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§ 134.807. State Specific Requirements

(a) A medical EDI transmission shall not exceed a file size of 1.5 megabytes. A transaction set shall not contain more than 100 medical EDI records in a claimant hierarchical loop.

(b) Insurance carriers shall submit medical EDI transactions using Secure File Transfer Protocol (SFTP). All alphabetic characters used in the SFTP file name must be lower case and the file must be compressed/zipped. Files that do not comply with these requirements or the naming convention may be rejected and placed in appropriate failure folders. Insurance carriers must monitor these folders for file failures and make corrections in accordance with §134.804(e) of this title (relating to Reporting Requirements).

(c) SFTP files must comply with the following naming convention:

(1) Two digit alphanumeric state indicator of ‘tx’;

(2) Nine digit trading partner Federal Employer Identification Number (FEIN);

(3) Nine digit trading partner postal code;

(4) Nine digit insurance carrier FEIN or ‘xxxxxxxxx’ if the file contains medical EDI transactions from different insurance carriers;

(5) Three digit record type ‘837’;

(6) One character Test/Production indicator (‘t’ or ‘p’);

(7) Eight digit date file sent ‘CCYYMMDD’;

(8) Six digit time file sent ‘HHMMSS’;

(9) One character standard extension delimiter of ‘.’; and

(10) Three digit alphanumeric standard file extension of ‘zip’ or ‘txt’.

(d) The transaction types accepted by the division include ’00’ original, ’01’ cancel, and ’05’ replacement.

(e) Insurance carriers are required to use the following delimiters:

(1) Date Element Separator–‘*’ asterisk;

(2) Sub-element Separator–‘:’ colon; and

(3) Segment Terminator–‘~’.

(f) In addition to the requirements adopted under §134.803 of this title (relating to Reporting Standards), state reporting of medical EDI transactions shall comply with the following formatting requirements:

(1) Loop 2400 Service Line Information must not contain more than one type of service. Only one of the following data segments may be contained in an iteration of this loop: SV1 Professional Service, SV2 Institutional Service, SV3 Dental Service or SV4 Pharmacy Service.

(2) When reporting compound medications, Loop 2400 Service Line Information SV4 Pharmacy Drug Service must include a separate line for each reimbursable component of the compound medication. The same prescription number for each reimbursable component of the compound medication, including the compounding fee, must be reported. The compounding fee must be reported using a default NDC number equal to ‘99999999999’ as a separate service line.

(3) When reporting pharmacy medical EDI records, the following data element definition clarifications apply:

(A) DN501 Total Charge Per Bill is the total amount charged by the pharmacy or pharmacy processing agent;

(B) DN511 Date Insurer Received Bill is the date the insurance carrier received the bill;

(C) DN512 Date Insurer Paid Bill is the date the insurance carrier paid the pharmacy or pharmacy processing agent;

(D) DN638 Rendering Bill Provider Last/Group Name is the name of the dispensing pharmacy;

(E) DN690 Referring Provider Last/Group Name is the last name of the prescribing doctor; and

(F) DN691 Referring Provider First Name is the first name of the prescribing doctor.

(4) When ICD-10-CM and ICD-10-PCS codes are contained on the medical bill, the insurance carrier must report these codes in the associated ICD-9-CM data elements using the ICD-9-CM code qualifiers.

(5) If the injured employee’s social security number is unknown, it must be reported in accordance with §102.8(a)(1) of this title (relating to Information Requested on Written Communications to the Division).

(6) The DN53 data element must be reported on all medical EDI records.

(7) The provider agreement code must be reported on all medical EDI records, must not be reported with the value of “Y”, and must only contain one of the following values:

(A) “H” for services performed within a Certified Workers’ Compensation Health Care Network;

(B) “P” for services performed under a contractual fee arrangement, excluding services performed within a certified network; or

(C) “N” to indicate no contractual fee arrangement for services performed.

(8) When an insurance carrier calculated a reimbursement amount by applying the most recently adopted and effective Medicare Inpatient Prospective Payment System (IPPS) as required in §134.404 of this title (relating to Hospital Facility Fee Guideline–Inpatient), the DN515 (Contract Type Code) must be reported as “01” and the valid Diagnosis Related Group Code for DN518 must be reported.

(9) On a professional medical bill, an insurance carrier shall only report up to four (4) diagnosis codes on each medical EDI record.

(10) On a professional medical bill, an insurance carrier shall only report to the Division up to four diagnosis code pointers and those pointers must be reported numerically. If a professional medical bill containing more than four diagnosis pointers is reported to the insurance carrier, each diagnosis pointer after the first four shall be reported to the Division with the value of “1.

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

The provisions of this §134.807 adopted to be effective September 1, 2011, 36 TexReg 4136; amended to be effective February 17, 2013, 38 TexReg 673; amended to be effective September 1, 2015, 40 TexReg 595.

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§ 134.807. State Specific Requirements


Title 28. Insurance




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