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TITLE 28INSURANCE
PART 1TEXAS DEPARTMENT OF INSURANCE
CHAPTER 21TRADE PRACTICES
SUBCHAPTER TSUBMISSION OF CLEAN CLAIMS
RULE §21.2803Elements of a Clean Claim

(a) Filing a clean claim. A physician or a provider submits a clean claim by providing to an MCC or any other entity designated for receipt of claims under §21.2811 of this title (related to Disclosure of Processing Procedures):

  (1) for nonelectronic claims other than dental claims, the required data elements specified in subsection (b) of this section;

  (2) for nonelectronic dental claims filed with an HMO, the required data elements specified in subsection (c) of this section;

  (3) 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; and

  (4) if applicable, any coordination of benefits or nonduplication of benefits information under subsection (d) of this section.

(b) Required data elements. CMS has developed claim forms that provide much of the information needed to process claims. Insurance Code Chapter 1204 identifies two of these forms, HCFA 1500 and UB-82/HCFA, and their successor forms, as required for the submission of certain claims. The terms in paragraphs (1) - (3) of this subsection are based on the terms CMS used on successor forms CMS-1500 (02/12), CMS-1500 (08/05), UB-04 CMS-1450, and UB-04. The parenthetical information following each term and data element 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 refiled by physicians or noninstitutional providers are set out in paragraphs (1) and (2) of this subsection. Mandatory form usage dates and optional form transition dates for nonelectronic claims filed or refiled by institutional providers are set out in paragraph (3) of this subsection.

  (1) Required form and data elements for physicians or noninstitutional providers for claims filed or refiled on or after the later of April 1, 2014, or the earliest compliance date required by CMS for mandatory use of the CMS-1500 (02/12) claim form for Medicare claims. The CMS-1500 (02/12) claim form and the data elements described in this paragraph are required for claims filed or refiled by physicians or noninstitutional providers on or after the later of these two dates: April 1, 2014, or the earliest compliance date required by CMS for mandatory use of the CMS-1500 (02/12) claim form for Medicare claims. The CMS-1500 (02/12) claim form must be completed in compliance with the special instructions applicable to the data elements as described by this paragraph for clean claims filed by physicians and noninstitutional providers. Further, on notification that an MCC is prepared to accept claims filed or refiled on form CMS-1500 (02/12), a physician or noninstitutional provider may submit claims on form CMS-1500 (02/12) before the mandatory use date described in this paragraph, subject to the required data elements set out in this paragraph.

    (A) subscriber's or patient's plan ID number (CMS-1500 (02/12), field 1a) is required;

    (B) patient's name (CMS-1500 (02/12), field 2) is required;

    (C) patient's date of birth and sex (CMS-1500 (02/12), field 3) are required;

    (D) subscriber's name (CMS-1500 (02/12), field 4) is required if shown on the patient's ID card;

    (E) patient's address (street or P.O. Box, city, state, ZIP Code) (CMS-1500 (02/12), field 5) is required;

    (F) patient's relationship to subscriber (CMS-1500 (02/12), field 6) is required;

    (G) subscriber's address (street or P.O. Box, city, state, ZIP Code) (CMS-1500 (02/12), field 7) is required, but the physician or the provider may enter "Same" if the subscriber's address is the same as the patient's address required by subparagraph (E) of this paragraph;

    (H) other insured's or enrollee's name (CMS-1500 (02/12), 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 subparagraph (N) of this paragraph, "disclosure of any other health benefit plans," is answered "Yes," this element is required unless the physician or the provider submits with the claim documented proof that the physician or the provider has made a good faith but unsuccessful attempt to obtain from the enrollee or the insured any of the information needed to complete this data element;

    (I) other insured's or enrollee's policy or group number (CMS-1500 (02/12), field 9a) 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 subparagraph (N) of this paragraph, "disclosure of any other health benefit plans," is answered "Yes," this element is required unless the physician or the provider submits with the claim documented proof that the physician or the provider has made a good faith but unsuccessful attempt to obtain from the enrollee or the insured any of the information needed to complete this data element;

    (J) other insured's or enrollee's HMO or insurer name (CMS-1500 (02/12), field 9d) 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 subparagraph (N) of this paragraph, "disclosure of any other health benefit plans," is answered "Yes," this element is required unless the physician or the provider submits with the claim documented proof that the physician or the provider has made a good faith but unsuccessful attempt to obtain from the enrollee or the insured any of the information needed to complete this data element;

    (K) whether the patient's condition is related to employment, auto accident, or other accident (CMS-1500 (02/12), field 10) is required, but facility-based radiologists, pathologists, or anesthesiologists must enter "N" if the answer is "No" or if the information is not available;

    (L) subscriber's policy number (CMS-1500 (02/12), field 11) is required;

    (M) HMO or insurance company name (CMS-1500 (02/12), field 11c) is required;

    (N) disclosure of any other health benefit plans (CMS-1500 (02/12), field 11d) is required;

      (i) if answered "Yes," then:

        (I) data elements specified in subparagraphs (H) - (J) of this paragraph are required unless the physician or the provider submits with the claim documented proof that the physician or the provider has made a good faith but unsuccessful attempt to obtain from the enrollee or the insured any of the information needed to complete the data elements in subparagraphs (H) - (J) of this paragraph;

        (II) when submitting claims to secondary payor MCCs the data element specified in subparagraph (GG) of this paragraph is required;

      (ii) if answered "No," the data elements specified in subparagraphs (H) - (J) of this paragraph are not required if the physician or the provider has on file a document signed within the past 12 months by the patient or authorized person stating that there is no other health care coverage. Although the submission of the signed document is not a required data element, the physician or the provider must submit a copy of the signed document to the MCC on request;

    (O) patient's or authorized person's signature or a notation that the signature is on file with the physician or the provider (CMS-1500 (02/12), field 12) is required;

    (P) subscriber's or authorized person's signature or a notation that the signature is on file with the physician or the provider (CMS-1500 (02/12), field 13) is required;

    (Q) date of injury (CMS-1500 (02/12), field 14) is required if due to an accident;

    (R) when applicable, the physician or the provider must enter the name of the referring primary care physician, specialty physician, hospital, or other source (CMS-1500 (02/12), field 17). However, if there is no referral, the physician or the provider must enter "Self-referral" or "None";

    (S) if there is a referring physician noted in CMS-1500 (02/12), field 17, the physician or the provider must enter the ID Number of the referring primary care physician, specialty physician, or hospital (CMS-1500 (02/12), field 17a);

    (T) if there is a referring physician noted in CMS-1500 (02/12), field 17, the physician or the provider must enter the NPI number of the referring primary care physician, specialty physician, or hospital (CMS-1500 (02/12), field 17b) if the referring physician is eligible for an NPI number;

    (U) for diagnosis codes or nature of illness or injury (CMS-1500 (02/12), field 21), the physician or the provider:

      (i) must identify the ICD code version being used:

        (I) for all claims arising before the date on which CMS mandates the use of the ICD-10-CM for claims filed under the Medicare program, by entering either the number "9" to indicate the ICD-9-CM or the number "0" to indicate the ICD-10-CM between the vertical, dotted lines in the upper right-hand portion of the field;

        (II) for all claims arising on or after the date on which CMS mandates the use of the ICD-10-CM for claims filed under the Medicare program, by entering the number "0" to indicate the ICD-10-CM between the vertical, dotted lines in the upper right-hand portion of the field;

        (III) should CMS no longer require identification of the ICD code version being used, may indicate no ICD code version between the vertical dotted lines in the upper right-hand portion of the field;

      (ii) must enter at least one diagnosis code, and

      (iii) may enter up to 12 diagnosis codes, but the primary diagnosis must be entered first;

    (V) if the claim is a duplicate claim, a "D" is required; if the claim is a corrected claim, a "C" is required (CMS-1500 (02/12), field 22);

    (W) verification number is required (CMS-1500 (02/12), field 23) if services have been verified as provided by §19.1719 of this title (relating to Verification for Health Maintenance Organizations and Preferred Provider Benefit Plans). If no verification has been provided, a prior authorization number (CMS-1500 (02/12), field 23) is required when prior authorization is required and granted;

    (X) date(s) of service (CMS-1500 (02/12), field 24A) is required;

    (Y) place of service code(s) (CMS-1500 (02/12), field 24B) is required;

    (Z) procedure/modifier code(s) (CMS-1500 (02/12), field 24D) is required. If a physician or a provider uses an unlisted or not classified procedure code or a National Drug Code (NDC), the physician or provider must enter a narrative description of the procedure or the NDC in the shaded area above the corresponding completed service line;

    (AA) diagnosis code by specific service (CMS-1500 (02/12), field 24E) is required with the first code linked to the applicable diagnosis code for that service in field 21;

    (BB) charge for each listed service (CMS-1500 (02/12), field 24F) is required;

    (CC) number of days or units (CMS-1500 (02/12), field 24G) is required;

    (DD) the NPI number of the rendering physician or provider (CMS-1500 (02/12), field 24J, unshaded portion) is required if the rendering provider is not the billing provider listed in CMS-1500 (02/12), field 33, and if the rendering physician or provider is eligible for an NPI number;

    (EE) physician's or provider's federal tax ID number (CMS-1500 (02/12), field 25) is required;

    (FF) whether assignment was accepted (CMS-1500 (02/12), field 27) is required if assignment under Medicare has been accepted;

    (GG) total charge (CMS-1500 (02/12), field 28) is required;

    (HH) amount paid (CMS-1500 (02/12), field 29) is required if an amount has been paid to the physician or the provider submitting the claim by the patient or subscriber, or on behalf of the patient or subscriber or by a primary plan in compliance with subparagraph (N) of this paragraph and as required by subsection (d) of this section;

    (II) signature of physician or provider or a notation that the signature is on file with the MCC (CMS-1500 (02/12), field 31) is required;

    (JJ) name and address of the facility where services were rendered, if other than home, (CMS-1500 (02/12), field 32) is required;

    (KK) the NPI number of the facility where services were rendered, if other than home, (CMS-1500 (02/12), field 32a) is required if the facility is eligible for an NPI;

    (LL) physician's or provider's billing name, address, and telephone number (CMS-1500 (02/12), field 33) is required;

    (MM) (MM) the NPI number of the billing provider (CMS-1500 (02/12), field 33a) is required if the billing provider is eligible for an NPI number; and

    (NN) provider number (CMS-1500 (02/12), field 33b) is required if the MCC required provider numbers and gave notice of the requirement to physicians and providers before June 17, 2003.

  (2) Required form and data elements for physicians or noninstitutional providers for claims filed or refiled before the later of April 1, 2014, or the earliest compliance date required by CMS for mandatory use of the CMS-1500 (02/12) claim form for Medicare claims. The CMS-1500 (08/05) claim form and the data elements described in this paragraph are required for claims filed or refiled by physicians or noninstitutional providers before the later of these two dates: April 1, 2014, or the Cont'd...

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