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TITLE 28INSURANCE
PART 2TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION
CHAPTER 133GENERAL MEDICAL PROVISIONS
SUBCHAPTER CMEDICAL BILL PROCESSING/AUDIT BY INSURANCE CARRIER
RULE §133.200Insurance Carrier Receipt of Medical Bills from Health Care Providers

(a) Upon receipt of medical bills submitted in accordance with §133.10(a)(1) and (2) of this chapter (relating to Required Medical Forms/Formats), an insurance carrier shall evaluate each medical bill for completeness as defined in §133.2 of this chapter (relating to Definitions).

  (1) Insurance carriers shall not return medical bills that are complete, unless the bill is a duplicate bill.

  (2) Within 30 days after the day it receives a medical bill that is not complete as defined in §133.2 of this chapter, an insurance carrier shall:

    (A) complete the bill by adding missing information already known to the insurance carrier, except for the following:

      (i) dates of service;

      (ii) procedure/modifier codes;

      (iii) number of units; and

      (iv) charges; or

    (B) return the bill to the sender, in accordance with subsection (c) of this section.

  (3) The insurance carrier may contact the sender to obtain the information necessary to make the bill complete, including the information specified in paragraph (2)(A)(i) - (iv) of this subsection. If the insurance carrier obtains the missing information and completes the bill, the insurance carrier shall document the name and telephone number of the person who supplied the information.

(b) An insurance carrier shall not return a medical bill except as provided in subsection (a) of this section. When returning a medical bill, the insurance carrier shall include a document identifying the reason(s) for returning the bill. The reason(s) related to the procedure or modifier code(s) shall identify the reason(s) by line item.

(c) The proper return of an incomplete medical bill in accordance with this section fulfills the insurance carrier's obligations with regard to the incomplete bill.

(d) An insurance carrier shall not combine bills submitted in separate envelopes as a single bill or separate single bills spanning several pages submitted in a single envelope.


Source Note: The provisions of this §133.200 adopted to be effective May 2, 2006, 31 TexReg 3544

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