updates these formats from time to
time by issuing new versions and the United States Department of Health
and Human Services adopts regulations regarding HIPAA that update
the version allowed for claim submissions.
(b) DSHS will make detailed specifications for these
data elements available to submitters and to the public.
(c) In addition to the data elements contained in the
ANSI 837 Institutional Guide, DSHS has specified the location where
additional data elements shall be reported in the ANSI 837 Institutional
Guide format. These are specified in §421.67(c) of this title
(relating to Event Files--Records, Data Fields and Codes.)
(d) Facilities shall submit the required minimum data
set in the following modified ANSI 837 Institutional Guide format
for all patients that are uninsured or considered self-pay or covered
by third party payers in which the payer requires the claim be submitted
in an ANSI 837 Institutional Guide format for which an event claim
is required by this subchapter. The required minimum data set for
the modified (as specified in subsection (c) of this section) ANSI
837 Institutional Guide format includes the following data elements
as listed in this subsection:
(1) Patient Name:
(A) Patient Last Name;
(B) Patient First Name; and
(C) Patient Middle Initial.
(2) Patient Address:
(A) Patient Address Line 1;
(B) Patient Address Line 2 (if applicable);
(C) Patient City;
(D) Patient State;
(E) Patient ZIP; and
(F) Patient Country (if address is not in United States
of America, or one of its territories).
(3) Patient Birth Date;
(4) Patient Sex;
(5) Patient Race;
(6) Patient Ethnicity;
(7) Patient Social Security Number;
(8) Patient Account Number;
(9) Patient Medical Record Number;
(10) Claim Filing Indicator Code (primary and secondary);
(11) Payer Name - Primary and secondary (if applicable,
for both);
(12) National Plan Identifier - for primary and secondary
(if applicable) payers (National Health Plan Identification number,
if applicable and when assigned by the Federal Government);
(13) Type of Bill (Facility Type Code plus Claim Frequency
Code);
(14) Statement Dates;
(15) Principal Diagnosis;
(16) Patient's Reason for Visit;
(17) External Cause of Injury (E-Code) up to 10 occurrences
(if applicable);
(18) Other Diagnosis Codes - up to 24 occurrences (all
applicable);
(19) Occurrence Code - up to 24 occurrences (if applicable);
(20) Occurrence Code Associated Date - up to 24 occurrences
(if applicable);
(21) Value Code - up to 24 occurrences (if applicable);
(22) Value Code Associated Amount - up to 24 occurrences
(if applicable);
(23) Condition Code - up to 24 occurrences (if applicable);
(24) Related Cause Code - up to 3 occurrences (if applicable);
(25) Attending Physician or Attending Practitioner
Name (if applicable):
(A) Attending Practitioner Last Name;
(B) Attending Practitioner First Name; and
(C) Attending Practitioner Middle Initial.
(26) Attending Practitioner Primary Identifier (National
Provider Identifier) (if applicable);
(27) Attending Practitioner Secondary Identifier (Texas
state license number) (if applicable);
(28) Operating Physician or Other Health Professional
Name (if applicable):
(A) Operating Physician or Other Health Professional
Last Name;
(B) Operating Physician or Other Health Professional
First Name; and
(C) Operating Physician or Other Health Professional
Middle Initial.
(29) Operating Physician or Other Health Professional
Primary Identifier (National Provider Identifier) (if applicable);
(30) Operating Physician or Other Health Professional
Secondary Identifier (Texas state license number) (if applicable);
(31) Total Claim Charges;
(32) Revenue Service Line Details (up to 999 service
lines) (all applicable);
(A) Revenue Code;
(B) Procedure Code;
(C) HCPCS Procedure Modifier 1 (applicable to each
submitted Procedure code);
(D) HCPCS Procedure Modifier 2 (applicable to each
submitted Procedure code);
(E) HCPCS Procedure Modifier 3 (applicable to each
submitted Procedure code);
(F) HCPCS Procedure Modifier 4 (applicable to each
submitted Procedure code);
(G) Charge Amount;
(H) Unit Code;
(I) Unit Quantity;
(J) Unit Rate; and
(K) Non-covered Charge Amount.
(33) Service Line Date;
(34) Service Provider Name;
(35) Service Provider Primary Identifier - Provider
Federal Tax ID (EIN) or National Provider Identifier;
(36) Service Provider Address:
(A) Service Provider Address Line 1;
(B) Service Provider Address Line 2 (if applicable);
(C) Service Provider City;
(D) Service Provider State; and
(E) Service Provider ZIP; and
(37) Service Provider Secondary Identifier - THCIC
6-digit facility ID assigned to each facility;
(38) Point of Origin (Source of Admission); and
(39) Patient Status.
(e) Facilities shall submit the required minimum data
set to DSHS for each patient who has one or more of the following
revenue codes in this subsection. Facilities operating in the State
of Texas shall submit the required data elements as specified in subsection
(d) of this section relating to the revenue codes in this subsection.
(1) 0450 Emergency Room--General Classification;
(2) 0451 Emergency Room--EMTALA Emergency Medical Screening;
(3) 0452 Emergency Room--Emergency Room beyond EMTALA;
(4) 0456 Emergency Room--Urgent Care; and
(5) 0459 Emergency Room--Other Emergency Room;
(f) This section is effective 90 calendar days after
being published in the Texas Register.
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