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Advisory 97-04

CLARIFICATION OF ELECTRONIC SUBMISSION OF UB-92 MEDICAL BILL INFORMATION FROM INSURANCE CARRIERS TO THE COMMISSION

The following clarifications are provided by the Commission to insurance carriers electronically submitting workers' compensation UB-92 medical bill information to the Commission.

Effective August 1, 1997, new Commission Rule 134.401, Acute Care Inpatient Hospital Fee Guideline, will require insurance carriers electronically submitting UB-92 information to the Commission to include the "additional reimbursements" listed at Rule 134.401(c)(4). These "additional reimbursements" must be submitted to the Commission as provided in this Advisory.

In addition to the normal per diem reimbursement, the following "additional reimbursements" for inpatient care are to be reimbursed at cost to the hospital plus 10%:

Implantables
Orthotics and prosthetics

The following "additional reimbursements" are to be reimbursed at a fair and reasonable cost:

Magnetic Resonance Imaging (MRIs)
Computerized Axial Tomography (CAT scans)
Hyperbaric oxygen
Blood
Air ambulance

Electronic submission of the standard per diem, implantables, MRIs, and CAT scans will continue to be itemized as outlined in the UB-92 Record Layout Specifications (X1, X2, X3, and/or X4 records). However, submission of orthotics and prosthetics, hyperbaric oxygen, blood, and air ambulance will not be itemized in the record layout ( X2, X3, or X4 records).

For inpatient bills:

Per diems billed must be itemized in the X1 record ("Itemized Charge #1" or "Itemized Charge #2" specification fields with corresponding "Charges" amount) and the paid amounts must be listed in the X1 record ("Amount Paid"). Per diem paid amounts must also be included in the 1B record ("Estimated amount due").

Implantables billed must be itemized in the X2 record ("Itemized Charge #3" specification field with corresponding "Charges" amount) and the paid amount must be listed in the X2 record ("Amount Paid"). Implantables paid amount must also be included in the 1B record ("estimated amount due").

MRIs and CAT scans billed must be itemized in the X2, X3, and X4 records ("Itemized Charge #4, 5, 6, and 7" specification fields with corresponding "Charges" amount) and the paid amounts must be listed in the X2, X3, and X4 records ("Amount Paid"). MRIs and CAT scans paid amounts must also be included in the 1B record ("Estimated amount due").

Orthotics and prosthetics, hyperbaric oxygen, blood, air ambulance and other items billed must be itemized only in the 1B record ("Total Charges" specification field) and the paid amounts must be listed only in the 1B record ("Estimated amount due").

For Outpatient Bills:

All items must be itemized in the 1B record ("Total Charges" specification field) and the paid amounts must be listed in the 1B record ("Estimated amount due"). NOTE: Outpatient hospital services are not included in any fee guideline or rule adopted by the Commission. Carriers must determine a fair and reasonable payment amount for outpatient services pursuant to section 413.011(b) of the Texas Labor Code and Commission Rule 134.1 (f).



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