<<Prev Rule

Texas Administrative Code

Next Rule>>
TITLE 28INSURANCE
PART 1TEXAS DEPARTMENT OF INSURANCE
CHAPTER 21TRADE PRACTICES
SUBCHAPTER TSUBMISSION OF CLEAN CLAIMS
RULE §21.2803Elements of a Clean Claim

earliest compliance date required by CMS for mandatory use of the CMS-1500 (02/12) claim form for Medicare claims. The CMS-1500 (08/05) claim form must be completed in compliance with the special instructions applicable to the data element as described in this paragraph for clean claims filed by physicians and noninstitutional providers. However, on notification that an MCC is prepared to accept claims filed or refiled on form CMS-1500 (02/12), a physician or noninstitutional provider may submit claims on form CMS-1500 (02/12) before the subsection (b)(1) of this section mandatory use date described in this paragraph, subject to the subsection (b)(1) of this section required data elements set out in the paragraph.

    (A) subscriber's or patient's plan ID number (CMS-1500 (08/05), field 1a) is required;

    (B) patient's name (CMS-1500 (08/05), field 2) is required;

    (C) patient's date of birth and sex (CMS-1500 (08/05), field 3) is required;

    (D) subscriber's name (CMS-1500 (08/05), field 4) is required, if shown on the patient's ID card;

    (E) patient's address (street or P.O. Box, city, state, ZIP Code) (CMS-1500 (08/05), field 5) is required;

    (F) patient's relationship to subscriber (CMS-1500 (08/05), field 6) is required;

    (G) subscriber's address (street or P.O. Box, city, state, ZIP Code) (CMS-1500 (08/05), field 7) is required, but physician or provider may enter "Same" if the subscriber's address is the same as the patient's address required by subparagraph (E) of this paragraph;

    (H) other insured's or enrollee's name (CMS-1500 (08/05), field 9) is required if the patient is covered by more than one health benefit plan, generally in situations described in subsection (d) of this section. If the required data element specified in subparagraph (Q) of this paragraph, "disclosure of any other health benefit plans," is answered "Yes," this element is required unless the physician or the provider submits with the claim documented proof that the physician or the provider has made a good faith but unsuccessful attempt to obtain from the enrollee or the insured any of the information needed to complete this data element;

    (I) other insured's or enrollee's policy or group number (CMS-1500 (08/05), field 9a) is required if the patient is covered by more than one health benefit plan, generally in situations described in subsection (d) of this section. If the required data element specified in subparagraph (Q) of this paragraph, "disclosure of any other health benefit plans," is answered "Yes," this element is required unless the physician or the provider submits with the claim documented proof that the physician or the provider has made a good faith but unsuccessful attempt to obtain from the enrollee or the insured any of the information needed to complete this data element;

    (J) other insured's or enrollee's date of birth (CMS-1500 (08/05), field 9b) is required if the patient is covered by more than one health benefit plan, generally in situations described in subsection (d) of this section. If the required data element specified in subparagraph (Q) of this paragraph, "disclosure of any other health benefit plans," is answered "Yes," this element is required unless the physician or the provider submits with the claim documented proof that the physician or the provider has made a good faith but unsuccessful attempt to obtain from the enrollee or the insured any of the information needed to complete this data element;

    (K) other insured's or enrollee's plan name (employer, school, etc.), (CMS-1500 (08/05), field 9c) is required if the patient is covered by more than one health benefit plan, generally in situations described in subsection (d) of this section. If the required data element specified in subparagraph (Q) of this paragraph, "disclosure of any other health benefit plans," is answered "Yes," this element is required unless the physician or the provider submits with the claim documented proof that the physician or the provider has made a good faith but unsuccessful attempt to obtain from the enrollee or the insured any of the information needed to complete this data element. If the field is required and the physician or the provider is a facility-based radiologist, pathologist, or anesthesiologist with no direct patient contact, the physician or the provider must either enter the information or enter "NA" (not available) if the information is unknown;

    (L) other insured's or enrollee's HMO or insurer name (CMS-1500 (08/05), field 9d) is required if the patient is covered by more than one health benefit plan, generally in situations described in subsection (d) of this section. If the required data element specified in subparagraph (Q) of this paragraph, "disclosure of any other health benefit plans," is answered "Yes," this element is required unless the physician or the provider submits with the claim documented proof that the physician or the provider has made a good faith but unsuccessful attempt to obtain from the enrollee or the insured any of the information needed to complete this data element;

    (M) whether the patient's condition is related to employment, auto accident, or other accident (CMS-1500 (08/05), field 10) is required, but facility-based radiologists, pathologists, or anesthesiologists must enter "N" if the answer is "No" or if the information is not available;

    (N) if the claim is a duplicate claim, a "D" is required; if the claim is a corrected claim, a "C" is required (CMS-1500 (08/05), field 10d);

    (O) subscriber's policy number (CMS-1500 (08/05), field 11) is required;

    (P) HMO or insurance company name (CMS-1500 (08/05), field 11c) is required;

    (Q) disclosure of any other health benefit plans (CMS-1500 (08/05), field 11d) is required;

      (i) if answered "Yes," then:

        (I) data elements specified in subparagraphs (H) - (L) of this paragraph are required unless the physician or the provider submits with the claim documented proof that the physician or the provider has made a good faith but unsuccessful attempt to obtain from the enrollee or the insured any of the information needed to complete the data elements in subparagraphs (H) - (L) of this paragraph;

        (II) the data element specified in subparagraph (KK) of this paragraph is required when submitting claims to secondary payor MCCs;

      (ii) if answered "No," the data elements specified in subparagraphs (H) - (L) of this paragraph are not required if the physician or the provider has on file a document signed within the past 12 months by the patient or authorized person stating that there is no other health care coverage. Although the submission of the signed document is not a required data element, the physician or the provider must submit a copy of the signed document to the MCC on request;

    (R) patient's or authorized person's signature or a notation that the signature is on file with the physician or the provider (CMS-1500 (08/05), field 12) is required;

    (S) subscriber's or authorized person's signature or a notation that the signature is on file with the physician or the provider (CMS-1500 (08/05), field 13) is required;

    (T) date of injury (CMS-1500 (08/05), field 14) is required if due to an accident;

    (U) when applicable, the physician or the provider must enter the name of the referring primary care physician, specialty physician, hospital, or other source (CMS-1500 (08/05), field 17). However, if there is no referral, the physician or the provider must enter "Self-referral" or "None";

    (V) if there is a referring physician noted in CMS-1500 (08/05), field 17, the physician or the provider must enter the ID Number of the referring primary care physician, specialty physician, or hospital (CMS-1500 (08/05), field 17a);

    (W) if there is a referring physician noted in CMS-1500 (08/05), field 17, the physician or the provider must enter the NPI number of the referring primary care physician, specialty physician, or hospital (CMS-1500 (08/05), field 17b) if the referring physician is eligible for an NPI number;

    (X) narrative description of procedure (CMS-1500 (08/05), field 19) is required when a physician or a provider uses an unlisted or unclassified procedure code or an NDC code for drugs;

    (Y) for diagnosis codes or nature of illness or injury (CMS-1500 (08/05), field 21), up to four diagnosis codes may be entered. At least one is required, but the primary diagnosis must be entered first;

    (Z) verification number (CMS-1500 (08/05), field 23) is required if services have been verified under §19.1719 of this title (relating to Verification for Health Maintenance Organizations and Preferred Provider Benefit Plans). If no verification has been provided, a prior authorization number (CMS-1500 (08/05), field 23) is required when prior authorization is required and granted;

    (AA) date(s) of service (CMS-1500 (08/05), field 24A) is required;

    (BB) place of service code(s) (CMS-1500 (08/05), field 24B) is required;

    (CC) procedure/modifier code (CMS-1500 (08/05), field 24D) is required;

    (DD) diagnosis code by specific service (CMS-1500 (08/05), field 24E) is required with the first code linked to the applicable diagnosis code for that service in field 21;

    (EE) charge for each listed service (CMS-1500 (08/05), field 24F) is required;

    (FF) number of days or units (CMS-1500 (08/05), field 24G) is required;

    (GG) the NPI number of the rendering physician or provider (CMS-1500 (08/05), field 24J, unshaded portion) is required if the rendering provider is not the billing provider listed in CMS-1500 (08/05), field 33, and if the rendering physician or provider is eligible for an NPI number;

    (HH) physician's or provider's federal tax ID number (CMS-1500 (08/05), field 25) is required;

    (II) whether assignment was accepted (CMS-1500 (08/05), field 27) is required if assignment under Medicare has been accepted;

    (JJ) total charge (CMS-1500 (08/05), field 28) is required;

    (KK) amount paid (CMS-1500 (08/05), field 29) is required if an amount has been paid to the physician or the provider submitting the claim by the patient or subscriber, or on behalf of the patient or subscriber or by a primary plan to comply with subparagraph (Q) of this paragraph and as required by subsection (d) of this section;

    (LL) signature of physician or provider or a notation that the signature is on file with the MCC (CMS-1500 (08/05), field 31) is required;

    (MM) name and address of the facility where services were rendered, if other than home, (CMS-1500 (08/05), field 32) is required;

    (NN) the NPI number of the facility where services were rendered, if other than home, (CMS-1500 (08/05), field 32a) is required if the facility is eligible for an NPI;

    (OO) physician's or provider's billing name, address, and telephone number (CMS-1500 (08/05), field 33) is required;

    (PP) the NPI number of the billing provider (CMS-1500 (08/05), field 33a) is required if the billing provider is eligible for an NPI number; and

    (QQ) provider number (CMS-1500 (08/05), field 33b) is required if the MCC required provider numbers and gave notice of the requirement to physicians and providers before June 17, 2003.

  (3) Required form and data elements for institutional providers. The UB-04 claim form and the data elements described in this paragraph are required for claims filed or refiled by institutional providers. The UB-04 claim form must be completed under the special instructions applicable to the data elements as described by this paragraph for clean claims filed by institutional providers.

    (A) provider's name, address, and telephone number (UB-04, field 1) are required;

    (B) patient control number (UB-04, field 3a) is required;

    (C) type of bill code (UB-04, field 4) is required and must include a "7" in the fourth position if the claim is a corrected claim;

    (D) provider's federal tax ID number (UB-04, field 5) is required;

    (E) statement period (beginning and ending date of claim period) (UB-04, field 6) is required;

    (F) patient's name (UB-04, field 8a) is required;

    (G) patient's address (UB-04, field 9a - 9e) is required;

    (H) patient's date of birth (UB-04, field 10) is required;

    (I) patient's sex (UB-04, field 11) is required;

    (J) date of admission (UB-04, field 12) is required for admissions, observation stays, and emergency room care;

    (K) admission hour (UB-04, field 13) is required for admissions, observation stays, and emergency room care;

    (L) type of admission (such as emergency, urgent, elective, newborn) (UB-04, field 14) is required for admissions;

    (M) point of origin for admission or visit code (UB-04, field 15) is required;

    (N) discharge hour (UB-04, field 16) is required for admissions, outpatient surgeries, or observation stays;

    (O) patient discharge status code (UB-04, field 17) is required for admissions, observation stays, and emergency room care;

    (P) condition codes (UB-04, fields 18 - 28) are required if the CMS UB-04 manual contains a condition code appropriate to the patient's condition;

Cont'd...

Next Page Previous Page

Link to Texas Secretary of State Home Page | link to Texas Register home page | link to Texas Administrative Code home page | link to Open Meetings home page