| (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
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