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

    (Q) occurrence codes and dates (UB-04, fields 31 - 34) are required if the CMS UB-04 manual contains an occurrence code appropriate to the patient's condition;

    (R) occurrence span codes and from and through dates (UB-04, fields 35 and 36) are required if the CMS UB-04 manual contains an occurrence span code appropriate to the patient's condition;

    (S) value code and amounts (UB-04, fields 39 - 41) are required for inpatient admissions, and may be entered as value code "01" if no value codes are applicable to the inpatient admission;

    (T) revenue code (UB-04, field 42) is required;

    (U) revenue description (UB-04, field 43) is required;

    (V) Healthcare Common Procedure Coding System (HCPCS) codes or rates (UB-04, field 44) are required if Medicare is a primary or secondary payor;

    (W) service date (UB-04, field 45) is required if the claim is for outpatient services;

    (X) date bill submitted (UB-04, field 45, line 23) is required;

    (Y) units of service (UB-04, field 46) are required;

    (Z) total charge (UB-04, field 47) is required;

    (AA) MCC name (UB-04, field 50) is required;

    (BB) prior payments-payor (UB-04, field 54) are required if payments have been made to the provider by a primary plan as required by subsection (d) of this section;

    (CC) the NPI number of the billing provider (UB-04, field 56) is required if the billing provider is eligible for an NPI number;

    (DD) other provider number (UB-04, field 57) is required if the HMO or preferred provider carrier, before June 17, 2003, required provider numbers and gave notice of that requirement to physicians and providers;

    (EE) subscriber's name (UB-04, field 58) is required if shown on the patient's ID card;

    (FF) patient's relationship to subscriber (UB-04, field 59) is required;

    (GG) patient's or subscriber's certificate number, health claim number, and ID number (UB-04, field 60) are required if shown on the patient's ID card;

    (HH) insurance group number (UB-04, field 62) is required if a group number is shown on the patient's ID card;

    (II) verification number (UB-04, field 63) is required if services have been verified under §19.1719 of this title. If no verification has been provided, treatment authorization codes (UB-04, field 63) are required when authorization is required and granted;

    (JJ) principal diagnosis code (UB-04, field 67) is required;

    (KK) diagnosis codes other than principal diagnosis code (UB-04, fields 67A - 67Q) are required if there are diagnoses other than the principal diagnosis;

    (LL) admitting diagnosis code (UB-04, field 69) is required;

    (MM) principal procedure code (UB-04, field 74) is required if the patient has undergone an inpatient or outpatient surgical procedure;

    (NN) other procedure codes (UB-04, fields 74 - 74e) are required as an extension of subparagraph (MM) of this paragraph if additional surgical procedures were performed;

    (OO) attending physician NPI number (UB-04, field 76) is required if the attending physician is eligible for an NPI number; and

    (PP) attending physician ID (UB-04, field 76, qualifier portion) is required.

(c) Required data elements for dental claims. The data elements described in this subsection are required as indicated and must be completed or provided under the special instructions applicable to the data elements for nonelectronic clean claims filed by dental providers with HMOs.

  (1) patient's name is required;

  (2) patient's address is required;

  (3) patient's date of birth is required;

  (4) patient's sex is required;

  (5) patient's relationship to subscriber is required;

  (6) subscriber's name is required;

  (7) subscriber's address is required, but the provider may enter "Same" if the subscriber's address is the same as the patient's address required by paragraph (2) of this subsection;

  (8) subscriber's date of birth is required, if shown on the patient's ID card;

  (9) subscriber's sex is required;

  (10) subscriber's identification number is required, if shown on the patient's ID card;

  (11) subscriber's plan or group number is required, if shown on the patient's ID card;

  (12) HMO's name is required;

  (13) HMO's address is required;

  (14) disclosure of any other plan providing dental benefits is required and must include a "No" if the patient is not covered by another plan providing dental benefits. If the patient does have other coverage, the provider must indicate "Yes," and the elements in paragraphs (15) - (20) of this subsection are required unless the provider submits with the claim documented proof that the provider has made a good faith but unsuccessful attempt to obtain from the enrollee any of the information needed to complete the data elements;

  (15) other insured's or enrollee's name is required as called for by the response to and requirements of paragraph (14) of this subsection;

  (16) other insured's or enrollee's date of birth is required as called for by the response to and requirements of the element in paragraph (14) of this subsection;

  (17) other insured's or enrollee's sex is required as called for by the response to and requirements of the element in paragraph (14) of this subsection;

  (18) other insured's or enrollee's identification number is required as called for by the response to and requirements of the element in paragraph (14) of this subsection;

  (19) patient's relationship to other insured or enrollee is required as called for by the response to and requirements of the element in paragraph (14) of this subsection;

  (20) name of other HMO or insurer is required as called for by the response to and requirements of the element in paragraph (14) of this subsection;

  (21) verification or preauthorization number is required, if a verification or preauthorization number was issued by an HMO to the provider;

  (22) date(s) of service(s) or procedure(s) is required;

  (23) area of oral cavity is required, if applicable;

  (24) tooth system is required, if applicable;

  (25) tooth number(s) or letter(s) are required, if applicable;

  (26) tooth surface is required, if applicable;

  (27) procedure code for each service is required;

  (28) description of procedure for each service is required, if applicable;

  (29) charge for each listed service is required;

  (30) total charge for the claim is required;

  (31) missing teeth information is required, if a prosthesis constitutes part of the claim. A provider that provides information for this element must include the tooth number(s) or letter(s) of the missing teeth;

  (32) notification of whether the services were for orthodontic treatment is required. If the services were for orthodontic treatment, the elements in paragraphs (33) and (34) of this subsection are required;

  (33) date of orthodontic appliance placement is required, if applicable;

  (34) months of orthodontic treatment remaining is required, if applicable;

  (35) notification of placement of prosthesis is required, if applicable. If the services included placement of a prosthesis, the element in paragraph (36) of this subsection is required;

  (36) date of prior prosthesis placement is required, if applicable;

  (37) name of billing provider is required;

  (38) address of billing provider is required;

  (39) billing provider's provider identification number is required, if applicable;

  (40) billing provider's license number is required;

  (41) billing provider's social security number or federal tax identification number is required;

  (42) billing provider's telephone number is required; and

  (43) treating provider's name and license number are required if the treating provider is not the billing provider.

(d) Coordination of benefits or nonduplication of benefits.

  (1) If a claim is submitted for covered services or benefits for which coordination of benefits is necessary under §§3.3501 - 3.3511 of this title (relating to Group Coordination of Benefits), a successor rule adopted by the commissioner, or §11.511(1) of this title (relating to Optional Provisions), the amount paid as a covered claim by the primary plan is a required element of a clean claim for purposes of the secondary plan's claim processing and CMS-1500 (02/12), field 29, or CMS-1500 (08/05), field 29, or UB-04, field 54, as applicable, must be completed under subsection (b)(1)(GG), (2)(KK), and (3)(BB) of this section.

  (2) If a claim is submitted for covered services or benefits for which nonduplication of benefits under §3.3053 of this title (relating to Non-duplication of Benefits Provision) is an issue, the amounts paid as a covered claim by all other valid coverage is a required element of a clean claim, and CMS-1500 (02/12), field 29, or CMS-1500 (08/05), field 29, or UB-04, field 54, as applicable, must be completed under subsection (b)(1)(GG), (2)(KK), and (3)(BB) of this section.

  (3) If a claim is submitted for covered services or benefits and the policy contains a variable deductible provision as set out in §3.3074(a)(4) of this title (relating to Minimum Standards for Major Medical Expense Coverage), the amount paid as a covered claim by all other health insurance coverages, except for amounts paid by individually underwritten and issued hospital confinement indemnity, specified disease, or limited benefit plans of coverage, is a required element of a clean claim, and CMS-1500 (02/12), field 29, or CMS-1500 (08/05), field 29, or UB-04, field 54, as applicable, must be completed under subsection (b)(1)(GG), (2)(KK), and (3)(BB) of this section. Despite these requirements, an MCC may not require a physician or a provider to investigate coordination of other health benefit plan coverage.

(e) Submission of electronic clean claim. A physician or a provider submits an electronic clean claim by using the applicable format that complies with all applicable federal laws related to electronic health care claims, including applicable implementation guides, companion guides, and trading partner agreements.

(f) Coordination of benefits on electronic clean claims. If a physician or a provider submits an electronic clean claim that requires coordination of benefits under §§3.3501 - 3.3511 of this title, a successor rule adopted by the commissioner, or §11.511(1) of this title, the MCC processing the claim as a secondary payor must rely on the primary payor information submitted on the claim by the physician or the provider. The primary payor may submit primary payor information electronically to the secondary payor using the ASC X12N 837 format and in compliance with federal laws related to electronic health care claims, including applicable implementation guides, companion guides, and trading partner agreements.

(g) Format of elements. The elements of a clean claim set out in subsections (b) - (f) of this section, as applicable, must be complete, legible, and accurate.

(h) Additional data elements or information. The submission of data elements or information on or with a claim form by a physician or a provider in addition to those required for a clean claim under this section does not render such claim deficient.


Source Note: The provisions of this §21.2803 adopted to be effective May 23, 2000, 25 TexReg 4543; amended to be effective February 14, 2001, 26 TexReg 1341; amended to be effective October 2, 2001, 26 TexReg 7542; amended to be effective October 5, 2003, 28 TexReg 8647; amended to be effective February 1, 2004, 29 TexReg 1001; amended to be effective July 11, 2007, 32 TexReg 4215; amended to be effective February 16, 2014, 39 TexReg747

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