Part 2.
TEXAS WORKERS' COMPENSATION COMMISSION
Chapter 102.
PRACTICES AND PROCEDURES--GENERAL PROVISIONS
28 TAC §§102.3 - 102.5
The Texas Workers' Compensation Commission (the commission)
proposes amendments to §§102.3, 102.4, and 102.5 in Chapter 102,
concerning Practices and Procedures--General Provisions. The amendments are
proposed to support the exchange of billing and reimbursement data, as well
as electronic exchange of medical documentation in the workers' compensation
system.
The
Texas Register
published text shows
words proposed to be added to or deleted from the current text, and should
be read to determine all proposed changes.
Currently, the majority of medical bills in the Texas workers' compensation
system are submitted on paper forms to insurance carriers, third party administrators,
or to medical bill review vendors. Minimal electronic billing occurs in the
system. Insurance carriers report professional and hospital bill payment data
to the commission in electronic file formats developed specifically for Texas
workers' compensation. The commission does not currently collect pharmacy
and dental data.
House Bill 2511 (HB 2511), passed in 1999 by the 76th Texas Legislature
added Texas Labor Code §401.024 which allows the commission to adopt
rules to permit or require electronic transmission in place of established
forms, manners, or procedures that require paper processing. The proposed
amendments are part of the commission's Electronic Billing and Reimbursement
(eBill) project initiated to identify and implement an electronic billing
solution for the Texas workers' compensation system. The eBill project is
a component of the commission's Business Process Improvement (BPI) initiative;
a coordinated set of projects that use technology to streamline agency processes
to meet the goals set out in HB 2511.
Proposed amendments to Chapter 102, concerning Practices and Procedures--General
Provisions, apply the provisions of that chapter to medical benefits; modify
language to define electronic communication and electronic transmission; and
include Claim and Medical Electronic Data Interchange (EDI) and electronic
billing and reimbursement as electronic transmissions. Current rule language
referencing the insurance carrier representative's physical mailbox is eliminated
to support the transition to electronic mail communication under the BPI initiative.
Currently Chapters 124 through 139 are exempted from the provisions of §102.3,
concerning Computation of Time. Proposed amendment to subsection 102.3(f)
removes the reference to specific rules and states that if there is a conflict
between this rule and provisions of another rule applicable to a specific
type of benefit, the other rule prevails.
Proposed amendment to subsection (h) of §102.4, concerning General
Rules for Non-Commission Communications, clarifies that the provision of (h)(2)
refer to mail sent via the United States Postal Service regular mail. Subsection
(k) is amended to expand the definition of written communication by including
"submissions." Subsection (m) is amended to define electronic communications
and electronic transmissions. This amendment is consistent with §401.024(a)
of the Texas Workers' Compensation Act. Proposed new §102.4(p) establishes
the date of receipt for non-commission communications. The current rule defines
the term "sent date". Received date is important in medical bill submission
and processing. Defining received date allows the commission to more effectively
enforce current rules and proposed amendments.
Proposed amendments to subsection (d) of §102.5, concerning General
Rules for Written Communications to and from the Commission, add the term
"the earliest of" related to the received date for communications sent by
mail and clarifies that the term mail applies to United States Postal Service
regular mail. Amendments also remove language that references the insurance
carrier Austin representative's physical mailbox at the commission's main
office in Austin. This amendment allows the commission to implement use of
an electronic mail box in place of the physical mailbox currently used by
insurance carrier Austin representatives. Subsections (e) and (f) have been
amended to be consistent with language in §102.4(m) and Texas Labor Code §401.024(a),
which define electronic communication and electronic transmission. Amendments
also include Claim and Medical Electronic Data Interchange (EDI) and electronic
billing and reimbursement as electronic transmissions. Subsection (g) is amended
to expand the definition of written communication by including "submissions."
Subsection (h) is amended to define the meaning of electronic transmissions
and is consistent with §401.024(a) of the Texas Workers' Compensation
Act.
Stacey Jefferson, Director of the Business and Information Technology Services
Division, has determined that for the first five-year period the proposed
rule is in effect there will be no fiscal implication for state or local governments
as a result of enforcing or administering the amended rules. Ms. Jefferson
has determined that there will be no cost to the commission in enforcing or
administering the amended rules.
Local government and state government as a covered regulated entity will
be impacted in the same manner as described below in this preamble for persons
and entities required to comply with the rules as amended.
Ms. Jefferson has also determined that for each year of the first five
years the amended rules are in effect, the public benefit will be greater
flexibility for system participants to exchange medical billing, reimbursement,
and documentation data electronically.
Health care provider and insurance carriers should experience no direct
economic impact from the requirement to comply with the proposed amendments.
Employers who purchase workers' compensation insurance should experience
no direct economic impact from the requirement to comply with these proposed
amendments because there is no additional administrative requirement for the
employer.
There will be no economic costs to employees, as these amendments do not
impose any requirements on injured employees.
There is no anticipated adverse economic impact on small businesses or
micro-businesses as a result of these amendments. There will be no difference
in anticipated costs of compliance for small and micro-businesses as compared
to large businesses.
Comments on the proposed rule amendments must be received by 5:00 p.m.,
March 7, 2005. You may comment via the Internet by accessing the commission's
website at
www.twcc.state.tx.us
and clicking
on "Rules" then clicking on "Proposed Rules for Comment." This medium for
commenting will help you organize your comments by rule chapter. You may also
comment by emailing your comments to
RuleComments@twcc.state.tx.us
or by mailing or delivering your comments to Linda Velasquez at the
Office of the General Counsel, Mailstop #4-D, Texas Workers' Compensation
Commission, 7551 Metro Center Drive, Suite 100, Austin, TX 78744.
Commenters are requested to clearly identify by number the specific rule
and paragraph (e.g., 102.3(a)(1), 102.4(m), 102.5, etc.) commented upon. The
commission may not be able to respond to comments that cannot be linked to
a particular proposed rule. Along with your comment, it is suggested that
you include the reasoning for the comment in order for commission staff to
fully evaluate your recommendations.
Based upon various considerations, including comments received and the
staff's or commissioners' review of those comments, or based upon the commissioners'
action at the public meeting, the rule as adopted may be revised from the
rule as proposed in whole or in part.
A public hearing on this proposal will be held on February 17, 2005 at
the Austin central office of the commission (7551 Metro Center Drive, Suite
100, Austin, Texas). Those persons interested in attending the public hearing
should contact the Commission's Office of Executive Communications at (512)
804-4430 to confirm the date, time, and location of the public hearing for
this proposal. The public hearing schedule will also be available on the commission's
website at www.twcc.state.tx.us.
The amendments are proposed under the following statutes: Texas
Labor Code §401.024, which provides the commission the authority to require
use of facsimile or other electronic means to transmit information in the
system; Texas Labor Code §402.042 which authorizes the Executive Director
to enter orders as authorized by the statute as well as to prescribe the form,
manner, and procedure for transmission of information to the commission; Texas
Labor Code §402.061, which authorizes the commission to adopt rules necessary
for the implementation and enforcement of the Texas Workers' Compensation
Act; Texas Labor Code §413.008 which authorizes the commission to collect
certain medical bill and payment information from the insurance carrier; and
HB 2511, 76th Texas Legislature which sets goals for the reduction of paper
communication requirements.
No other code, statute, or article is affected by this rule action.
§102.3.Computation of Time.
(a)
Due dates and time periods under this Act shall be computed
as follows:
(1)
computing a period of days. In counting a period of time
measured by days, the first day is excluded and the last day is included.
(2)
computing a period of months. If a number of months is
to be computed by counting the months from a particular day, the period ends
on the same numerical day in the concluding month as the day of the month
from which the computation is begun, unless there are not that many days in
the concluding month, in which case the period ends on the last day of that
month.
(3)
unless otherwise specified, if the last day of any period
is not a working day, the period is extended to include the next day that
is a working day.
(b)
A working day is any day, Monday-Friday, other than a national
holiday as defined by Texas Government Code, §662.003(a) and the Friday
after Thanksgiving Day, December 24th and December 26th. Use in this title
of the term "day," rather than "working day" shall mean a calendar day.
(c)
Normal business hours in the Texas workers' compensation
system are 8:00 a.m. to 5:00 p.m. Central Standard Time with the exception
of the Commission's El Paso field office whose normal business hours are 8:00
a.m. to 5:00 p.m. Mountain Standard Time.
(d)
Any written or telephonic communications received other
than during normal business hours on working days are considered received
at the beginning of normal business hours on the next working day.
(e)
Unless otherwise specified by rule, any written or telephonic
communications required to be filed by a specified time will be considered
timely only if received prior to the end of normal business hours on the last
permissible day of filing.
(f)
If there is a conflict between this rule and a specific
provision of another rule that is applicable to a specific type of benefit,
the other rule prevails.
[
§102.4.General Rules for Non-Commission Communications.
(a)
All written communications to a claimant (who is either
an employee, an employee's legal beneficiary, or a subclaimant) shall be sent
to the most recent address or facsimile number supplied by the claimant. If
an address has not been supplied by the claimant, the most recent address
provided by the employer shall be used.
(b)
After an insurance carrier, employer, or health care provider
is notified in writing that a claimant is represented by an attorney or other
representative, copies of all written communications related to the claim
to the claimant shall thereafter be mailed or delivered to the representative
as well as the claimant, unless the claimant requests delivery to the representative
only.
(c)
Insurance carriers shall provide a toll free telephone
number for receipt of communication from claimants and/or their representatives
with a sufficient quantity of lines to service their volume of business.
(d)
Insurance carriers and health care providers shall provide
telephone and facsimile numbers in sufficient quantity of lines to service
the volume of business for receiving required verbal and written communications
regarding workers' compensation claims.
(e)
Insurance carriers must ensure effective and timely communication
with claimants and other parties in the system. If a claimant is unable to
communicate with a carrier due to a language barrier and the claimant is unable
to provide a person who he or she trusts to serve as a translator, the carrier
shall provide a means to translate except as needed for a Commission proceeding.
The claimant shall not be required to contract with or otherwise employ a
translator.
(f)
When a claimant contacts a carrier and requests a response
regarding their claim, the response shall be verbally provided or sent in
writing by the carrier within five working days of receiving the request,
unless the request is redundant or the response is duplicative of information
previously provided.
(g)
Insurance carriers shall employ or provide sufficient numbers
of person, including adjusters appropriately licensed by the Texas Department
of Insurance to meet their obligations under the Act and this title.
(h)
Unless the great weight of evidence indicates otherwise,
written communications shall be deemed to have been sent on:
(1)
the date received, if sent by fax, personal delivery or
electronic transmission or,
(2)
the date postmarked if sent by mail
via United States
Postal Service regular mail
, or, if the postmark date is unavailable,
the later of the signature date on the written communication or the date it
was received minus five days. If the date received minus five days is a Sunday
or legal holiday, the date deemed sent shall be the next previous day which
is not a Sunday or legal holiday.
(i)
A carrier shall maintain adjuster's notes on activities
and verbal communications involved with the administration of a claim, with
the exception of privileged attorney-client communications. The adjuster's
notes shall, at a minimum, include the date of the activity or communication,
the identity of the carrier staff involved in the contact, the person contacted
by or contacting the carrier and a summary of the activity or communication.
(j)
An insurance carrier, employer or health care provider
that receives a written communication related to a workers' compensation claim
shall date stamp or otherwise annotate the document indicating the date the
written communication was received.
(k)
Written communications include all records, reports, notices,
filings,
submissions,
and other information contained either on
paper or in an electronic format.
(l)
For purposes of this title, if a written communication
is required to be filed with both the Commission and another person by the
Act or Commission rules, the other person shall be presumed to have received
the written communication on the date the Commission received its copy, unless
the other person annotated the date of receipt as provided in subsection (j)
of this section or the means of delivery of the communication was different.
In this situation, the other person has the burden of proving that it did
not receive or timely receive the written communication.
(m)
Electronic
communication
[
(n)
If the Commission receives an allegation that a carrier
or health care provider has failed to provide a sufficient number of toll-free
telephone, toll telephone, or facsimile lines or that a carrier has not provided
a sufficient number of adjusters as required by this section, unless the violation
appears to be willful or intentional, the Commission will not issue a monetary
penalty or other sanctions prior to:
(1)
notifying the alleged violator of the allegation;
(2)
affording the alleged violator the opportunity to either
disprove the allegation or provide mitigating information; and
(3)
if the violator is unable to disprove the allegation, issuing
a written warning to the violator allowing a reasonable grace period of not
less than 30 days to correct the noncompliance. The grace period may be less
than 30 days if the noncompliance prevents the violator from fulfilling other
obligations under this title.
(o)
A violation as described in subsection (n) will be considered
willful or intentional if the violator has been advised of complaints such
that the violator knew or should have known that the number of toll-free telephone,
toll telephone, facsimile lines, or adjusters was insufficient and the violator
cannot establish that it made good faith efforts to correct the deficiency
or if the violator otherwise exhibited willful or intentional conduct.
(p)
For purposes of determining the date of
receipt for non-commission written communications, unless the great weight
of evidence indicates otherwise, the Commission shall deem the received date
to be five days after the date mailed via United States Postal Service regular
mail; or the date faxed or electronically transmitted.
§102.5.General Rules for Written Communications to and from the Commission.
(a)
After the Commission is notified in writing that a claimant
is represented by an attorney or other representative, all copies of written
communications to the claimant shall thereafter be sent to the representative
as well as the claimant, unless the claimant requests delivery to the representative
only. However, copies of settlements, notices setting benefit review conferences
and hearings, and orders of the Commission shall always be sent to the claimant
regardless of representation status. All written communications to the claimant
or claimant's representative will be sent to the most recent address or facsimile
number supplied on either the employer's first report of injury, any verbal
or written communication from the claimant, or any claim form filed by the
carrier via written notice or electronic transmission.
(b)
All written communications to persons other than carriers
and claimants will be sent to the most recent address or fax number reported
to the Commission by the intended recipient or, in the absence of an address
or fax number supplied by the intended recipient, to an address or fax number
identified by the Commission.
(c)
Unless otherwise specified by rule, written communications
required to be filed with the Commission should be sent to the local Commission
field office managing the claim, however, written communications shall also
be accepted at any Commission office.
(d)
For purposes of determining the date of receipt for those
written communications sent by the Commission which require the recipient
to perform an action by a specific date after receipt, unless the great weight
of evidence indicates otherwise, the Commission shall deem the received date
to be
the earliest of:
five days after the date mailed
via
United States Postal Service regular mail
; the first working day after
the date the written communication was placed in a carrier's Austin representative
box [
(e)
Electronic
[
(1)
which do not pass the required edit checks in accordance
with the International Association of Industrial Accident Boards and Commissions
(IAIABC) and Texas EDI Implementation Guides shall be rejected back to the
trading partner. Rejected records are not considered received by the Commission
and must be corrected and re-submitted. Rejected records must be re-submitted
by the original due date to be considered timely filed;
(2)
which are accepted but in which the Commission identifies
errors shall be corrected and resubmitted, in accordance with the Texas EDI
Implementation Guide, within 90 days of receipt of the notification of the
acceptance with errors through the corresponding transaction acknowledgment.
(f)
Unless the great weight of evidence indicates otherwise,
written communications received by the Commission by means other than electronic
filing described in subsection (e) of this section and §124.2 of this
title, and §134.802 of this title (relating to Insurance
Carrier
[
(1)
the date received if sent by fax, personal delivery or
electronic transmission or,
(2)
the date postmarked if sent by
United States Postal
Service regular
mail, or, if the postmark date is unavailable, the later
of the signature date on the written communication or the date it was received
minus five days. If the date received minus five days is a Sunday or legal
holiday, the date deemed sent shall be the next previous day which is not
a Sunday or legal holiday.
(g)
Written communications include all records, reports, notices,
filings,
submissions,
and other information contained either on
paper or in an electronic format.
(h)
Electronic transmission
is defined as
[
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State on January 24, 2005.
TRD-200500292
Susan Cory
General Counsel
Texas Workers' Compensation Commission
Earliest possible date of adoption: March 6, 2005
For further information, please call: (512) 804-4287
Subchapter I. PROVIDER BILLING PROCEDURES
28 TAC §134.800, §134.802
The Texas Workers' Compensation Commission (the commission)
proposes amendments to §134.800 and §134.802 in Chapter 134, concerning
Benefits--Guidelines for Medical Services, Charges and Payments. The amendments
are proposed to support the exchange of billing and reimbursement data, as
well as electronic exchange of medical documentation in the workers' compensation
system.
The
Texas Register
published text shows
words proposed to be added to or deleted from the current text, and should
be read to determine all proposed changes.
Currently, the majority of medical bills in the Texas workers' compensation
system are submitted on paper forms to insurance carriers, third party administrators,
or to medical bill review vendors. Minimal electronic billing occurs in the
system. Insurance carriers report professional and hospital bill payment data
to the commission in electronic file formats developed specifically for Texas
workers' compensation. The commission does not currently collect pharmacy
and dental data.
House Bill 2511 (HB 2511), passed in 1999 by the 76th Texas Legislature
added Texas Labor Code §401.024 which allows the commission to adopt
rules to permit or require electronic transmission in place of established
forms, manners, or procedures that require paper processing. The proposed
amendments are part of the commission's Electronic Billing and Reimbursement
(eBill) project initiated to identify and implement an electronic billing
solution for the Texas workers' compensation system. The eBill project is
a component of the commission's Business Process Improvement (BPI) initiative;
a coordinated set of projects that use technology to streamline agency processes
to meet the goals set out in HB 2511.
Proposed amendments to Chapter 134, concerning Benefits--Guidelines for
Medical Services, Charges, and Payments, specify that the use of standard
medical billing forms is applicable to medical bills submitted in paper form
and does not apply to medical bills submitted electronically. Additionally,
the proposed amendments clarify that a carrier's reporting of medical billing
data to the commission includes payment data.
Proposed amendments to subsections (a) and (e) of §134.800, concerning
Required Billing Forms and Instructions, are amended to allow health care
providers and insurance carriers to exchange medical bill data, payment data,
and documentation electronically by mutual agreement. The proposed amendment
requires that the agreement must include stipulations defining a complete
electronic medical bill and the method and manner related documentation is
submitted to the insurance carrier. The proposed amendments exclude transmission
by facsimile and electronic mail in the mutual agreement provision. Proposed
amendments replace the term "Commission" in place of the "Medical Review Division"
in subsection (f) and eliminate subsection (g).
Amendments to §134.802, concerning Insurance Carrier's Submission
of Medical Bills to the Commission, adds the phrase "and payment" to the insurance
carrier requirement to submit medical billing data to the commission. The
amendment does not change current reporting processes or requirements. It
makes the language consistent with the intent to collect medical bill and
payment information, which includes payment, denial, and refund data. The
amendment also changes the title from "Insurance Carrier's Submission of Medical
Bills to the Commission" to "Insurance Carrier Medical Electronic Data Interchange
to the Commission" and is consistent with the commission's BPI Medical EDI
project.
Stacey Jefferson, Director of the Business and Information Technology Services
Division, has determined that for the first five-year period the proposed
rule is in effect there may be fiscal implications for state or local governments
as a result of enforcing or administering the rule. There is no adverse fiscal
impact for state or local governments that do not change medical billing and
reimbursement processes, as the amendments do not mandate electronic exchange
of billing and reimbursement data. The potential fiscal impact is related
to administrative costs affected by a reduction in paper processing for state
or local governments that choose to implement electronic billing and reimbursement.
Start up costs anticipated to implement an electronic interface may be offset
by a reduction in administrative costs for paper processing, however, the
overall impact cannot be quantified at this time.
Local government and state government as a covered regulated entity will
be impacted in the same manner as described below in this preamble for persons
and entities required to comply with the rules as amended.
Ms. Jefferson has also determined that for each year of the first five
years the amended rules are in effect, the public benefit will be greater
flexibility for system participants to exchange medical billing, reimbursement,
and documentation data electronically.
There is no anticipated economic impact to those persons or entities that
choose to continue their existing medical bill submission and processing practices,
as these amendments do not mandate electronic exchange of information.
Health care providers and insurance carriers, including certified self-insured
employers, who are not already exchanging data electronically but choose to
initiate electronic processes may experience start up costs related to implementation
of an electronic interface. It is expected that start up costs will likely
be offset by a decrease in overall administrative costs for generating and
processing paper medical bills and documentation.
Employers who purchase workers' compensation insurance should experience
no direct economic impact from the requirement to comply with these proposed
amendments because there is no additional administrative requirement for the
employer.
There will be no economic costs to employees, as these amendments do not
impose any requirements on injured employees.
There may be costs of compliance for small businesses that do not currently
exchange data electronically but choose to implement electronic interfaces.
Start up costs related to implementation of electronic interfaces may be offset
by a decrease in overall administrative costs related to paper processing
of medical bills and data.
There is no anticipated adverse economic impact on small businesses or
micro-businesses as a result of these amendments, as electronic exchange of
information is not mandated. There will be no difference in anticipated costs
of compliance for small and micro-businesses as compared to large businesses.
Comments on the proposed rule amendments must be received by 5:00 p.m.,
March 7, 2005. You may comment via the Internet by accessing the commission's
website at
www.twcc.state.tx.us
and clicking
on "Rules" then clicking on "Proposed Rules for Comment." This medium for
commenting will help you organize your comments by rule chapter. You may also
comment by emailing your comments to
RuleComments@twcc.state.tx.us
or by mailing or delivering your comments to Linda Velasquez at the
Office of the General Counsel, Mailstop #4-D, Texas Workers' Compensation
Commission, 7551 Metro Center Drive, Suite 100, Austin, TX 78744.
Commenters are requested to clearly identify by number the specific rule
and paragraph (e.g., 134.800 (a), 134.802(a), etc.) commented upon. The commission
may not be able to respond to comments that cannot be linked to a particular
proposed rule. Along with your comment, it is suggested that you include the
reasoning for the comment in order for commission staff to fully evaluate
your recommendations.
Based upon various considerations, including comments received and the
staff's or commissioners' review of those comments, or based upon the commissioners'
action at the public meeting, the rule as adopted may be revised from the
rule as proposed in whole or in part.
A public hearing on this proposal will be held on February 17, 2005 at
the Austin central office of the commission (7551 Metro Center Drive, Suite
100, Austin, Texas). Those persons interested in attending the public hearing
should contact the Commission's Office of Executive Communications at (512)
804-4430 to confirm the date, time, and location of the public hearing for
this proposal. The public hearing schedule will also be available on the commission's
website at
www.twcc.state.tx.us
.
The proposed amendments are proposed under the following statutes:
Texas Labor Code §402.061, which gives the Commission the authority to
adopt rules as necessary to implement and enforce the Act; Texas Labor Code §401.024,
which provides the Commission the authority to require use of facsimile or
other electronic means to transmit information in the system; Texas Labor
Code §402.042, which authorizes the executive director to enter orders
as authorized by the statute as well as to prescribe the form manner and procedure
for transmission of information to the Commission; Texas Labor Code §408.025,
which requires the Commission to specify by rule the reports a health care
provider is required to file; Texas Labor Code §408.027, which provides
for insurance carrier payment of health care providers; Texas Labor Code §413.007,
which directs the Medical Review Division to maintain a statewide database
of medical billing information; Texas Labor Code §413.008 which authorizes
the commission to collect certain medical bill and payment information from
the insurance carrier; and HB 2511, 76th Texas Legislature which sets goals
for the reduction of paper communication requirements.
No other code, statute, or article is affected by this rule action.
§134.800.Required Billing Forms and Information.
(a)
Except as provided by §134.801 of this title (relating
to Submitting Medical Bills for Payment), health care providers shall submit
medical bills for payment on standard forms used by the Centers for Medicare
and Medicaid Services (CMS)
,
[
(b)
Except as provided in subsections (c), [
(c)
Pharmacists shall submit bills using the Commission form
TWCC-66, Statement for Pharmacy Services, prepared according to Commission
instructions.
(d)
Dentists shall submit bills using a billing form currently
approved by the American Dental Association prepared according to Commission
instructions.
(e)
Health care providers
and the insurance carrier may
mutually agree to exchange medical bill and reimbursement data electronically.
The mutual agreement shall stipulate the elements that constitute a complete
electronic medical bill and the method and manner related documentation is
submitted to the insurance carrier. For the purposes of this subsection, electronic
billing and reimbursement excludes transmission by facsimile or electronic
mail.
[
(f)
The
Commission
[
[
§134.802.Insurance Carrier [
(a)
The insurance carrier shall submit medical
bill and
payment
[
(b)
Insurance carriers shall submit medical
bill and payment
[
(c)
The Commission shall prescribe the form, format, and content
of the required medical
bill and payment
[
(d)
This rule shall apply to all dates of service on or after
July 15, 2000, for facility and professional medical services except pharmacy
and dental services.
(e)
This rule shall apply to all dates of service on or after
January 1, 2005, for pharmacy and dental services in addition to the already
required facility and professional medical services.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State on January 24, 2005.
TRD-200500293
Susan Cory
General Counsel
Texas Workers' Compensation Commission
Earliest possible date of adoption: March 6, 2005
For further information, please call: (512) 804-4287
This section does not apply to the computation
of periods of entitlement to benefits. (Periods of entitlement to benefits
are computed in accordance with specific rules on benefits set forth in Chapters
124 through 139 of this title (relating to Carriers: Required Notices And
Mode of Payment; Education and Training Of Ombudsman; General Provisions Applicable
To All Benefits; Benefits--Calculation Of Average Weekly Wage; Income Benefits--Temporary
Income Benefits; Impairment And Supplemental Income Benefits; Benefits-Lifetime
Income Benefits; Death Benefits--Death And Burial Benefits; General Medical
Provisions; Benefits-Guidelines For Medical Services, Charges, and Payments;
And Benefits-Vocational Rehabilitation)).
]
transmission
] refers to
the electronic
transmission
of claim or
medical information.
[
by means such as e-mail
]
Electronic
transmission is defined as transmission of information by facsimile, electronic
mail, electronic data interchange, or any other similar method
and does
not include telephonic communication
. Electronic communication for reporting
purposes is
[
or electronic filing as
] described in §102.5(e)
of this chapter (relating to General Rules for Written Communications to and
from the Commission), §124.2 of this title (relating to Carrier Reporting
and Notification Requirements), and §134.802 of this title (relating
to Insurance
Carrier
[
Carrier's Submission of
] Medical
Electronic Data Interchange
[
Bills
] to the Commission).
located at the Commission's main office in Austin as indicated by
the Commission's date stamp
]; or the date faxed or electronically transmitted.
Electronically filed records
or
] communications shall be filed or submitted in the format, form,
and manner prescribed by the Commission.
Electronic communication
[
A record
] is considered filed [
when submitted electronically
]
if on the date received, the record meets the required edit checks to insure
data quality. Electronic
communication is defined
[
filing
is different than "electronic transmission" as described
] in subsection
(h) of this section, §102.4(m) of this chapter (relating to General Rules
for Non-Commission Communications), and §134.802 of this title (relating
to Insurance
Carrier
[
Carrier's Submission of
] Medical
Electronic Data Interchange
[
Bills
] to the Commission).
Claim
Electronic Data Interchange records filed pursuant to §124.2
of this title (relating to Carrier Reporting and Notification Requirements):
Carrier's Submission of
] Medical
Electronic Data
Interchange
[
Bills
] to the Commission) shall be deemed to
have been sent on:
refers to
] transmission
of information
by [
means such
as
]
facsimile, electronic mail,
[
e-mail
]
electronic data interchange or any other similar method
and does not
include telephonic communication[
or electronic filing as described in
subsection (e) of this section, §124.2 of this title and §134.802
of this title
].
Chapter 134.
BENEFITS--GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS
or
] applicable forms prescribed
in subsections (b)
,
[
and
] (c),
and (d)
, completed
in accordance with Commission instructions
, or electronic transmissions
submitted in accordance with subsection (e) of this section
. All information
on medical bills shall be legible when submitted.
and
]
(d)
, and (e)
of this section, all health care providers, as defined
in §401.011 of the Texas Labor Code, shall submit medical bills using
national standard health insurance claim forms, prepared according to Commission
instructions.
may submit medical bills by facsimile or electronic transmission,
when mutually agreed upon between the health care provider and the insurance
carrier, unless the bill and/or supporting documentation cannot be sent by
those media, in which case the health care provider shall send the documentation
by mail or personal delivery.
]
Medical Review Division
] may order the health care provider to reimburse a carrier when the
carrier pays the health care provider in excess of the amount allowed by the
appropriate Commission fee guideline.
(g)
This rule shall apply to all
dates of service on or after September 1, 2004.]
Carrier's Submission of ] Medical Electronic Data Interchange [ Bills ] to the Commission.
billing
] data to the Commission within 30 days after
the insurance carrier makes payment, denies payment, or receives a refund
of overpayment on a medical bill.
billing
] data electronically in the form and format prescribed
by the Commission.
billing
] data
submission.
Chapter 166.
WORKERS' HEALTH AND SAFETY--ACCIDENT PREVENTION SERVICES