| (a) Applicable health benefit plans must include the
following information as a cover page to each report:
(1) reporting period;
(2) company or plan name;
(3) NAIC number, issued to the company by the National
Association of Insurance Commissioners;
(4) TDI company number;
(5) contact information for the person designated to
discuss the report with TDI staff, including name, telephone number,
and email address;
(6) an indication of whether the report is for insurance
business or HMO business, consistent with subsection (d) of this section,
or "NA" for reports limited to self-insured business;
(7) an indication of whether the report includes data
on self-insured business, including data for certain governmental
plans required to report under Insurance Code Chapter 38, Subchapter
H; and
(8) a certification that the information provided is
a full and true statement of the data required under this subchapter.
(b) Applicable health benefit plans must submit the
following data, for in-network and out-of-network claims, for each
geographic region, as defined by §21.4503 of this title, for
each service identified in subsection (c) of this section, with data
columns reported in the following order:
(1) network status of the claims data, using "IN" to
indicate in-network claims and "OON" to indicate out-of-network claims;
(2) geographic region of the claims data, using the
three-digit ZIP code to indicate the applicable region;
(3) total number of unique claim identifiers for all
claim types;
(4) for inpatient procedure facility claims, the total
number of discharges;
(5) total amount billed;
(6) total amount allowed;
(7) mean amount billed;
(8) mean amount allowed;
(9) median amount billed;
(10) median amount allowed;
(11) maximum amount billed;
(12) maximum amount allowed;
(13) minimum amount billed;
(14) minimum amount allowed;
(15) lower quartile amount billed, representing the
25th percentile of all amounts billed;
(16) lower quartile amount allowed, representing the
25th percentile of all amounts allowed;
(17) upper quartile amount billed, representing the
75th percentile of all amounts billed; and
(18) upper quartile amount allowed, representing the
75 percentile of all amounts allowed.
(c) Data elements identified in subsection (b) of this
section must be reported in the specified manner for each category
of services in this subsection.
(1) Inpatient procedures. Data on inpatient procedure
claims must be reported separately for facility claims and professional
claims.
(A) Facility claims data must be grouped by discharge
and only include claims that occurred in an inpatient hospital.
(B) Professional claims data must be reported separately
for surgical claims, radiology claims, pathology claims, and anesthesia
claims, as applicable, and only include claims for which the place-of-service
code indicates inpatient hospital.
(C) Inpatient procedure claims data must be reported
for the full cost of any claim, or the full cost of any discharge
for facility claims, for the following services, using the medical
billing codes specified by TDI consistent with §21.4505(b) of
this title:
(i) cesarean section delivery;
(ii) vaginal delivery;
(iii) hysterectomy;
(iv) hip replacement;
(v) knee replacement;
(vi) coronary artery bypass grafting;
(vii) back surgery - laminectomy;
(viii) inguinal hernia repair, unilateral;
(ix) inguinal hernia repair, bilateral;
(x) laparoscopic cholecystectomy; and
(xi) appendectomy.
(2) Outpatient procedures. Data on outpatient facility
procedure claims must be reported separately for facility claims and
professional claims.
(A) Facility claims data must be reported separately
for outpatient procedures that occurred in an outpatient hospital
and those that occurred in an ambulatory surgical center or freestanding
clinic.
(B) Professional claims data must only include claims
for which the place-of-service code indicates outpatient hospital
or ambulatory surgical center, and be reported separately for surgical
claims, radiology claims, pathology claims, and anesthesia claims,
as applicable.
(C) Data on outpatient procedure facility claims must
be reported for the full cost of any claim for the following services,
using the medical billing codes specified by TDI, consistent with §21.4505(b)
of this title:
(i) back surgery - laminectomy
(ii) inguinal hernia repair, unilateral;
(iii) inguinal hernia repair, bilateral;
(iv) laparoscopic cholecystectomy;
(v) appendectomy;
(vi) tonsillectomy;
(vii) adenoidectomy;
(viii) tonsillectomy and adenoidectomy;
(ix) tympanostomy;
(x) colonoscopy;
(xi) upper GI endoscopy;
(xii) upper and lower GI endoscopy;
(xiii) bunion repair;
(xiv) ACL repair;
(xv) rotator cuff repair;
(xvi) cardiac catheterization, left;
(xvii) cardiac catheterization, right;
(xviii) cardiac catheterization, left and right; and
(xix) percutaneous transluminal coronary angioplasty.
(3) Emergency services. Data on emergency room visits
must be reported only for professional claims for which the place
of service is an emergency room or outpatient hospital. An emergency
room includes both a hospital emergency room and a freestanding emergency
medical care facility. Data must be reported at the claim-line level
for the following types of emergency room visits, using the medical
billing codes specified by TDI, consistent with §21.4505(b) of
this title:
(A) emergency department visit, self-limited or minor
problem;
(B) emergency department visit, low to moderately severe
problem;
(C) emergency department visit, moderately severe problem;
(D) emergency department visit, problem of high severity;
and
(E) emergency department visit, problem with significant
threat to life or function.
(4) Imaging services. Data on imaging services must
be reported separately for facility claims and professional claims.
(A) Facility claims must include only claims that occurred
in an outpatient hospital, and for which units of service equal one.
(B) Professional claims must be reported only for claims
for which units of service equal one. Data must be reported separately
for claims billed with CPT code modifiers for the professional component
(26), technical component (TC), and a missing or null modifier. Data
must be reported separately by place-of-service code:
(i) outpatient hospital;
(ii) office; and
(iii) all other place-of-service codes, excluding office,
inpatient hospital, outpatient hospital, and emergency room.
(C) Data must be reported at the claim-line level for
the following imaging services, using the medical billing codes specified
by TDI, consistent with §21.4505(b) of this title:
(i) CT abdomen and pelvis;
(ii) CT scan abdomen;
(iii) CT scan pelvis;
(iv) CT scan head/brain;
(v) CT scan mouth, jaw, and neck;
(vi) CT scan soft tissue neck;
(vii) CT scan chest;
(viii) CT scan lumbar lower spine;
(ix) CT scan lower extremity;
(x) MRI brain;
(xi) MRI head, orbit/face/neck;
(xii) MRI angiography head;
(xiii) MRI neck spine;
(xiv) MRI spine;
(xv) MRI lumbar spine;
(xvi) MRI lower limb;
(xvii) MRI upper limb, other than joint;
(xviii) MRI lower limb with joint;
(xix) MRI upper limb with joint;
(xx) MRI abdomen;
(xxi) MRI one breast;
Cont'd... |
