Medical state reporting FAQ

Applicability

Q: Who is required to report workers’ compensation medical billing data to Texas?

A: All insurance carriers are required to report information prescribed by the commissioner under Texas Labor Code §§401.011, 413.007 and 413.008 for each medical bill on a workers' compensation claim.

Responsibility

Q: If I contract with an external Trading Partner to send Texas workers’ compensation medical billing data on my behalf, will I still be responsible or held liable for any acts of omissions, late, or inaccurate reporting of medical billing data?

A: Yes. 28 Texas Administrative Code (TAC) §134.808(f) provides that insurance carriers are responsible for the acts or omissions of their trading partners. The insurance carrier commits an administrative violation if the insurance carrier or its trading partner fails to timely or accurately submit medical EDI records.

Reporting standards

Q: What guidelines and format do I use to report workers’ compensation medical billing data to Texas?

A: In 28 TAC §134.803, DWC adopted the IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 1.0, dated July 4, 2002 (IAIABC EDI Implementation Guide) published by the International Association of Industrial Accident Boards and Commissions (IAIABC).

In addition, DWC adopted the Texas EDI Medical Data Element Requirement Table, Version 2.0, dated September 2015; the Texas EDI Medical Data Element Edits Table, Version 2.0, dated September 2015; and the Texas EDI Medical Difference Table, Version 3.0, dated September 2015. All tables are published by DWC.

Getting started

Q: What do I need to do before I can begin reporting workers’ compensation medical billing data to DWC in the test environment?

A: 28 TAC §134.808(d) provides that at least five working days prior to sending its first test transaction to DWC under this subchapter, the insurance carrier or trading partner sending the medical EDI transmission shall send a notice, DWC EDI-02, to DWC.

Q: Are there requirements I have to fulfill in order to submit workers’ compensation medical billing data to DWC in the test environment before I can send data in the production environment?

A: 28 TAC §134.808(e) provides that insurance carriers and trading partners must successfully complete testing prior to transmitting any production data. Trading partners must receive approval to submit data for at least one insurance carrier prior to initiating the testing process. Insurance carriers and trading partners must submit each transaction type during the testing process which can be successfully processed by DWC. DWC will not approve an insurance carrier or trading partner for production submissions until the insurance carrier or trading partner has:

1. successfully submitted ten percent of its anticipated monthly volume per service type, not to exceed 100 bills per service type;
2. received and reviewed the acknowledgments generated by DWC; and
3. correctly resubmitted rejected records identified in the acknowledgments.

Reporting requirements

Q: What are the actions that trigger the responsibility to report workers’ compensation medical billing data to Texas?

A: 28 TAC §134.805(a) provides that insurance carriers shall submit medical EDI records when the insurance carrier: 

1. pays a medical bill;
2. reduces or denies payment for a medical bill, including duplicate bills;
3. receives a refund for a medical bill;
4. discovers that a medical EDI record should not have been submitted to the division and the medical EDI record had previously been accepted by the division;
5. reimburses an injured employee for health care paid in accordance with §133.270; or
6. reimburses an employer for health care paid in accordance with §133.280.

Q: What medical EDI transaction types are accepted in Texas?

A: 28 TAC §134.807(d) defines the transaction types accepted by DWC include '00' original, '01' cancel, and '05' replacement.  ‘02’ and ‘09’ medical EDI transaction types are not accepted in Texas.

Q: How long do I have to report my workers’ compensation medical billing data to Texas after action has been taken on a workers’ compensation medical bill?

A: 28 TAC §134.804(a) provides that insurance carriers shall submit an '00' original medical EDI record for each action (initial processing, request for reconsideration, or subsequent orders) taken on an individual medical bill. Original medical EDI records shall be reported within 30 days after the date of the action. 

Q: Can I report an original ‘00’ workers’ compensation medical bill with the same unique bill ID number as another original ‘00’ workers’ compensation medical bill?

A: No.  28 TAC §134.804(a) provides that each iteration of an '00' original medical EDI record must contain a different unique medical bill identification number.

Q: How do I report a reconsideration workers’ compensation medical bill that has gone through a reconsideration or appeal?

A: 28 TAC §134.804(a) provides that original medical EDI records on subsequent payment actions must contain a service adjustment reason code of 'W3'.

Please note that in addition to reporting ‘W3” on a reconsideration medical bill, another service adjustment reason code(s) must be reported when the medical service charge(s) is denied or reduced.

Q: What happens if I report a workers’ compensation medical bill that should not have been sent or contained an incorrect insurance carrier identification number?

A: 28 TAC §134.804(b) provides that insurance carriers shall submit an '01' cancel medical EDI record if the '00' original medical EDI record should not have been sent or contained the incorrect insurance carrier identification number. The '01' cancel medical EDI record must contain the same unique bill identification number as the '00' original medical EDI record that was previously submitted and accepted.

Q: What is the timeframe to report a cancel medical EDI record ‘01’?

A: 28 TAC §134.804(b) provides that cancel medical EDI records shall be reported within 30 days after the earliest date the insurance carrier discovered the reporting error.

Q: What do I do if I report a workers’ compensation medical bill with inaccurate medical billing data?

A: 28 TAC §134.804(c) provides that insurance carriers shall submit an '05' replacement medical EDI record when correcting data on a previously submitted medical EDI record. The '05' replacement medical EDI record must contain the same unique bill identification number as the associated '00' original medical EDI record.

Q: What is the timeframe to report a replacement medical EDI record ‘05’?

A: 28 TAC §134.804(c) provides that replacement medical EDI records shall be reported within 30 days after the earliest date the insurance carrier discovered the reporting error.

Q: When does DWC consider a workers’ compensation medical bill to be accurately filed?

A: 28 TAC §134.804(d) provides that insurance carriers are responsible for the timely and accurate submission of medical EDI records. For the purpose of this section, a medical EDI record is considered to have been accurately submitted when the record:

1. received an Application Acknowledgment Code of accepted;
2. contained accurate medical EDI data; medical EDI data may be obtained from all sources, including the medical bill, explanation of benefits; and insurance carrier’s claim file; and
3. to the extent supported by the format, contained all appropriate modifiers, code qualifiers, and data elements necessary to identify health care services, charges and payments.

Q: When does DWC consider a workers’ compensation medical bill to be timely filed?

A: 28 TAC §134.804(d) provides that insurance carriers are responsible for the timely and accurate submission of medical EDI records. For the purpose of this section, a medical EDI record is considered to have been accurately submitted when the record: (1) received an Application Acknowledgment Code of accepted; (2) contained accurate medical EDI data; medical EDI data may be obtained from all sources, including the medical bill, explanation of benefits; and insurance carrier’s claim file; and (3) to the extent supported by the format, contained all appropriate modifiers, code qualifiers, and data elements necessary to identify health care services, charges and payments.

However, 28 TAC §134.805(b) further provides that regardless of the Application Acknowledgment Code returned in an acknowledgment, medical EDI records are not considered received by DWC if the medical EDI record: 

1. contains data which does not accurately reflect the code values used or actions taken when the insurance carrier processed the medical bill; or
2. fails to contain a conditional data element and the mandatory trigger condition existed at the time the insurance carrier processed the medical bill.

Q: What do I do if a workers’ compensation medical bill that I reported gets rejected by Texas?

A: 28 TAC §134.805(c) provide that except in situations where the health care provider included an invalid service or procedure code on the medical bill, rejected medical EDI records are not considered received and shall be corrected and resubmitted to DWC as provided in §134.804(e) of this title (relating to Reporting Requirements).  §134.804(e) requires the resubmitted medical EDI record to contain the same unique bill identification number as the previously rejected medical EDI record.

Q: How long do I have to resubmit a medical bill that was rejected by Texas?

A: 28 TAC §134.804(e) provides that insurance carriers are responsible for correcting and resubmitting rejected medical EDI records within 30 days of the action that triggered the reporting requirement. The insurance carrier's receipt of a rejection does not modify, extend or otherwise change the date the transaction is required to be reported to DWC. The resubmitted medical EDI record must contain the same unique bill identification number as the previously rejected medical EDI record.

Q: Do I have to report every workers’ compensation medical bill to Texas?

A: No.  28 TAC §134.806 provides that insurance carriers shall not report medical EDI records for health care services: 

1. rendered outside the United States;
2. related to dates of injury before January 1, 1991;
3. rendered at a Federal health care facility and the health care facility does not provide the insurance carrier with the data required to be reported;
4. related to an injured employee's travel reimbursement as provided in §134.110 of this title (relating to Reimbursement of Injured Employee for Travel Expenses Incurred); or
5. related to a request for reimbursement by a health care insurer in accordance with the provisions of Labor Code §409.0091.

In addition, insurance carriers shall not report interest and penalty payments paid on health care services, medical cost containment expenses, medical bill review expenses or data transmission expenses in medical EDI records

State specific requirements

Q: What transmission method do I use to submit my workers’ compensation medical bills to Texas?

A: 28 TAC §134.807(b) provides that 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.

Q: How often can I drop off my medical EDI 837 files on DWC’s SFTP server?

A: Except during maintenance and upgrade operations, DWC’s environment to receive inbound medical EDI 837 files is available on a 24/7 basis. However, files are expected to be placed on the SFTP server by trading partners no later than 5:00 p.m. each business day to ensure they are deemed received by DWC that business day.

Q: How often does DWC process medical EDI 837 files?

A: We process medical EDI 837 files 7 days a week, excluding when the system is down for maintenance or upgrades, if there is data present to process. Medical EDI acknowledgments are generated throughout the day as each of the inbound 837 files are processed. The acknowledgments are currently being delivered to the trading partners’ outbound SFTP mailboxes at 8:00 a.m., 10:00 a.m., 1:00 p.m. and 4:00 p.m. In order to avoid picking up incomplete files, trading partners should avoid picking up any outbound files (acknowledgments and error logs) for 30 minutes after the scheduled start of DWC’s processing schedule.

Q: How long will you retain my medical EDI 837 inbound and outbound files on the SFTP server?

A: In order to ensure adequate space on the SFTP server, DWC recommends that insurance carriers delete transaction files that have already been processed.  DWC will delete batches approximately thirty days after the files are placed in the inbound or outbound folders. As such, insurance carriers are encouraged to actively monitor production operations and schedules, identify any issues or defects, and quickly notify the EDI Support Help Desk at EDISupport@tdi.texas.gov. 

Q: Can I send multiple medical EDI 837 files with the same SFTP file name at the same time?

A: No. DWC’s system does a batch processing run every hour for new inbound medical EDI 837 files. If multiple files with the same SFTP file name are processed in the same hourly run, DWC’s system will only process the last medical EDI 837 file received with the duplicate naming convention. Therefore, DWC did not receive the medical bills in the medical EDI 837 files that were not processed. 

Q: What is the difference between DWC’s 997 and 824 acknowledgments?

A: The two possible acknowledgments generated in response to an 837 transmission are, 1) 997 Functional Acknowledgment, and 2) 824 Detail Acknowledgment, also identified by ANSI as the Application Advice.

The 997 acknowledgments indicate:

• The 837 file has been received by the TDI system,
• The DWC system was able to identify the sender and intended receiver,
• The DWC system validated the file structure to be an 837 file, and
• The DWC system accepted or rejected the file based on results of the structural validation.

Any medical EDI 837 file that fails functional or structural validations will not receive an 824 Detail Acknowledgment.  

The 824 acknowledgments indicate the results of the data content edits specific to the Texas Medical EDI 837 application. The medical bills inside the medical EDI 837 file are accepted or rejected based on the results of the data content edits.

Q: Is there a limit to the size of an 837 file that will be accepted and processed by Texas?

A: 28 TAC §134.807(a) provides that 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.

Q: What naming convention do I use for my SFTP file name?

A: 28 TAC §134.807(b) and (c) require 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. 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'.

Q: What delimiter values are accepted in Texas Medical Bill Reporting?

A: 28 TAC §134.807(e) provides that insurance carriers are required to use the following delimiters:

1. Date Element Separator--'*' asterisk;
2. Sub-element Separator--':' colon; and
3. Segment Terminator--'~' tilde.

Q: Can Loop 2400 Service Line Information contain more than one type of service?

A: No.  28 TAC §134.807(f)(1) provides that 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.

Communication questions

Q: Am I required to have a contact person available to answer any question DWC may have regarding my workers’ compensation medical billing data?

A: Yes. 28 TAC §134.808(b) provides that each insurance carrier, including those using external trading partners, must designate one individual to DWC as the EDI Compliance Coordinator and provide the individual's name, working title, mailing address, email address, and telephone number in the form and manner prescribed by the division. The EDI Compliance Coordinator must:

1. be a centrally-located employee of the insurance carrier who has the responsibility for EDI reporting;
2. receive and appropriately disperse data reporting information received from the division; and
3. serve as the central compliance control for data reporting under this subchapter.

Q: How do I let DWC know who my EDI Compliance Coordinator will be?

A: DWC has prescribed the DWC EDI-03, Medical EDI Compliance Coordinator and Trading Partner Notification for this notification.

Q: When is the DWC EDI-03, Medical EDI Compliance Coordinator and Trading Partner Notification form considered to be filed timely with DWC?

A: 28 TAC §134.808(c) states at least five working days prior to sending its first transaction to the division under this subchapter, the insurance carrier shall send a notice (DWC EDI-03) to DWC. The notice shall include the name of the insurance carrier, the insurance carrier's FEIN, the insurance carrier's TxCOMP customer number, the name of the trading partner(s) authorized to conduct medical EDI transactions on behalf of the insurance carrier, the FEIN of the trading partner(s), and the EDI Compliance Coordinator's signature.

Q: Am I required to report to DWC any changes to the information previously reported on the DWC EDI-03 form filed with DWC?

A: Yes. 28 TAC §134.808(c) provides that the insurance carrier shall report changes within five working days of any amendment to data sharing agreements, including the addition or removal of any trading partners. The failure to timely submit updated information may result in the rejection of medical EDI records.

General reporting questions

Q: What is the Texas DWC nine-digit zip code to be used in the medical billing trading partner profile?

A: 787441609

Q: What value do I use for data element 08 in the Group Header Segment (GS08)?

A: 004010.  Texas utilizes Version 4010 as indicated in the IAIABC Release 1 Implementation Guide and is referenced in the adopted Texas EDI Medical Difference Table.

Q: What if more than four diagnosis codes are listed on a physician’s bill and a trading partner can report up to 12 diagnosis codes, how many diagnosis codes can be sent to DWC?

A: 28 TAC §134.807(f)(9) provides that on a professional medical bill, an insurance carrier shall only report up to four diagnosis codes on each medical EDI record.  However, a file will not reject if more than 4 diagnosis codes are reported.

Q: Do I have to report a decimal in the diagnosis code?

A: Yes.  Although the 4010 Guide gives guidance not to transmit the decimal, Texas requires the decimal to be reported in the diagnosis code as referenced in the format requirements in the adopted Texas EDI Medical Data Element Edits Table and also referenced in the comments section in the adopted Texas EDI Medical Difference Table.

Q: How many diagnosis pointers can be reported? And how do I report alpha characters for diagnosis codes?

A: 28 TAC §134.807(f)(10) provides that on a professional medical bill, an insurance carrier shall only report to DWC up to four diagnosis code pointers and those pointers must be reported numerically.  A crosswalk will need to occur to convert the diagnosis pointers from the alpha characters to a numeric format. Please see the memo issued by DWC on February 21, 2014.  28 TAC §134.807(f)(10) further provides 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 DWC with the value of ‘1’.

Not reporting a medical bill because it has a diagnosis pointers greater than ‘D’ is not an option. 

Q: What is the format requirement for reporting state license numbers?

A: Please see 28 TAC §133.10(h). As a general rule, state license numbers are reported using the following format:  license type, license number, jurisdiction state code e.g. MDF1234TX.

Q: What is the format requirement for reporting state license numbers when the entity does not have a state license number?

A: Please see 28 TAC §133.10(i). When an entity does not have a state license number, the state license number is reported using the following format: license type, jurisdiction state code e.g. DMTX.

Data element reporting (DN)

Q: How is DN42, Employee Social Security Number, reported if the social security number is unknown?

A: This is a mandatory data element.  28 TAC §134.807(f)(5) provides 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). If a social security number is unknown, insert the numerical digits "999" followed by the employee’s birth date or if unknown, the employee’s date of injury, listed by the month, day, and year (MMDDYY).

Q: Do I have to report DN53, Employee Gender Code, on all medical bills?

A: Yes.  28 TAC §134.807(f)(6) provides that the DN53 data element must be reported on all medical EDI records.

Q: Can I re-use the same Unique Bill Identification, DN500, after I have canceled a medical transaction?

A: No, once a Unique Bill Identification Number (DN500) is used, it stays with the bill even when the bill is canceled.

Q: What are acceptable values for DN507, Provider Agreement Code?

A: Only a ‘P’, ‘N’ or ‘H’ is a valid value in Texas.  The value of ‘Y’ is not acceptable for any bill type. 28 TAC §134.807(f)(7) provides that 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.

Q: How is DN508, Bill Submission Reason Code, reported and sequenced?

A: Per 28 TAC §134.807(d), the transaction types accepted by DWC include 00’ original, ‘01’ cancel and ‘05’ replacement. The following chart shows the appropriate sequencing of medical EDI records:

Q: Do I need to report National Provider Identifier (NPI)?

A: If the specific data element (DN592, DN647, DN699) has a mandatory trigger and the condition exists, then the NPI becomes reportable.

Institutional bill reporting

Q: Do I have to report Diagnosis Related Group Codes, DN518 DRG Code?

A: 28 TAC §134.807(f)(8) provides 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.

Pharmacy bill reporting

Q: How do I report pharmacy compound medications in Texas?

A: 28 TAC §134.807(f)(2) states 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.

Q: Do I report the prescription number for each line when reporting compound drugs?

A: Yes. 28 TAC §134.807(f)(2) provides the same prescription number for each reimbursable component of the compound medication, including the compounding fee, must be reported.

Q: Are there any clarifications to reporting pharmacy bills in Texas?

A: Yes. Please see 28 TAC §134.807(f)(3). Specifically:

• DN501 Total Charge Per Bill is the total amount charged by the pharmacy or pharmacy processing agent.
• DN511 Date Insurer Received Bill is the date the insurance carrier received the bill
• DN512 Date Insurer Paid Bill id the date the insurance carrier paid the pharmacy or pharmacy processing agent
• DN 638 Rendering Bill Provider Last/Group Name is the name of the dispensing pharmacy
• DN 690 Referring Provider Last/Group Name is the last name of the prescribing doctor
• DN691 Referring First Name is the first name of the prescribing doctor

Durable medical equipment reporting

Q: Do I use SV5 for reporting Durable Medical Equipment (DME)?

A: No. In Texas, use Loop 2400 SV1 for reporting DME. The SV5 segment is not used in Texas as referenced in the adopted Texas Medical EDI Difference Table.

Compliance

Q: What are the penalties for inaccurate or late reporting of medical data?

A: Texas Labor Code (TLC) §415.021 provides for DWC to assess up to $25,000 per day per occurrence of non-compliance. DWC takes TLC §415.021 and 28 TAC §180.26 into consideration before assessing penalties.

Q: What do I do if I discover inaccurate data reporting or late reporting?

A: If you discover a problem, we encourage you to self-report. Any party may self-report. Claim administrators and EDI trading partners should notify the workers compensation insurance carrier before or at the same time that the self-report is filed.

To file a self-report, send an email to edisupport@tdi.texas.gov with:

• a description of the issue;
• the date the issue was discovered;
• the number of EDI records affected;
• the corrective action that was or will be taken; and
• the date the corrected records were or will be filed.