The following words and terms when used in this subchapter
have the following meanings unless the context clearly indicates otherwise:
(1) Audit--A procedure authorized by and described
in §21.2809 of this title (relating to Audit Procedures) under
which a managed care carrier (MCC) may investigate a claim beyond
the statutory claims payment period without incurring penalties under §21.2815
of this title (relating to Failure to Meet the Statutory Claims Payment
(2) Batch submission--A group of electronic claims
submitted for processing at the same time within a HIPAA standard
ASC X12N 837 Transaction Set and identified by a batch control number.
(3) Billed charges--The charges for medical care or
health care services included on a claim submitted by a physician
or a provider. For purposes of this subchapter, billed charges must
comply with all other applicable requirements of law, including Health
and Safety Code §311.0025, Occupations Code §105.002, and
Insurance Code Chapter 552.
(4) CMS--The Centers for Medicare and Medicaid Services
of the U.S. Department of Health and Human Services.
(5) Catastrophic event--An event, including an act
of God, civil or military authority, or public enemy; war, accident,
fire, explosion, earthquake, windstorm, flood, or organized labor
stoppage, that cannot reasonably be controlled or avoided and that
causes an interruption in the claims submission or processing activities
of an entity for more than two consecutive business days.
(6) Clean claim--
(A) For nonelectronic claims, a claim submitted by
a physician or a provider for medical care or health care services
rendered to an enrollee under a health care plan or to an insured
under a health insurance policy that includes:
(i) the required data elements set out in §21.2803(b)
or (c) of this title (relating to Elements of a Clean Claim); and
(ii) if applicable, the amount paid by the primary
plan or other valid coverage under §21.2803(d) of this title;
(B) For electronic claims, a claim submitted by a physician
or a provider for medical care or health care services rendered to
an enrollee under a health care plan or to an insured under a health
insurance policy using the ASC X12N 837 format and in compliance with
all applicable federal laws related to electronic health care claims,
including applicable implementation guides, companion guides, and
trading partner agreements.
(7) Condition code--The code utilized by CMS to identify
conditions that may affect processing of the claim.
(8) Contracted rate--Fee or reimbursement amount for
a preferred provider's services, treatments, or supplies as established
by agreement between the preferred provider and the MCC.
(9) Corrected claim--A claim containing clarifying
or additional information necessary to correct a previously submitted
(10) Deficient claim--A submitted claim that does not
comply with the requirements of §21.2803(b), (c), or (e) of this
(11) Diagnosis code--Numeric or alphanumeric codes
from the International Classification of Diseases (ICD-9-CM), Diagnostic
and Statistical Manual (DSM-IV), or their successors, valid at the
time of service.
(12) Duplicate claim--Any claim submitted by a physician
or a provider for the same health care service provided to a particular
individual on a particular date of service that was included in a
previously submitted claim. The term does not include:
(A) corrected claims; or
(B) claims submitted by a physician or a provider at
the request of the MCC.
(13) Exclusive provider carrier--An insurer that issues
an exclusive provider benefit plan as provided by Insurance Code Chapter
(14) HMO--A health maintenance organization as defined
by Insurance Code §843.002(14).
(15) HMO delivery network--As defined by Insurance
(16) Institutional provider--An institution providing
health care services, including, but not limited to, hospitals, other
licensed inpatient centers, ambulatory surgical centers, skilled nursing
centers, and residential treatment centers.
(17) MCC or managed care carrier--An HMO, a preferred
provider carrier, or an exclusive provider carrier.
(18) NPI number--The National Provider Identifier standard
unique health identifier number for health care providers assigned
under 45 Code of Federal Regulations Part 162 Subpart D or a successor
(19) Occurrence span code--The code used by the Centers
for Medicare and Medicaid Services (CMS) to define a specific event
relating to the billing period.
(20) Patient control number--A unique alphanumeric
identifier assigned by the institutional provider to facilitate retrieval
of individual financial records and posting of payment.
(21) Patient financial responsibility--Any portion
of the contracted rate for which the patient is responsible under
the terms of the patient's health benefit plan.
(22) Patient discharge status code --The code used
by CMS to indicate the patient's status at the time of discharge or
(23) Physician--Anyone licensed to practice medicine
in this state.
(24) Place of service code--The code used by CMS that
identifies the place where the service was rendered.
(25) Point of Origin for Admission or Visit code--The
code used by CMS to indicate the source of an inpatient admission.
(26) Preferred provider--
(A) with regard to a preferred provider carrier or
an exclusive provider carrier, a preferred provider as defined by
Insurance Code §1301.001; and
(B) with regard to an HMO:
(i) a physician, as defined by Insurance Code §843.002,
who is a member of that HMO's delivery network; or
(ii) a provider, as defined by Insurance Code §843.002,
who is a member of that HMO's delivery network.
(27) Preferred provider carrier--An insurer that issues
a preferred provider benefit plan as provided by Insurance Code Chapter
(28) Primary plan--As defined in §3.3506 of this
title (relating to Use of the Terms "Plan," "Primary Plan," "Secondary
Plan," and "This Plan" in Policies, Certificates, and Contracts),
or in a successor rule adopted by the commissioner.
(29) Procedure code--Any alphanumeric code representing
a service or treatment that is part of a medical code set that is
adopted by CMS as required by federal statute and valid at the time
of service. In the absence of an existing federal code, and for nonelectronic
claims only, this definition may also include local codes developed
specifically by Medicaid, Medicare, or an MCC to describe a specific
service or procedure.
(30) Provider--Any practitioner, institutional provider,
or other person or organization that furnishes health care services
and that is licensed or otherwise authorized to practice in this state,
other than a physician.
(31) Revenue code--The code assigned by CMS to each
cost center for which a separate charge is billed.
(32) Secondary plan--As defined in §3.3506 of
this title, or in a successor rule adopted by the commissioner.
(33) Statutory claims payment period--
(A) the 45 calendar days during which an MCC must pay
or deny a claim, in whole or in part, after receipt of a nonelectronic
clean claim under Insurance Code Chapters 843 and 1301, and any extended
period permitted under §21.2804 of this title (relating to Requests
for Additional Information from Treating Provider) or §21.2819
of this title (relating to Catastrophic Event);
(B) the 30 calendar days during which an MCC must pay
or deny a claim, in whole or in part, after receipt of an electronically
submitted clean claim under Insurance Code Chapters 843 and 1301,
and any extended period permitted under §21.2804 or §21.2819
of this title;
(C) the 21 calendar days during which an MCC must pay
a claim after affirmative adjudication of a claim for a prescription
benefit that is not electronically submitted under Insurance Code
Chapters 843 and 1301 and §21.2814 of this title (relating to
Adjudication of Prescription Benefits), and any extended period permitted
under §21.2804 or §21.2819; or
(D) the 18 calendar days during which an MCC must make
a claim payment after affirmative adjudication of an electronically
submitted claim for a prescription benefit under Insurance Code Chapters
843 and 1301 and §21.2814 of this title, and any extended period
permitted under §21.2804 or §21.2819 of this title.
(34) Subscriber--If individual coverage, the individual
who is the contract holder and is responsible for payment of premiums
to the MCC; or if group coverage, the individual who is the certificate
holder and whose employment or other membership status, except for
family dependency, is the basis for eligibility for enrollment in
a group health benefit plan issued by the MCC.
(35) Type of bill code--The three-digit alphanumeric
code used by CMS to identify the type of facility, the type of care,
and the sequence of the bill in a particular episode of care.
|Source Note: The provisions of this §21.2802 adopted to be effective May 23, 2000, 25 TexReg 4543; amended to be effective October 5, 2003, 28 TexReg 8647; amended to be effective February 1, 2004, 29 TexReg 1001; amended to be effective January 19, 2006, 31 TexReg 295; amended to be effective July 11, 2007, 32 TexReg 4215; amended to be effective February 16, 2014, 39 TexReg 747