| (a) Insurance carriers shall submit medical EDI records
when the insurance carrier:
(1) pays a medical bill;
(2) reduces or denies payment for a medical bill, including
duplicate bills;
(3) receives a refund for a medical bill;
(4) discovers that a medical EDI record should not
have been submitted to the division and the medical EDI record had
previously been accepted by the division;
(5) reimburses an injured employee for health care
paid in accordance with §133.270; or
(6) reimburses an employer for health care paid in
accordance with §133.280.
(b) Regardless of the Application Acknowledgment Code
returned in an acknowledgment, medical EDI records are not considered
received by the division if the medical EDI record:
(1) contains data which does not accurately reflect
the code values used or actions taken when the insurance carrier processed
the medical bill; or
(2) fails to contain a conditional data element and
the mandatory trigger condition existed at the time the insurance
carrier processed the medical bill.
(c) Except in situations where the health care provider
included an invalid service or procedure code on the medical bill,
rejected medical EDI records are not considered received and shall
be corrected and resubmitted to the division as provided in §134.804(e)
of this title (relating to Reporting Requirements). Medical EDI records
submitted in the test environment are not considered received and
do not comply with the reporting requirements of this section.
(d) This section is effective September 1, 2015.
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