| (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 |
