The rules in 28 Texas Administrative Code (TAC) Chapter 133 apply to both non-network and network medical bills with some network exceptions.
Billing
Texas Labor Code Section 408.0251 requires health care providers and insurance carriers to submit and process medical bills electronically. The rules in Chapter 133, Subchapter G (relating to electronic medical billing, reimbursement, and documentation) outline the transaction sets required for electronic medical bill processing and provide limited exemptions from the electronic medical bill processing requirements.
When a medical bill cannot be submitted electronically, the bill can be submitted on a paper form.
Health care provider billing procedures (28 TAC, Chapter 133, Subchapter B)
A medical bill must be submitted:
- In the name of the licensed health care provider who provided the health care, or who directly supervised an unlicensed individual who provided the health care.
- In an amount that does not exceed the health care provider’s usual and customary charges.
- Using the correct billing codes from the applicable DWC fee guidelines in effect on the date of service.
With few exceptions, the filing deadline for Texas workers' compensation medical bills is 95 days from the date of service. If a medical bill for payment is not submitted timely, the health care provider loses the right to reimbursement of that medical bill.
Exceptions to the 95-day filing deadline are provided in Texas Labor Code Section 408.0272
Billing for services provided by a Federal Military Treatment Facility (28 TAC Section 134.150)
Medical documentation
The requirements for medical documentation in 28 TAC Section 133.210 apply to non-network claims. Workers' compensation health care networks may establish different documentation requirements. Refer to the specific workers’ compensation network for requirements.
Paper medical billing forms/formats
28 TAC Chapter 133, Subchapter B, Rule Section 133.10
Submit paper medical bills for payment on:
- Professional: CMS-1500 Health Insurance Claim Form
- Hospital: Uniform Bill 04 (UB-04)
- Pharmacy: DWC Form-066, Statement of Pharmacy Services
- Dental: American Dental Association (ADA) Dental Claim form (DWC Form-070, Instructions for Competing the ADA J515 Dental Claim Form for Texas Workers’ Compensation Claims)
Electronic medical bill processing formats
Texas Labor Code Section 408.0251 requires health care providers and insurance carriers to submit and process medical bills electronically. The rules in Chapter 133, Subchapter G (relating to electronic medical billing, reimbursement, and documentation) outline the transaction sets required for electronic medical bill processing and provide limited exemptions from the electronic medical bill processing requirements.
28 TAC Chapter 133, subchapter G, Rule Section 133.500
Submit electronic medical bills for payment on:
- Professional: ASC X12 Standard Health Care Claim Professional (837)
- Hospital: ASC X12 Standard Health Care Claim Institutional (837)
- Pharmacy: Telecommunication Standard Version D.0
- Dental: ASC X12 Standard Health Care Claim Dental (837)