| (a) Insurance carriers shall submit an '00' original
medical EDI record for each action (initial processing, request for
reconsideration or appeal, or subsequent orders) taken on an individual
medical bill. Original medical EDI records shall be reported within
30 days after the date of the action. Each iteration of an '00' original
medical EDI record must contain a different unique medical bill identification
number. The amount paid on each action related to a medical bill must
contain only the amount issued for that event and must not contain
a cumulative amount reflecting all events related to an individual
medical bill. Original medical EDI records on subsequent actions must
contain a Texas-specific claim adjustment reason code of 'W3' to designate
the medical EDI record as a reconsideration or appeal. The Texas-specific
claim adjustment reason code must be included on the explanation of
benefits issued pursuant to §133.250 of this title (relating
to Reconsideration for Payment of Medical Bills).
(b) Insurance carriers shall submit an '01' cancel
medical EDI record if the '00' original medical EDI record should
not have been sent or contained the incorrect insurance carrier identification
number. Cancel medical EDI records shall be reported within 30 days
after the earliest date the insurance carrier discovered the reporting
error. The '01' cancel medical EDI record must contain the same unique
bill identification number as the '00' original medical EDI record
that was previously submitted and accepted. An '00' original medical
EDI record must be accepted by the division before an '01' cancel
medical EDI record may be submitted.
(c) Insurance carriers shall submit an '05' replacement
medical EDI record when correcting data on a previously submitted
medical EDI record. Replacement medical EDI records shall be submitted
within 30 days after the earliest date the insurance carrier discovered
the reporting error. The '05' replacement medical EDI record must
contain the same unique bill identification number as the associated
'00' original medical EDI record. An '00' original medical EDI record
must be accepted by the division before an '05' replacement medical
EDI record may be submitted.
(d) Insurance carriers must submit timely and accurate
medical EDI records to the division. For the purpose of this section,
a medical EDI record is considered to have been accurately submitted
when the record:
(1) received an Application Acknowledgment Code of
accepted;
(2) contained accurate medical EDI data; medical EDI
data may be obtained from all sources, including the medical bill,
explanation of benefits, and insurance carrier's claim file; and
(3) to the extent supported by the format, contained
all appropriate modifiers, code qualifiers, and data elements necessary
to identify health care services, charges and payments.
(e) Insurance carriers are responsible for correcting
and resubmitting rejected medical EDI records within 30 days of the
action that triggered the reporting requirement. The insurance carrier's
receipt of a rejection does not modify, extend or otherwise change
the date the transaction is required to be reported to the division.
The resubmitted medical EDI record must contain the same unique bill
identification number as the previously rejected medical EDI record.
(f) This section is effective September 1, 2015.
|
