Texas Register, Volume 32, Number 3, Pages 215-274, January 19, 2007 Page: 231
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[Article 3-7-3, #lel) (Preferred Provider Bnefit Plans) or Article
3-70-3, ~1) (Use of Advaneed Praetice Nurses and Physician As-
sistants by Preferred Provider Plans)].
(B) (No change.)
(24) [(23)] Preferred provider carrier--An insurer that is-
sues a preferred provider benefit plan as provided by Insurance Code
Chapter 1301 [Article 3-703C, Seetion 2 (Preferred Provider Bnefit
Plans)].
(25) [(24)] Primary plan--As defined in 3.3506 of this title
(relating to Use of the Terms "Plan," "Primary Plan," "Secondary Plan,"
and "This Plan" in Policies, Certificates and Contracts).
(26) [(25)] Procedure code--Any alphanumeric code repre-
senting a service or treatment that is part of a medical code set that is
adopted by CMS as required by federal statute and valid at the time of
service. In the absence of an existing federal code, and for non-elec-
tronic claims only, this definition may also include local codes de-
veloped specifically by Medicaid, Medicare, an HMO, or a preferred
provider carrier to describe a specific service or procedure.
(27) [(2{)] Provider--Any practitioner, institutional
provider, or other person or organization that furnishes health care
services and that is licensed or otherwise authorized to practice in this
state, other than a physician.
(28) [(27-{)] Revenue code--The code assigned by CMS to
each cost center for which a separate charge is billed.
(29) [(28)] Secondary plan--As defined in 3.3506 of this
title.
(30) [(29)] Source of admission code--The code utilized by
CMS to indicate the source of an inpatient admission.
(31) [(30)] Statutory claims payment period--
(A) the 45-calendar-day period in which an HMO or
preferred provider carrier shall make claim payment or denial, in whole
or in part, after receipt of a non-electronic clean claim pursuant to In-
surance Code Chapters 843 and 1301 [Article 3.-7 C,3A .(Preferred
Provider Benefit Plans) and Chapter 843];
(B) the 30-calendar-day period in which an HMO or
preferred provider carrier shall make claim payment or denial, in whole
or in part, after receipt of an electronically submitted clean claim pur-
suant to Insurance Code Chapters 843 and 1301 [Article 3 -70- G #3A
(Preferred Provider enefit Plans) and Ghapter 843]; or
(C) the 21-calendar-day period in which an HMO or
preferred provider carrier shall make claim payment after affirmative
adjudication of an electronically submitted clean claim for a prescrip-
tion benefit pursuant to Insurance Code Chapters 843 and 1301 [Article
370C 3A(f) (Preferred Provider nefit Plans) and 84339], and
21.2814 of this title (relating to Electronic Adjudication of Prescrip-
tion Benefits).
(32) [(34)] Subscriber--If individual coverage, the individ-
ual who is the contract holder and is responsible for payment of premi-
ums to the HMO or preferred provider carrier; or if group coverage, the
individual who is the certificate holder and whose employment or other
membership status, except for family dependency, is the basis for eligi-
bility for enrollment in a group health benefit plan issued by the HMO
or the preferred provider carrier.
(33) [(32-)] Type of bill code--The three-digit alphanumeric
code utilized by CMS to identify the type of facility, the type of care,
and the sequence of the bill in a particular episode of care.
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) (No change.)
(2) for electronic claims and for electronic dental claims
filed with an HMO, the required data elements specified in subsections
(e) and (f) of this section [subsection]; and
(3) (No change.)
(b) Required data elements. CMS has developed claim forms
which provide much of the information needed to process claims. In-
surance Code Chapter 1204 identifies two [Two] of these forms, HCFA
1500 and UB-82/HCFA, and their successor forms, [have been identi
fled by Insurance Code Article 21-52C] as required for the submission
of certain c lai ms. The terms in paragraphs (1) - (4) [and (2)] of this
subsection are based upon the terms CMS used [by GMS] on succes-
sor forms CMS-1500 (08/05), CMS-1500 (12/90), UB-04 CMS-1450,
and UB-92 CMS-1450 [claim forms]. The parenthetical information
following each term refers to the applicable CMS claim form[,] and
the field number to which that term corresponds on the CMS claim
form. Mandatory form usage dates and optional form transition dates
for nonelectronic claims filed or re-filed by physicians or non-institu-
tional providers are set forth in paragraphs (1) and (2) of this subsec-
tion. Mandatory form usage dates and optional form transition dates
for nonelectronic claims filed or re-filed by institutional providers are
set forth in paragraphs (3) and (4) of this subsection.
(1) Required form and data elements for physicians or non-
institutional providers for claims filed or re-filed on or after April 2,
2007. The CMS-1500 (08/05) and the data elements described in this
paragraph are required as indicated and must be completed in accor-
dance with the special instructions applicable to the data element for
clean claims filed by physicians and noninstitutional providers. Fur-
ther, upon notification that an HMO or preferred provider carrier is
prepared to accept claims filed or re-filed on form CMS-1500 (08/05),
a physician or noninstitutional provider may submit claims on form
CMS-1500 (08/05) prior to April 2, 2007, subject to the required data
elements set forth in this paragraph.
(A) subscriber's/patient's plan ID number (CMS-1500
(08/05), field la) is required;
(B) patient's name (CMS-1500 (08/05), field 2) is re-
quired;
(C) patient's date of birth and gender (CMS-1500
(08/05), field 3) is required;
(D) subscriber's name (CMS-1500 (08/05), field 4) is
required, if shown on the patient's ID card;
(E) patient's address (sreeet or P.O. Box, city, state, ZIP)
(CMS-1500 (08/05), field 5) is required;
(F) patient's relationship to subscriber (CMS-1500
(08/05), field 6) is required;
(G) subscriber's address (street or P.O. Box, city, state,
ZIP) (CMS-1500 (08/05), field 7) is required, but physician or provider
may enter "same" if the subscriber's address is the same as the patient's
address required by subparagraph (E) of this paragraph;
(08/05), field 9) is required if the patient is covered by more than one
health benefit plan, generally in situations described in subsection (d)
of this section. If the required data element specified in paragraph
(1)(Q) of this subsection, "disclosure of any other health benefit plans,"PROPOSED RULES January 19, 2007 32 TexReg 231
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Texas. Secretary of State. Texas Register, Volume 32, Number 3, Pages 215-274, January 19, 2007, periodical, January 19, 2007; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth97380/m1/16/: accessed May 4, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.