| (a) Health care providers, including those providing
services for a certified workers' compensation health care network
as defined in Insurance Code Chapter 1305 or to political subdivisions
with contractual relationships under Labor Code §504.053(b)(2),
shall submit medical bills for payment in an electronic format in
accordance with §133.500 and §133.501 of this title (relating
to Electronic Formats for Electronic Medical Bill Processing and Electronic
Medical Bill Processing), unless the health care provider or the billed
insurance carrier is exempt from the electronic billing process in
accordance with §133.501 of this title.
(b) Except as provided in subsection (a) of this section,
health care providers, including those providing services for a certified
workers' compensation health care network as defined in Insurance
Code Chapter 1305 or to political subdivisions with contractual relationships
under Labor Code §504.053(b)(2), shall submit paper medical bills
for payment on:
(1) the 1500 Health Insurance Claim Form Version 02/12
(CMS-1500);
(2) the Uniform Bill 04 (UB-04); or
(3) applicable forms prescribed for pharmacists, dentists,
and surgical implant providers specified in subsections (c), (d) and
(e) of this section.
(c) Pharmacists and pharmacy processing agents shall
submit bills using the Division form DWC-066. A pharmacist or pharmacy
processing agent may submit bills using an alternate billing form
if:
(1) the insurance carrier has approved the alternate
billing form prior to submission by the pharmacist or pharmacy processing
agent; and
(2) the alternate billing form provides all information
required on the Division form DWC-066.
(d) Dentists shall submit bills for dental services
using the 2006 American Dental Association (ADA) Dental Claim form.
(e) Surgical implant providers requesting separate
reimbursement for implantable devices shall submit bills using:
(1) the form prescribed in subsection (b)(1) of this
section when the implantable device reimbursement is sought under §134.402
of this title (relating to Ambulatory Surgical Center Fee Guideline);
or
(2) the form prescribed in subsection (b)(2) of this
section when the implantable device reimbursement is sought under §134.403
or §134.404 of this title (relating to Hospital Facility Fee
Guideline--Outpatient and Hospital Facility Fee Guideline--Inpatient).
(f) All information submitted on required paper billing
forms must be legible and completed in accordance with this section.
The parenthetical information following each term in this section
refers to the applicable paper medical billing form and the field
number corresponding to the medical billing form.
(1) The following data content or data elements are
required for a complete professional or noninstitutional medical bill
related to Texas workers' compensation health care:
(A) patient's Social Security Number (CMS-1500/field
1a) is required;
(B) patient's name (CMS-1500/field 2) is required;
(C) patient's date of birth and gender (CMS-1500/field
3) is required;
(D) employer's name (CMS-1500/field 4) is required;
(E) patient's address (CMS-1500/field 5) is required;
(F) patient's relationship to subscriber (CMS-1500,
field 6) is required;
(G) employer's address (CMS-1500, field 7) is required;
(H) workers' compensation claim number assigned by
the insurance carrier (CMS-1500/field 11) is required when known,
the billing provider shall leave the field blank if the workers' compensation
claim number is not known by the billing provider;
(I) date of injury and "431" qualifier (CMS-1500, field
14) are required;
(J) name of referring provider or other source is required
when another health care provider referred the patient for the services;
No qualifier indicating the role of the provider is required (CMS-1500,
field 17);
(K) referring provider's state license number (CMS-1500/field
17a) is required when there is a referring doctor listed in CMS-1500/field
17; the billing provider shall enter the '0B' qualifier and the license
type, license number, and jurisdiction code (for example, 'MDF1234TX');
(L) referring provider's National Provider Identifier
(NPI) number (CMS-1500/field 17b) is required when CMS-1500/field
17 contains the name of a health care provider eligible to receive
an NPI number;
(M) diagnosis or nature of injury (CMS-1500/field 21)
is required, at least one diagnosis code and the applicable ICD indicator
must be present;
(N) prior authorization number (CMS-1500/field 23)
is required when preauthorization, concurrent review or voluntary
certification was approved and the insurance carrier provided an approval
number to the requesting health care provider;
(O) date(s) of service (CMS-1500, field 24A) is required;
(P) place of service code(s) (CMS-1500, field 24B)
is required;
(Q) procedure/modifier code (CMS-1500, field 24D) is
required;
(R) diagnosis pointer (CMS-1500, field 24E) is required;
(S) charges for each listed service (CMS-1500, field
24F) is required;
(T) number of days or units (CMS-1500, field 24G) is
required;
(U) rendering provider's state license number (CMS-1500/field
24j, shaded portion) is required when the rendering provider is not
the billing provider listed in CMS-1500/field 33; the billing provider
shall enter the '0B' qualifier and the license type, license number,
and jurisdiction code (for example, 'MDF1234TX');
(V) rendering provider's NPI number (CMS-1500/field
24j, unshaded portion) is required when the rendering provider is
not the billing provider listed in CMS-1500/field 33 and the rendering
provider is eligible for an NPI number;
(W) supplemental information (shaded portion of CMS-1500/fields
24d - 24h) is required when the provider is requesting separate reimbursement
for surgically implanted devices or when additional information is
necessary to adjudicate payment for the related service line;
(X) billing provider's federal tax ID number (CMS-1500/field
25) is required;
(Y) total charge (CMS-1500/field 28) is required;
(Z) signature of physician or supplier, the degrees
or credentials, and the date (CMS-1500/field 31) is required, but
the signature may be represented with a notation that the signature
is on file and the typed name of the physician or supplier;
(AA) service facility location information (CMS-1500/field
32) is required;
(BB) service facility NPI number (CMS-1500/field 32a)
is required when the facility is eligible for an NPI number;
(CC) billing provider name, address and telephone number
(CMS-1500/field 33) is required;
(DD) billing provider's NPI number (CMS-1500/Field
33a) is required when the billing provider is eligible for an NPI
number; and
(EE) billing provider's state license number (CMS-1500/field
33b) is required when the billing provider has a state license number;
the billing provider shall enter the '0B' qualifier and the license
type, license number, and jurisdiction code (for example, 'MDF1234TX').
(2) The following data content or data elements are
required for a complete institutional medical bill related to Texas
workers' compensation health care:
(A) billing provider's name, address, and telephone
number (UB-04/field 01) is required;
(B) patient control number (UB-04/field 03a) is required;
(C) type of bill (UB-04/field 04) is required;
(D) billing provider's federal tax ID number (UB-04/field
05) is required;
(E) statement covers period (UB-04/field 06) is required;
(F) patient's name (UB-04/field 08) is required;
(G) patient's address (UB-04/field 09) is required;
(H) patient's date of birth (UB-04/field 10) is required;
(I) patient's gender (UB-04/field 11) is required;
(J) date of admission (UB-04/field 12) is required
when billing for inpatient services;
(K) admission hour (UB-04/field 13) is required when
billing for inpatient services other than skilled nursing inpatient
services;
(L) priority (type) of admission or visit (UB-04/field
14) is required;
(M) point of origin for admission or visit (UB-04/field
15) is required;
(N) discharge hour (UB-04/field 16) is required when
billing for inpatient services with a frequency code of "1" or "4"
other than skilled nursing inpatient services;
Cont'd... |
