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§ 133.502. Electronic Medical Billing Supplemental Data Requirements

(a) In addition to the data requirements and standards adopted under § 133.500(a) of this title (relating to Electronic Formats for Electronic Medical Bill Processing), all professional, institutional/hospital, and dental electronic medical bills submitted before January 1, 2012 must contain:

(1) the telephone number of the submitter;

(2) the workers’ compensation claim number assigned by the insurance carrier or, if that number is not known by the health care provider, a default value of “UNKNOWN”;

(3) the injured employee’s Social Security Number as the subscriber member identification number;

(4) the injured employee’s date of injury;

(5) the rendering health care provider’s state provider license number;

(6) the referring health care provider’s state provider license number;

(7) the billing provider’s state provider license number, if the billing provider has a state provider license number;

(8) the attending physician’s state medical license number, when applicable;

(9) the operating physician’s state medical license number, when applicable;

(10) the claim supplemental information, when electronic documentation is submitted with an electronic medical bill; and

(11) the resubmission condition code, when the electronic medical bill is a duplicate, request for reconsideration, or other resubmission.

(b) In reporting the injured employee Social Security Number and the state license numbers under subsection (a) of this section, health care providers must follow the data content and format requirements contained in § 133.10 of this title (relating to Required Billing Forms/Formats).

(c) In addition to the data requirements contained in the standards adopted under § 133.500(c) of this title, all professional, institutional/hospital, and dental electronic medical bills submitted on or after January 1, 2012 must contain:

(1) the telephone number of the submitter;

(2) the workers’ compensation claim number assigned by the insurance carrier or, if that number is not known by the health care provider, a default value of “UNKNOWN”;

(3) the injured employee’s date of injury;

(4) the claim supplemental information, when electronic documentation is submitted with an electronic medical bill; and

(5) the resubmission condition code, when the electronic medical bill is a duplicate, request for reconsideration, or other resubmission.

(d) In addition to the data requirements contained in the standards adopted under § 133.500 of this title, all pharmacy electronic medical bills must contain:

(1) the dispensing pharmacy’s National Provider Identification number; and

(2) the prescribing doctor’s National Provider Identification number.

(e) In reporting the resubmission condition code under this section, the resubmission condition codes shall have the definitions specified in § 133.10(j) of this title.

(f) This section does not apply to paper medical bills submitted for payment under § 133.10(b) of this title.

(g) This section is effective August 1, 2011.

The provisions of this §133.502 adopted to be effective August 1, 2011, 36 TexReg 929.

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At a Glance:

Title:

§ 133.502. Electronic Medical Billing Supplemental Data Requirements

Title:

Title 28. Insurance

Status:

Current

Usage:

New Law Rule

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