| (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 |
