Texas Workers' Compensation

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§ 134.802. Definitions

(a) The following words and terms, when used in this subchapter, shall have the following meaning, unless the context clearly indicates otherwise:

(1) Application Acknowledgment Code–A code used to identify the accepted or rejected status of the transaction being acknowledged.

(2) Claim Adjustment Reason Code (CARC)–A code that is used on a medical EDI record and an explanation of benefits to communicate why the amount paid for a medical bill or service line does not equal the amount charged. The term is synonymous with service adjustment reason code in the IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 1.0, dated July 4, 2002.

(3) Claim Administrator Claim Number–An identifier that distinguishes a specific claim within a claim administrator’s claim processing system and is used throughout the life of the claim.

(4) Division–The Texas Department of Insurance, Division of Workers’ Compensation or its data collection agent.

(5) EDI–Electronic data interchange.

(6) Element Requirement Table–A receiver specific list of requirement codes for each data element depending on the bill submission reason code.

(7) IAIABC–The International Association of Industrial Accident Boards and Commissions.

(8) Medical EDI Record–The accurate data associated with a single medical bill which is being reported in a Medical EDI Transaction obtained from all sources, including the medical bill, explanation of benefits, and insurance carrier’s claim file.

(9) Medical EDI Transmission–The data that is contained within the interchange envelope.

(10) Medical EDI Transaction–The data that is contained within the functional group.

(11) Person–An individual, partnership, corporation, hospital district, insurance carrier, organization, business trust, estate trust, association, limited liability company, limited liability partnership or other entity. This term does not include an injured employee.

(12) Trading Partner–A person that has entered into an agreement with the insurance carrier to format electronic data for transmission to the division, transmits electronic data to the division, and responds to any technical issues related to the contents or structure of an EDI file.

(13) W3–A Texas-specific claim adjustment reason code to designate the medical EDI record as a reconsideration or appeal.

(b) This section is effective September 1, 2015.

The provisions of this §134.802 adopted to be effective February 20, 1991, 16 TexReg 671; amended to be effective June 1, 1992, 17 TexReg 3250; amended to be effective December 1, 1992, 17 TexReg 7903; amended to be effective July 15, 2000, 25 TexReg 2139; amended to be effective July 11, 2004, 29 TexReg 6303; amended to be effective April 28, 2005, 30 TexReg 2398; amended to be effective May 2, 2006, 31 TexReg 3561; amended to be effective September 1, 2011, 36 TexReg 4136; amended to be effective September 1, 2015, 40 TexReg 595.

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At a Glance:

Title:

§ 134.802. Definitions

Title:

Title 28. Insurance

Status:

Current

Usage:

New Law Rule

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