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COMMISSIONER'S BULLETIN # B-0023-06

June 28, 2006


To: ALL INSURERS ISSUING PREFERRED PROVIDER HEALTH BENEFIT PLANS AND ALL HEALTH MAINTENANCE ORGANIZATIONS (HMOs)


Re: APPROPRIATE USE REQUIREMENTS FOR A DATA CONDITION IN PROFESSIONAL ASC X12N 837/ USE OF "REFERRING PROVIDER NAME" FIELD

Health Maintenance Organizations (HMOs) and/or Insurers issuing preferred provider benefit plans may not require physicians and non-institutional providers (collectively, providers) who submit electronic claims to affirmatively indicate, where applicable, the lack of a referring provider in the Professional 837 (ASC X12N 837) claim form. This prohibition includes requiring the use of terms such as "self-referral", "none", or "n/a" to indicate the lack of a referral through companion guides or trading partner agreements. Federal law holds that the Loop ID-2310A NM 1 segment (referring provider segment) of the Professional 837 is a situational requirement imposed only where services are tendered pursuant to a referral. Accordingly, where there is no referring provider, determining that a professional electronic claim is deficient based upon the lack of such a notation violates Texas Clean Claim laws.

Texas Insurance Code §§ 843.336(b) and 1301.131(a) state that an electronic claim by a provider is a clean claim if the claim is submitted using the Professional 837 format and certain successor formats. The Texas Administrative Code (TAC) also confirms that submission using the ASC X12N 837 format and compliance with all appropriate federal standards, including applicable implementation guides, companion guides, and trading partner agreements, define clean electronic claims [1].

The ASC X12N 837 format, adopted by the Secretary of the U.S. Department of Health and Human Services ("the Secretary") in accordance with 42 U.S.C. § 1320d-2(a), is the standard for professional electronic health claims [2]. Title 42 U.S.C. § 1320d-4 sets forth a health plan's compliance requirements regarding use of standard transactions. The Secretary also has promulgated an implementation guide [3] to establish standards for the maximum defined data sets for these claims [4]. In the Implementation Guide, the specifications for the referring provider segment clearly indicate that this data element's usage is situational and required only if the claim involved a referral.

Federal law forbids the required addition of any data elements or segments to the maximum defined data set even if providers agree to the requirement [5], and the Secretary has noted that to allow trading partners to negotiate which conditional data elements will be used in a standard transaction would defeat the purpose of standardization [6]. Thus, a covered entity may not enter into a trading partner agreement that would change the definition, data condition, or use of, a data element or segment in a standard or that would add any data elements or segments to the maximum defined data set [7]. The organization charged with maintaining the Professional 837 format [8], the Accredited Standards Committee X12N, has upheld this requirement in the specific context of the referring provider segment.

TDI will closely scrutinize any allegation that an insurer or HMO has imposed inappropriate use requirements for a data condition or a data element or segment in an electronic claim and may initiate enforcement action, as appropriate.

If you have any questions regarding this bulletin, please contact Katrina Daniel, Special Advisor for Policy Development, Life, Health & Licensing Program at (512) 305-7342 or at katrina.daniel@tdi.state.tx.us.

Jennifer Ahrens

Associate Commissioner

Life, Health & Licensing

_________________________

[1] 28 TAC §§ 21.2802(5) and 21.2803(e).

[2] 45 C.F.R. §§ 162.920(a)(2) and 162.1102(b)(3).

[3] ASC X12N 837-Health Care Claim: Professional, Volumes 1 and 2, Version 4010, May 2000, 004010X098 and Addenda to Health Care Claim: Professional, Volumes 1 and 2, Version 4010, October 2002, 004010X098A1.

[4] 45 C.F.R. § 162.920(a)(2) and 162.1102(b)(3).

[5] See the Final Rules on Health Insurance Reform: Standards for Electronic Transactions, preamble § D and 45 C.F.R. § 162.103's definition of "maximum defined data set."

[6] Final Rules on Health Insurance Reform: Standards for Electronic Transactions, preamble § D.

[7] 45 C.F.R. § 162.915.

[8] Final Rules on Health Insurance Reform: Modifications to Electronic Data Transaction Standards and

Code Sets, preamble § I.C.; 45 C.F.R. § 162.910.



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Last updated: 09/28/2015

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