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COMMISSIONER'S BULLETIN # B-0030-07

July 17, 2007


To: ALL INSURERS WRITING PREFERRED PROVIDER BENEFIT PLANS (PPBPs) AND ALL HEALTH MAINTENANCE ORGANIZATIONS (HMOs), AND ALL PHYSICIANS AND PROVIDERS


Re: MANDATORY USE DATE FOR CMS-1500 (08/05) AND UB-04 CMS-1450 CLAIM FORMS FOR SUBMISSION OF CLEAN HEALTH CARE CLAIMS IS JULY 18, 2007

The purpose of this bulletin is to remind insurers, HMOs, physicians, and providers that the implementation date for successor claim forms CMS-1500 (08/05) and UB-04 CMS-1450 is July 18, 2007. The CMS-1500 (08/05) form and the UB-04 CMS-1450 form are the successor forms to the CMS-1500 (12/90) and UB-92 CMS-1450 forms previously required for submission of health care clean claims under Insurance Code (TIC) §§843.336 and 1301.131.

The Department adopted amendments to Title 28 Texas Administrative Code (TAC) §§21.2802 and 21.2803, concerning elements of a clean health care claim, effective July 11, 2007, published on July 6, 2007, in the Texas Register, 32 TexReg 4215. ( available at http://www.tdi.state.tx.us/rules/documents/212802-212803.pdf). The amendments to §21.2803 include the mandatory CMS-1500 (08/05) and UB-04 CMS-1450 form use dates and optional form transition dates for nonelectronic claims filed or re-filed by physicians or non-institutional providers and for nonelectronic claims filed or re-filed by institutional providers. To more closely align the timeframes required by the amended rules for the successor forms with the timelines being implemented by the Centers for Medicare and Medicaid Services (CMS), the Department established mandatory use dates that would be responsive to any unforeseen delays in CMS implementation.

Section 21.2803(b)(1) mandates the use of form CMS-1500 (08/05) for physicians and noninstitutional providers for nonelectronic claims filed or re-filed on or after the later of July 18, 2007 , or the earliest compliance date required by CMS for mandatory use of the CMS-1500 (08/05) form for Medicare claims. Section 21.2803(b)(2) mandates the use of form CMS-1500 (12/90) for physicians and noninstitutional providers for nonelectronic claims filed or re-filed before the later of July 18, 2007, or the earliest compliance date required by CMS for mandatory use of the CMS-1500 (08/05) form for Medicare claims.

Pursuant to guidance from the CMS website, the earliest date established by CMS for mandatory use of the CMS-1500 (08/05) version is July 1, 2007 and later.

Effective July 1, 2007, Medicare will reject any 12-90 version forms received. Since July 1 is a Sunday that means that any CMS-1500 (12-90) forms not received by June 29, 2007, the last business day on which mail will be received and processed in June, will be returned to the submitters for resubmission on the 08-05 version of the form. (http://www.cms.hhs.gov/ElectronicBillingEDITrans/Downloads/Webterminateold1500.pdf).

Because CMS mandated use of CMS-1500 (08/05) effective July 1, 2007, July 18, 2007 is the later of the two dates referenced in §21.2803(b)(1) and (b)(2). Physicians and noninstitutional providers filing or re-filing nonelectronic claims pursuant to TIC §§843.336 and 1301.131 must use form CMS-1500 (08/05) on or after July 18, 2007. Physicians and noninstitutional providers filing or re-filing nonelectronic claims before July 18, 2007 pursuant to TIC §§843.336 and 1301.131 must use form CMS-1500 (12/90). Both §21.2803(b)(1) and (b)(2) include optional transition periods for earlier use of the CMS-1500 (08/05) form upon notification that an HMO or preferred provider carrier is prepared to accept the CMS-1500 (08/05) claim form.

Further, for purposes of clean claims, §21.2803(b)(3) requires that institutional providers filing or re-filing claims on or after July 18, 2007 must use the UB-04 CMS-1450 claim form, and §21.2803(b)(4) requires that institutional providers filing or re-filing claims before July 18, 2007 must use form UB-92 CMS-1450. These rules similarly include optional transition periods for earlier use of the form UB-04 CMS-1450 upon notification that an HMO or preferred provider carrier is prepared to accept the UB-04 CMS-1450 claim form.

All insurers writing PPBPs and HMOs must comply with prompt payment and clean claim requirements applicable to claims submitted on the new CMS-1500 (08/05) and UB-04 CMS-1450 as set forth in TIC Chapter 843, Subchapter J, Chapter 1301, Subchapters C and C-1, consistent with the timelines established in §21.2803(b). If you have any questions concerning this bulletin, please contact Katrina Daniel, Special Advisor for Policy Development, Life, Health & Licensing, at (512) 322-4315 or Katrina.Daniel@tdi.state.tx.us.

____________________________

Jennifer Ahrens

Senior Associate Commissioner

Life, Health & Licensing

Texas Department of Insurance

Created [July 17, 2007]



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