Texas Register, Volume 32, Number 3, Pages 215-274, January 19, 2007 Page: 236
215-274 p. ; 28 cmView a full description of this periodical.
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(MM) principal procedure code (UB-04, field 74) is re-
quired if the patient has undergone an inpatient or outpatient surgical
procedure;
(NN) other procedure codes (UB-04, fields 74 - 74e)
are required as an extension of subparagraph (MM) of this paragraph
if additional surgical procedures were performed;
(00) attending physician NPI number (UB-04, field
76) is required on or after May 23, 2007, if attending physician is eli-
gible for an NPI number; and
(PP) attending physician ID (UB-04, field 76, qualifier
portion) is required.
(4) [(2)] Required form and data elements for institutional
providers for claims filed or re-filed before May 23, 2007. The UB-92
CMS-1450 and the data elements described in this paragraph are
required as indicated and must be completed in accordance with the
special instructions applicable to the data element for clean claims
filed by institutional providers. However, upon notification that an
HMO or preferred provider carrier will accept claims filed or re-filed
on form UB-04 CMS-1450, an institutional provider may submit
claims on form UB-04 CMS-1450 at any time between March 1, 2007
and May 22, 2007, subject to the required data elements set forth in
subsection (b)(3) of this section.
(A) - (E) (No change.)
(F) covered days (UB-92, field 7)[,] is required if Medi-
care is a primary or secondary payor;
(G) noncovered days (UB-92, field 8)[,] is required if
Medicare is a primary or secondary payor;
(H) coinsurance days (UB-92, field 9)[,] is required if
Medicare is a primary or secondary payor;
(I) lifetime reserve days (UB-92, field 10)[,] is required
if Medicare is a primary or secondary payor[,] and the patient was an
inpatient;
(J) - (R) (No change.)
(S) discharge hour (UB-92, field 21)[,] is required for
admissions, outpatient surgeries, or observation stays;
(T) (No change.)
(U) condition codes (UB-92, fields 24 - 30)[,] are re-
quired if the CMS UB-92 manual contains a condition code appropri-
ate to the patient's condition;
(V) occurrence codes and dates (UB-92, fields 32 -
35)[,] are required if the CMS UB-92 manual contains an occurrence
code appropriate to the patient's condition;
(W) - (Z) (No change.)
(AA) HCPCS/Rates (UB-92, field 44)[,] are required if
Medicare is a primary or secondary payor;
(BB) - (EE) (No change.)
(FF) provider number (UB-92, field 51)[,] is required if
the HMO or preferred provider carrier, prior to June 17, 2003, required
provider numbers and gave notice of that requirement to physicians and
providers.
(GG) prior payments-payor and patient (UB-92, field
54)[,] are required if payments have been made to the physician or
provider by the patient or another payor or subscriber, on behalf of the
patient or subscriber, or by a primary plan as required by subsection (d)
of this section;(HH) subscriber's name (UB-92, field 58)[,] is required
if shown on the patient's ID card;
(II) (No change.)
(JJ) patient's/subscriber's certificate number, health
claim number, ID number (UB-92, field 60)[,] is required if shown on
the patient's ID card;
(KK) insurance group number (UB-92, field 62)[,] is
required if a group number is shown on the patient's ID card;
(LL) verification number (UB-92, field 63)[;] is re-
quired if services have been verified pursuant to 19.1724 of this
title [(relating to Verification)]. If no verification has been provided,
treatment authorization codes (UB-92, field 63) are required when
authorization is required and granted;
(MM) (No change.)
(NN) diagnoses codes other than principal diagnosis
code (UB-92, fields 68 - 75)[,] are required if there are diagnoses other
than the principal diagnosis;
(00) (No change.)
(PP) procedure coding methods used (UB-92, field
79)[,] is required if the CMS UB-92 manual indicates a procedural
coding method appropriate to the patient's condition;
(QQ) principal procedure code (UB-92, field 80)[,] is
required if the patient has undergone an inpatient or outpatient surgical
procedure;
(RR) other procedure codes (UB-92, field 81)[,] are re-
quired as an extension of subparagraph (QQ) of this paragraph if addi-
tional surgical procedures were performed;
(SS) - (UU) (No change.)
(c) (No change.)
(d) Coordination of benefits or non-duplication of benefits. If
a claim is submitted for covered services or benefits in which coordi-
nation of benefits pursuant to 3.3501 - 3.3511 of this title (relating to
Group Coordination of Benefits) and 11.511(1) of this title (relating to
Optional Provisions) is necessary, the amount paid as a covered claim
by the primary plan is a required element of a clean claim for purposes
of the secondary plan's processing of the claim and CMS-1500 (08/05),
field 29; CMS-1500 (12/90), field 29; UB-04, field 54; [GMS 1500,
field 29] or UB-92, field 54, as applicable, must be completed pursuant
to subsection (b)(1)(KK), (2)(II), (3)(BB), [{b)(1)(II)}] and (4)(GG)
[(b)(2 )(GGC)] of this section. If a claim is submitted for covered services
or benefits in which non-duplication of benefits pursuant to 3.3053 of
this title (relating to Non-duplication of Benefits Provision) is an is-
sue, the amounts paid as a covered claim by all other valid coverage is
a required element of a clean claim and CMS-1500 (08/05), field 29;
CMS-1500 (12/90), field 29; UB-04, field 54; [CMS 1500, field 29] or
UB-92, field 54, as applicable, must be completed pursuant to subsec-
tion (b)(1)(KK), (2)(II), (3)(BB), [(b)(1)(I)] and (4)(GG) [(b)(2)(GG)]
of this section. If a claim is submitted for covered services or benefits
and the policy contains a variable deductible provision as set forth in
3.3074(a)(4) of this title (relating to Minimum Standards for Major
Medical Expense Coverage), the amount paid as a covered claim by all
other health insurance coverages, except for amounts paid by individu-
ally underwritten and issued hospital confinement indemnity, specified
disease, or limited benefit plans of coverage, is a required element of a
clean claim and CMS-1500 (08/05), field 29; CMS-1500 (12/90), field
29; UB-04, field 54; [CMS 1599, lield 29] or UB-92, field 54, as ap-
plicable, must be completed pursuant to subsection (b)(1)(KK), (2)(II),
(3)(BB), [{b)(!)(I)] and (4)(GG) [(b)(2)(GG)] of this section. Notwith-32 TexReg 236 January 19, 2007 Texas Register
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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/m1/21/: accessed May 4, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.