The general billing rules may be found at 28 Texas Administrative Code (TAC) Chapter 133, subchapters A and B.
- General definitions
General billing requirements apply to health care certified network claims | Memoranda | Medical billing standards | Electronic medical billing | Texas-specific billing requirements | Medical documentation | Timeframe for submission
General billing requirements apply to health care certified network claims
The general billing rules found at 28 Texas Administrative Code Chapter 133 apply to health care certified network claims, with any exceptions provided by the applicable rules.
- Texas Insurance Code Chapter 1305, Section 1305.106(a)
- Texas Labor Code Section 408.027
- 28 Texas Administrative Code Chapter 133, subchapter A, Rule §133.1
Memoranda
Medical billing standards
Health care providers must submit medical bills for payment in an electronic format unless the health care provider or the billed insurance carrier is exempt from the electronic billing.
Submit electronic medical bills for payment on:
- Professional: the ASC X12 Standard Health Care Claim Professional (837)
- Hospital: the ASC X12 Standard Health Care Claim Institutional (837)
- ASC: the ASC X12 Standard Health Care Claim Professional (837)
- Pharmacy: the Telecommunication Standard Version D.0
- Dental: the ASC X12 Standard Health Care Claim Dental (837)
Submit paper medical bills for payment on:
- Professional: the CMS-1500 Health Insurance Claim Form
- Hospital: the Uniform Bill 04 (UB-04);
- ASC: the CMS-1500 Health Insurance Claim Form
- Pharmacy: division form DWC-066
- Dental: (ADA) Dental Claim form
Electronic medical billing
The Texas Labor Code (TLC) §408.0251 requires electronic medical billing in the Texas workers' compensation system. The rules adopted by the Division of Workers' Compensation (DWC) outline the electronic transaction sets that must be used and provides limited exemptions based on specific criteria.
Texas-specific billing requirements
There are billing requirements that are specific to Texas workers' compensation.
- For electronic medical bills: 28 TAC §133.502
- For paper medical bills: 28 TAC §133.10
A health care provider is also required to include correct billing codes from the applicable Division fee guidelines in effect on the date(s) of service when submitting medical bills (28 Texas Administrative Code rule §133.20). The fee rules may be found at 28 Texas Administrative Code, Chapter 134 as follows:
- 28 Texas Administrative Code, Chapter 134, Subchapter C
- For professional services, see Rule §134.203
- For workers' compensation specific services, see Rule §134.204
- For dental services, see Rule §134.302
- 28 Texas Administrative Code, Chapter 134, Subchapter E
- For ASC services, see Rule §134.402
- For hospital outpatient services, see Rule §134.403
- For hospital inpatient services, see Rule §134.404
- 28 Texas Administrative Code, Chapter 134, Subchapter F
- For pharmacy services, see Rule §134.502
Medical documentation
There are documentation requirements that are specific to Texas workers' compensation. Workers' compensation health care networks established under Insurance Code Chapter 1305 may decrease the documentation requirements of this section.
- For electronic or paper medical bills: 28 TAC §133.210
Timeframe for submission
The general filing deadline for Texas workers' compensation medical bills is 95 days. Failure by the health care provider to timely submit a claim for payment constitutes a forfeiture of the provider's right to reimbursement for that claim for payment.
Exceptions to the 95 day filing deadline
For more information or to request training contact CompConnection at 800-252-7031 option 3 or email CompConnection@tdi.texas.gov.