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You are here: Home . rules . 2003 . 1020b-059
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Subchapter T. Submission of Clean Claims

§§21.2802, 21.2803

The Texas Department of Insurance (the department) proposes amendments to §§21.2802 and 21.2803, concerning required data elements for non-electronic clean claims submitted to health maintenance organizations (HMOs) by dental providers. The proposed amendments are the result of Senate Bill (SB) 418, 78 th Regular Session, which contained numerous provisions regarding the prompt payment of claims by HMOs, as well as preferred provider carriers. Among other things, SB 418 added new Texas Insurance Code §843.336(d) concerning the adoption of required data fields on HMO claim forms that must be completed by a physician or provider in order for a claim to be considered clean. The purpose of this proposal is to implement those provisions, as described more fully herein.

Pursuant to Insurance Code Sec. 843.336(d), on July 4, 2003, the department proposed rules implementing major portions of SB 418, including amendments to §21.2803 that listed required elements for non-electronic clean claims. Comments the department received on the proposed rules, as well as discussions with the Technical Advisory Committee on Claims Processing, indicated, among other things, that those rules did not reflect dental-specific requirements for clean claims submitted to HMOs. As a result, the department committed to work with interested parties to develop required data elements necessary to accommodate dental claims that are subject to SB 418, and this proposal is meant to achieve that purpose.

Section 21.2802(5) and (9), and §21.2803(g) are amended to reflect changes in references to subsections of §21.2803, which are being relettered. The proposed amendment adds new subsection (c) to §21.2803 which lists the information that must be included on a dental claim form. Because dental providers do not use, nor do HMOs require, one standard claim form when submitting a claim for dental services, the proposal does not prescribe a claim form or list the fields on which the information must be provided. In proposing the clean claim elements for dental claims, however, the department has referenced commonly-used American Dental Association claim forms, specifically the ADA-J515 and the ADA-J512. The proposal thus provides the standardization contemplated by SB 418, while allowing sufficient flexibility to accommodate the actual practice of dental providers and HMOs. Subsection (a) of §21.2803 was also amended to add language which reflects the addition of proposed new subsection (c). In addition, the proposal reletters existing §21.2803(c)-(g).

Kimberly Stokes, Senior Associate Commissioner for Life, Health and Licensing, has determined that for each year of the first five years the proposed sections will be in effect there will be no fiscal impact to state and local governments as a result of the enforcement and administration of the rule. There will be no measurable effect on local employment or the local economy as a result of the proposal.

Ms. Stokes has determined that for each year of the first five years the section is in effect, the public benefits anticipated as a result of amended §§21.2802 and 21.2803 will be more appropriate, dental-specific claims elements that will allow the more efficient processing of dental claims under SB 418. Any cost to persons required to comply with these sections for each of the first five years the proposed amendments will be in effect is the result of the enactment of SB 418 and not the result of the adoption, enforcement, or administration of the sections.

Ms. Stokes has determined that there is no adverse economic impact on entities that qualify as a small business or micro-business under Government Code §2006.001 as a result of the proposed section. In addition, i t is neither legal nor feasible to waive the provisions of the proposed section for small or micro businesses since §843.336(d) provides for more efficient processing and payment of all claims received by an HMO without regard for the size of the provider or HMO.

To be considered, written comments on the proposal must be submitted no later than 5:00 p.m. on December 1, 2003 , to Gene C. Jarmon, General Counsel and Chief Clerk, Mail Code 113-2A, Texas Department of Insurance, P. O. Box 149104 , Austin , Texas 78714-9104 . An additional copy of the comment must be simultaneously submitted to Kimberly Stokes, Senior Associate Commissioner, Life, Health and Licensing Program, Mail Code 107-2A, Texas Department of Insurance, P.O. Box 149104 , Austin , Texas 78714-9104 . A request for a public hearing should be submitted separately to the Office of the Chief Clerk.

The amendments are proposed under the Insurance Code §§36.001 and 843.336(d). Section 843.336(d) says the commissioner may adopt rules that specify the information that must be entered into the appropriate fields on the applicable claim form for a claim to be a clean claim. Section 36.001 of the Insurance Code provides that the commissioner of insurance may adopt any rules necessary and appropriate to implement the powers and duties of the Texas Department of Insurance under the Insurance Code and other laws of this state.

The following statute is affected by this proposal: Insurance Code §843.336(d)

§21.2802. Definitions. The following words and terms when used in this subchapter shall have the following meanings:

(1) ­ (4) (No change.)

(5) Clean claim--

(A) For non-electronic claims, a claim submitted by a physician or provider for medical care or health care services rendered to an enrollee under a health care plan or to an insured under a health insurance policy that includes:

(i) the required data elements set forth in §21.2803(b) or (c) of this title (relating to Elements of a Clean Claim); and

(ii) if applicable, the amount paid by the primary plan or other valid coverage pursuant to §21.2803(d) [§21.2803(c)] of this title (relating to Elements of a Clean Claim);

(B) For electronic claims, a claim submitted by a physician or provider for medical care or health care services rendered to an enrollee under a health care plan or to an insured under a health insurance policy using the ASC X12N 837 format and in compliance with all applicable federal laws related to electronic health care claims, including applicable implementation guides, companion guides and trading partner agreements.

(6) ­ (8) (No change.)

(9) Deficient claim--A submitted claim that does not comply with the requirements of §21.2803(b) , (c) or (e) [(d)] of this title.

(10) ­ (30) (No change.)

§21.2803. Elements of a Clean Claim.

(a) Filing a Clean Claim. A physician or provider submits a clean claim by providing to an HMO, preferred provider carrier, or any other entity designated for receipt of claims pursuant to §21.2811 of this title (related to Disclosure of Processing Procedures):

(1) for non-electronic claims, the required data elements specified in subsection (b)of this section , or for non-electronic dental claims filed with an HMO, the required data elements specified in subsection (c) of this section;

(2) for electronic claims and for electronic dental claims filed with an HMO, the required data elements specified in subsections (e) and (f) [d and e] of this subsection; and

(3) if applicable, any coordination of benefits or non-duplication of benefits information pursuant to subsection (d) [c] of this section.

(b) (No change.)

(c) Required data elements-dental claims. The data elements described in this subsection are required as indicated and must be completed or provided in accordance with the special instructions applicable to the data element for non-electronic clean claims filed by dental providers with HMOs.

(1) Patient´s name is required;

(2) Patient´s address is required;

(3) Patient´s date of birth is required;

(4) Patient´s gender is required;

(5) Patient´s relationship to subscriber is required;

(6) Subscriber´s name is required, if shown on the patient´s ID card;

(7) Subscriber´s address is required, but provider may enter "same" if the subscriber´s address is the same as the patient´s address required by paragraph (2) of this subsection;

(8) Subscriber´s date of birth is required, if shown on the patient´s ID card;

(9) Subscriber´s gender is required;

(10) Subscriber´s identification number is required, if shown on the patient´s ID card;

(11) Subscriber´s plan/group number is required, if shown on the patient´s ID card;

(12) HMO´s name is required;

(13) HMO´s address is required;

(14) Disclosure of any other plan providing dental benefits is required and shall include a "no" if the patient is not covered by another plan providing dental benefits. If the patient does have other coverage, the provider shall indicate "yes" and the elements in paragraph (15) ­ (20) of this subsection are required unless the provider submits with the claim documented proof to the HMO that the provider has made a good faith but unsuccessful attempt to obtain from the enrollee any of the information needed to complete the data elements;

(15) Other insured´s or enrollee´s name is required in accordance with the response to and requirements of paragraph (14) of this subsection;

(16) Other insured´s or enrollee´s date of birth is required in accordance with the response to and requirements of the element in paragraph (15) of this subsection;

(17) Other insured´s or enrollee´s gender is required in accordance with the response to and requirements of the element in paragraph (15) of this subsection;

(18) Other insured´s or enrollee´s identification number is required in accordance with the response to and requirements of the element in paragraph (15) of this subsection;

(19) Patient´s relationship to other insured or enrollee is required in accordance with the response to and requirements of the element in paragraph (15) of this subsection;

(20) Name of other HMO or insurer is required in accordance with the response to and requirements of the element in paragraph (15) of this subsection;

(21) Verification or preauthorization number is required, if a verification or preauthorization number was issued by an HMO to the provider;

(22) Date(s) of service(s) or procedure(s) is required;

(23) Area of oral cavity is required, if applicable;

(24) Tooth system is required, if applicable;

(25) Tooth number(s) or letter(s) are required, if applicable;

(26) Tooth surface is required, if applicable;

(27) Procedure code for each service is required;

(28) Description of procedure for each service is required, if applicable;

(29) Charge for each listed service is required;

(30) Total charge for the claim is required;

(31) Missing teeth information is required, if a prosthesis constitutes part of the claim. A provider that provides information for this element shall include the tooth number(s) or letter(s) of the missing teeth;

(32) Notification whether the services were for orthodontic treatment is required. If the services were for orthodontic treatment, the elements in paragraph (34) and (35) of this subsection are required;

(33) Date of orthodontic appliance placement is required, if applicable;

(34) Months of orthodontic treatment remaining is required, if applicable;

(35) Notification of placement of prosthesis is required, if applicable. If the services included placement of a prosthesis, the element in paragraph (36) of this subsection is required;

(36) Date of prior prosthesis placement is required, if applicable;

(37) Name of billing provider is required;

(38) Address of billing provider is required;

(39) Billing provider´s provider identification number is required, if applicable;

(40) Billing provider´s license number is required;

(41) Billing provider´s social security number or federal tax identification number is required;

(42) Billing provider´s telephone number is required; and

(43) Treating provider´s name and license number are required if the treating provider is not the billing provider.

(d) [(c)] Coordination of benefits or non-duplication of benefits. If a claim is submitted for covered services or benefits in which coordination of benefits pursuant to §§3.3501-3.3511 of this title (relating to Group Coordination of Benefits) and §11.511(1) of this title (relating to Optional Provisions) is necessary, the amount paid as a covered claim by the primary plan is a required element of a clean claim for purposes of the secondary plan's processing of the claim and CMS 1500, field 29 or UB-92, field 54 must be completed pursuant to subsection (b)(1)(II) and (b)(2)(GG) of this section. If a claim is submitted for covered services or benefits in which non-duplication of benefits pursuant to §3.3053 of this title (relating to Non-duplication of Benefits Provision) is an issue, the amounts paid as a covered claim by all other valid coverage is a required element of a clean claim and CMS 1500, field 29 or UB-92, field 54 must be completed pursuant to subsection (b)(1)(II) and (b)(2)(GG) of this section. If a claim is submitted for covered services or benefits and the policy contains a variable deductible provision as set forth in §3.3074(a)(4) of this title (relating to Minimum Standards for Major Medical Expense Coverage) the amount paid as a covered claim by all other health insurance coverages, except for amounts paid by individually underwritten and issued hospital confinement indemnity, specified disease, or limited benefit plans of coverage, is a required element of a clean claim and CMS 1500, field 29 or UB-92, field 54 must be completed pursuant to subsection (b)(1)(II) and (b)(2)(GG) of this section. Notwithstanding these requirements, an HMO or preferred provider carrier may not require a physician or provider to investigate coordination of other health benefit plan coverage.

(e) [(d)] A physician or provider submits an electronic clean claim by submitting a claim using the applicable format that complies with all applicable federal laws related to electronic health care claims, including applicable implementation guides, companion guides and trading partner agreements.

(f) [(e)] If a physician or provider submits an electronic clean claim that requires coordination of benefits pursuant to §§3.3501-3.3511 of this title (relating to Group Coordination of Benefits) or §11.511(1) of this title (relating to Optional Provisions), the HMO or preferred provider carrier processing the claim as a secondary payor shall rely on the primary payor information submitted on the claim by the physician or provider. The primary payor may submit primary payor information electronically to the secondary payor using the ASC X12N 837 format and in compliance with federal laws related to electronic health care claims, including applicable implementation guides, companion guides and trading partner agreements.

(g)[(f)]Format of elements. The elements of a clean claim set forth in subsections (b), (c), (d) , (e) and (f) [and (e)], if applicable, of this section must be complete, legible and accurate.

(h) [(g)] Additional data elements or information. The submission of data elements or information on or with a claim form by a physician or provider in addition to those required for a clean claim under this section shall not render such claim deficient.



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