|(a) Insurance carriers may submit medical EDI records
directly to the division or may contract with an external trading
partner to submit the records on the insurance carrier's behalf.
(b) Each insurance carrier, including those using external
trading partners, must designate one individual to the division as
the EDI Compliance Coordinator and provide the individual's name,
working title, mailing address, email address, and telephone number
in the form and manner prescribed by the division. The EDI Compliance
(1) be a centrally-located employee of the insurance
carrier who has the responsibility for EDI reporting;
(2) receive and appropriately disperse data reporting
information received from the division; and
(3) serve as the central compliance control for data
reporting under this subchapter.
(c) At least five working days prior to sending its
first transaction to the division under this subchapter, the insurance
carrier shall send a notice to the division. The notice shall be in
the form and manner established by the division. The notice shall
include the name of the insurance carrier, the insurance carrier's
FEIN, the insurance carrier's TxCOMP customer number, the name of
the trading partner(s) authorized to conduct medical EDI transactions
on behalf of the insurance carrier, the FEIN of the trading partner(s),
and the EDI Compliance Coordinator's signature. The insurance carrier
shall report changes within five working days of any amendment to
data sharing agreements, including the addition or removal of any
trading partners. The failure to timely submit updated information
may result in the rejection of medical EDI records.
(d) At least five working days prior to sending its
first test transaction to the division under this subchapter, the
insurance carrier or trading partner sending the medical EDI transmission
shall send a notice to the division. The notice shall be in the form
and manner established by the division. The notice shall include the
entity's name, FEIN, nine-digit postal code, address, and the technical
contact's name, address, phone number, and email address. The insurance
carrier or trading partner shall report changes within five working
days of any amendment to the information required to be reported.
(e) Insurance carriers and trading partners must successfully
complete testing prior to transmitting any production data. Trading
partners must receive approval to submit data for at least one insurance
carrier prior to initiating the testing process. Insurance carriers
and trading partners must submit each transaction type during the
testing process which can be successfully processed by the division.
The division will not approve an insurance carrier or trading partner
for production submissions until the insurance carrier or trading
(1) successfully submitted ten percent of its anticipated
monthly volume per service type, not to exceed 100 medical EDI records
per service type;
(2) received and reviewed the acknowledgments generated
by the division; and
(3) correctly resubmitted rejected records identified
in the acknowledgments.
(f) Insurance carriers are responsible for the acts
or omissions of their trading partners. The insurance carrier commits
an administrative violation if the insurance carrier or its trading
partner fails to timely or accurately submit medical EDI records.
(g) This section is effective September 1, 2015.