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TITLE 25HEALTH SERVICES
PART 1DEPARTMENT OF STATE HEALTH SERVICES
CHAPTER 421HEALTH CARE INFORMATION
SUBCHAPTER DCOLLECTION AND RELEASE OF OUTPATIENT SURGICAL AND RADIOLOGICAL PROCEDURES AT HOSPITALS AND AMBULATORY SURGICAL CENTERS
RULE §421.67Event Files--Records, Data Fields and Codes

(a) Facilities shall submit event files, electronically in the file format for outpatient bills defined by the American National Standards Institute (ANSI), commonly known as the ANSI ASC X12N form 837 Health Care Claims transaction for institutional claims or ANSI ASC X12N form 837 Health Care Claims transaction for professional claims. ANSI updates these formats from time to time by issuing new versions and the United States Department of Health and Human Services adopts regulations regarding HIPAA that update the version allowed for claim submissions.

(b) DSHS will make detailed specifications for these data elements available to submitters and to the public.

(c) In addition to the data elements contained in the ANSI 837 Institutional Guide and the ANSI 837 Professional Guide, DSHS has specified the location where each of the following data elements in this subsection shall be reported in the ANSI 837 Institutional Guide format and the ANSI 837 Professional Guide format. Data element content, format and locations may change as state legislative requirements, or federal legislative or regulation requirements change (i.e., HIPAA).

  (1) Patient race - This data element shall be reported at Loop 2300 in the K3 segment as the second numeric value in this data segment. Acceptable codes are 1 = American Indian/Eskimo/Aleut, 2 = Asian or, Pacific Islander, 3 = Black, 4 = White and 5 = Other Race. In order to obtain this data, the facility staff retrieves the patient's response from a written form or asks the patient, or the person speaking for the patient, to classify the patient. If the patient, or person speaking for the patient, declines to answer, the facility staff is to use its best judgment to make the correct classification based on available data.

  (2) Patient ethnicity - This data element shall be reported at Loop 2300 in the segment K3 as the first numeric value. Acceptable codes are 1 = Hispanic or Latino Origin and 2 = Not of Hispanic or Latino Origin. In order to obtain this data, the facility staff retrieves the patient's response from a written form or asks the patient, or the person speaking for the patient, to classify the patient. If the patient, or person speaking for the patient, declines to answer, the facility staff is to use its best judgment to make the correct classification based on available data.

  (3) Other E-codes - These additional E-codes (maximum of 9 other E-codes, a total of 10 E-codes may be submitted) shall be reported (if applicable) in the following ANSI 837 Institutional Guide locations: Loop 2300, segments, HI05-2, HI06-2, HI07-2, HI08-2, HI09-2, HI10-2, HI11-2 and HI12-2. (The first E-code is generally reported in Loop 2300 segment HI04-2). E-codes may be submitted in the ANSI 837 Professional Guide in the following locations Loop 2300, data fields: HI02-2, HI03-2, HI04-2, HI05-2, HI06-2, HI07-2 or HI08-2 if applicable preceded by "BN" qualifying code in the respective data field HI02-1, HI03-1, HI04-1, HI05-1, HI06-1, HI07-1 or HI08-1.

  (4) THCIC Identification Number - This data element shall be submitted in data segment REF02 (Secondary Identification Number) of one of the following Loops where the patient received the event services:

    (A) Loop 2010AA associated with the "Billing Provider"; or

    (B) Loop 2010AB associated with the "Pay-to provider"; or

    (C) Loop 2310E (ANSI 837 Institutional Guide) or Loop 2310D (ANSI 837 Professional Guide) associated with the "Service Facility Provider".

(d) Facilities shall submit the required minimum data set in the following modified ANSI 837 Institutional Guide format for all patients that are uninsured or considered self-pay or covered by third party payers in which the payer requires the claim be submitted in an ANSI 837 Institutional Guide format or CMS-1450 format for which an event claim is required by this subchapter. The required minimum data set for the modified (as specified in subsection (c) of this section) ANSI 837 Institutional Guide format includes the following data elements as listed in this subsection:

  (1) Patient Name:

    (A) Patient Last Name;

    (B) Patient First Name; and

    (C) Patient Middle Initial.

  (2) Patient Address:

    (A) Patient Address Line 1;

    (B) Patient Address Line 2 (if applicable);

    (C) Patient City;

    (D) Patient State;

    (E) Patient ZIP; and (A)

    (F) Patient Country (if address is not in the United States of America, or one of its territories).

  (3) Patient Birth Date;

  (4) Patient Sex;

  (5) Patient Race;

  (6) Patient Ethnicity;

  (7) Patient Social Security Number;

  (8) Patient Account Number;

  (9) Patient Medical Record Number;

  (10) Claim Filing Indicator Code (primary and secondary);

  (11) Payer Name - Primary and secondary (if applicable, for both);

  (12) National Plan Identifier - for primary and secondary (if applicable) payers (National Health Plan Identification number, if applicable and when assigned by the Federal Government);

  (13) Type of Bill (Facility Type Code plus Claim Frequency Code);

  (14) Statement Dates;

  (15) Principal Diagnosis;

  (16) Patient's Reason for Visit;

  (17) External Cause of Injury (E-Code) up to 10 occurrences (if applicable);

  (18) Other Diagnosis Codes - up to 24 occurrences (all applicable);

  (19) Occurrence Code - up to 24 occurrences (if applicable);

  (20) Occurrence Code Associated Date - up to 24 occurrences (if applicable);

  (21) Value Code - up to 24 occurrences (if applicable);

  (22) Value Code Associated Amount - up to 24 occurrences (if applicable);

  (23) Condition Code - up to 24 occurrences (if applicable);

  (24) Related Cause Code - up to 3 occurrences (if applicable);

  (25) Other Provider or Other Health Professional Name (if applicable):

    (A) Other Provider or Other Health Professional Last Name;

    (B) Other Provider or Other Health Professional First Name; and

    (C) Other Provider or Other Health Professional Middle Initial.

  (26) Other Provider or Other Health Professional Primary Identifier (National Provider Identifier) (if applicable);

  (27) Other Provider or Other Health Professional Secondary Identifier (Texas state license number) (if applicable);

  (28) Operating Physician or Other Health Professional Name (if applicable):

    (A) Operating Physician or Other Health Professional Last Name;

    (B) Operating Physician or Other Health Professional First Name; and

    (C) Operating Physician or Other Health Professional Middle Initial.

  (29) Operating Physician or Other Health Professional Primary Identifier (National Provider Identifier) (if applicable);

  (30) Operating Physician or Other Health Professional Secondary Identifier (Texas state license number) (if applicable);

  (31) Total Claim Charges;

  (32) Revenue Service Line Details (up to 999 service lines) (all applicable);

    (A) Revenue Code;

    (B) Procedure Code;

    (C) HCPCS Procedure Modifier 1 (applicable to each submitted Procedure code);

    (D) HCPCS Procedure Modifier 2 (applicable to each submitted Procedure code);

    (E) HCPCS Procedure Modifier 3 (applicable to each submitted Procedure code);

    (F) HCPCS Procedure Modifier 4 (applicable to each submitted Procedure code);

    (G) Charge Amount;

    (H) Unit Code;

    (I) Unit Quantity;

    (J) Unit Rate; and

    (K) Non-covered Charge Amount.

  (33) Service Line Date (effective 90 calendar days after being published in the Texas Register );

  (34) Service Provider Name;

  (35) Service Provider Primary Identifier - Provider Federal Tax ID (EIN) or National Provider Identifier;

  (36) Service Provider Address:

    (A) Service Provider Address Line 1;

    (B) Service Provider Address Line 2 (if applicable);

    (C) Service Provider City;

    (D) Service Provider State; and

Cont'd...

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