Part 2. TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION

Chapter 133. GENERAL MEDICAL PROVISIONS

Subchapter B. HEALTH CARE PROVIDER BILLING PROCEDURES

28 TAC §133.10

The Texas Department of Insurance, Division of Workers' Compensation ("Division"), proposes amendments to §133.10(a)(3), (b), and (c) of this title (relating to Required Billing Forms/Formats).

The proposed amendment to §133.10(a)(3) of this title provides that medical bills submitted in an electronic format are to be submitted in accordance with Subchapter G (relating to Electronic Medical Billing, Reimbursement, and Documentation). This amendment is necessary because current §133.10(a)(3) incorrectly cites Subchapter F of this chapter as the subchapter that governs electronic billing. Subchapter G of this chapter governs electronic billing. This amendment will correct this citation error.

The proposed amendment to §133.10(b) of this title removes the current National Council for Prescription Drug Programs (NCPDP) Universal Claim Form (UCF) as the prescribed paper billing form for pharmacy billing and requires pharmacists and pharmacy processing agents to submit bills using the Division's form DWC-66 ("DWC-66"). Further, this proposed amendment allows pharmacists and pharmacy processing agents to submit bills on an alternate billing form if the insurance carrier pre-approves the alternate billing form and the alternate billing form provides all information required on the DWC-66. This proposed amendment is necessary because the current NCPDP UCF is not effectively adaptable for use in the Texas workers' compensation system.

Section 133.10(b) of this title designates the DWC-66 as the prescribed paper billing form for pharmacy services rendered on or before December 31, 2007. The DWC-66 is specifically designed for use in the Texas workers' compensation system and has been used in Texas since 1991. The DWC-66 is a very cost effective form, and workers' compensation system participants process this form with automated systems that utilize labor saving technology such as optical character recognition ("OCR") technology.

Effective January 1, 2008, §133.10(b) of this title designates the current NCPDP UCF as the prescribed paper billing form for pharmacy services. The Division adopted the current NCPDP UCF for use in the Texas workers' compensation system because this billing form is a nationally standardized pharmacy billing form that is used in other healthcare delivery systems. Prior to the NCPDP UCF's January 1, 2008 implementation date, the Division requested system participants to provide the Division with feedback regarding any issues they have faced in implementing this form into their processes. System participants have responded that, unlike the DWC-66, the current NCPDP UCF is not a suitable billing form for the Texas workers' compensation system because, with the Division's modified instructions, it is difficult to complete accurately and it will increase the costs associated with pharmacy billing.

The NCPDP UCF, when completed in accordance with its standard instructions, does not capture all information that is necessary for pharmacy billing in the Texas workers' compensation system. In order to make the NCPDP UCF workable in the Texas workers' compensation system, significant modifications to the standard instructions associated with the NCPDP UCF were necessary. For example, the NCPDP UCF does not contain a field for pharmacy benefit manager ("PBM") or pharmacy processing agent ("billing agent") information in cases where a PBM or billing agent processes a pharmacy bill on behalf of a pharmacy. In order to capture this information, the Division's modified instructions require PBM and billing agent information to be placed in fields that describe other information. Further, when completed in accordance with Division instructions, the NCPDP UCF does not provide enough space for carrier information. This necessitates very small fonts and/or overflow into other data fields. The Division's modified instructions also require information to be placed in white spaces, nonstandard locations on the form. These resulting modified instructions, according to system participants, make completing this form difficult; and this may lead to a high number of rejected bills. This would bring inefficiencies and increased costs into the Texas workers' compensation system.

In addition, system participants have responded that requiring small fonts, possible data overflow, and placement of data in nonstandard locations on the NCPDP UCF makes applying OCR technology to the NCPDP UCF difficult. The difficulty in applying OCR technology to the NCPDP UCF would hinder the development of automated systems like those created for the DWC-66 and thus require increased manual intervention to process this form. This will increase the labor costs associated with processing pharmacy bills.

The proposed amendment to §133.10(c) of this title provides that dentists shall use the current American Dental Association (ADA) claim form when billing for dental services. This proposed amendment is necessary to clarify the proper use of the current ADA claim form.

In addition to providing dental services, dentists may provide injured workers with professional medical services such as case management, certification of maximum medical improvement, and the assignment of impairment ratings. Billing for these types of professional medical services requires the use of non-dental codes in the Healthcare Common Procedure Coding System (HCPCS). Dentists have used the current ADA claim form when billing for these types of professional medical services. Carriers reject such bills on the basis that this is not the correct billing form for these types of professional medical services. The proper interpretation of current §133.10(c) is to require dentists to use the current ADA claim form when billing for dental services and, in accordance with §133.10(a)(1) of this title, to use the standard forms used by the Centers for Medicare and Medicaid Services when billing for professional medical services that have non-dental codes. This proposed amendment clarifies this interpretation.

Allen McDonald, Director, Information Management Services, has determined that, for each year of the first five years the proposed amendments are in effect, there will be no fiscal impact on state or local government as a result of enforcing or administering these proposed amendments; and there will be no effect on local employment or the local economy as a result of these proposed amendments.

Mr. McDonald has determined that, for each year of the first five years the proposed amendment to §133.10(a)(3) of this title is in effect, the anticipated public benefit will be the correction of an inaccurate citation in §133.10(a)(3) of this title.

Mr. McDonald has determined that, for each year of the first five years the proposed amendment to §133.10(b) of this title is in effect, the anticipated public benefit will be the continued use of the DWC-66 for pharmacy billing. This benefits the public because the DWC-66 is a cost effective pharmacy billing form that is specifically designed for use in the Texas workers' compensation system. The NCPDP UCF, in its current form, is not effectively adaptable for use in the Texas workers' compensation system; and requiring the use of the NCPDP UCF with the Division's modified instructions will impose inefficiencies and unnecessary costs. This proposed amendment will prevent these inefficiencies and costs from being imposed. Further, this proposed amendment provides system participants with the flexibility to utilize other pharmacy billing forms, through mutual agreement, that are effectively adaptable to the Texas workers' compensation system in lieu of the DWC-66.

Mr. McDonald has determined that, for each year of the first five years the proposed amendment to §133.10(c) of this title is in effect, the anticipated public benefit will be the clarification of the proper use of the ADA claim form and the reduction in the number of rejected bills for professional medical services submitted by dentists.

Mr. McDonald has determined that, for each year of the first five years the proposed amendment to §133.10(a)(3) of this title is in effect, there will be no economic cost to persons who are required to comply with this proposed amendment because this proposed amendment merely corrects a citation error.

Mr. McDonald has determined that, for each year of the first five years the proposed amendment to §133.10(b) of this title is in effect, there will be no economic cost to persons who are required to comply with this proposed amendment. System participants have processed pharmacy bills submitted on the DWC-66, a nonproprietary form, since 1991. System participants already have in place established procedures and systems to process bills submitted on this form. System participants will, therefore, not incur any costs associated with implementing the DWC-66 into their processes or any additional costs associated with processing bills submitted on the DWC-66. Further, this proposed amendment does not require system participants to use an alternate billing form in lieu of the DWC-66. An alternate billing form may be used by system participants by prior agreement provided the alternate billing form provides all the information required on the DWC-66. Thus, any costs associated with the implementation and use of an alternate billing form will be the result of an agreement between system participants and not a result of this proposed amendment.

Mr. McDonald has also determined that, for each year of the first five years the proposed amendment to §133.10(c) of this title is in effect, there will be no economic cost to persons who are required to comply with this proposed amendment because this proposed amendment clarifies the proper interpretation of current §133.10(c) of this title with regard to the proper use of the ADA claim form.

As required by Government Code, §2006.002(c), the Division has determined that these proposed amendments will not have an adverse economic effect on small or micro-businesses. The Division's analysis of any possible costs for compliance with these proposed amendments that are detailed in the Public Benefit/Cost Note section of this proposal is also applicable to small and micro-businesses. Because these proposed amendments will not have an adverse economic effect on small or micro-businesses, Government Code, §2006.002(c), does not require an economic impact statement or regulatory flexibility analysis.

The Division has determined that no private real property interests are affected by these proposed amendments; and these proposed amendments do not restrict or limit an owner's right to property that would otherwise exist in the absence of government action and, therefore, do not constitute a taking or require a takings impact assessment under Government Code, §2007.043.

To be considered, written comments on these proposed amendments must be submitted no later than 5:00 p.m. on March 17, 2008. Comments may be submitted via the Internet through the Division's Internet website at http://www.tdi.state.tx.us/wc/rules/proposedrules/toc.html or by mailing your comments to Victoria Ortega, Legal Services, MS-4D, Texas Department of Insurance, Division of Workers' Compensation, 7551 Metro Center Drive, Suite 100, Austin, Texas 78744.

Any request for a public hearing must be submitted separately to the Office of General Counsel, MS-1, 7551 Metro Center Drive, Austin, Texas 78744 by 5:00 p.m. on March 17, 2008. If a hearing is held, written and oral comments presented at the hearing will be considered.

These proposed amendments are proposed under Labor Code, §§413.053, 413.011, 413.0111, 408.0251, 402.00111, and 402.061.

Labor Code, §413.053, provides that the Commissioner of Workers' Compensation by rule shall establish standards of reporting and billing governing both form and content. Labor Code, §413.011, requires the Commissioner of Workers' Compensation to adopt the most current reimbursement methodologies, models, and values or weights used by the federal Centers for Medicare and Medicaid Services, including applicable payment policies relating to coding, billing, and reporting and may modify documentation requirements as necessary to meet other statutory requirements. This section also provides that the Commissioner of Workers' Compensation may adopt rules as necessary to implement this section. Labor Code, §413.0111, provides that the rules adopted by the Commissioner of Workers' Compensation for the reimbursement of prescription medications and services must authorize pharmacies to use agents or assignees to process claims and act on behalf of the pharmacies under terms and conditions agreed on by the pharmacies. Labor Code, §408.0251, provides that the Commissioner of Workers' Compensation, by rule and in cooperation with the Commissioner of Insurance, shall adopt rules regarding the electronic submission and processing of medical bills by health care providers to insurance carriers. This section also provides that the Commissioner of Workers' Compensation shall by rule establish criteria for granting exceptions to insurance carriers and health care providers who are unable to submit or accept medical bills electronically. Labor Code, §402.00111, provides that the Commissioner of Workers' Compensation shall exercise all executive authority, including rulemaking authority, under Title 5 of the Labor Code. Labor Code, §402.061, provides that the Commissioner of Workers' Compensation shall adopt rules as necessary for the implementation and enforcement of the Texas Workers' Compensation Act.

The following sections are affected by this proposal: Labor Code §§401.024, 402.00111, 406.010, 408.025, 408.0251, 408.027, 413.007, 413.008, 413.011, 413.0111, 413.015, and 413.053.

§133.10.Required Billing Forms/Formats.

(a) Health care providers shall submit medical bills for payment:

(1) on standard forms used by the Centers for Medicare and Medicaid Services (CMS);

(2) on applicable forms prescribed for pharmacists and dentists specified in subsections (b) and (c) of this section; or

(3) in electronic format in accordance with Subchapter G [ F ] of this chapter (relating to Electronic Medical Billing, Reimbursement, and Documentation).

(b) Pharmacists and pharmacy processing agents shall submit bills using the Division form DWC-66. A pharmacist or pharmacy processing agent may submit bills using an alternate billing form if: [ current National Council for Prescription Drug Programs (NCPDP) Universal Claim Form (UCF) for health care provided on or after January 1, 2008. Pharmacists and pharmacy processing agents shall use the Division form DWC-66 for health care provided on or before December 31, 2007. ]

(1) the insurance carrier has approved the alternate billing form prior to submission by the pharmacist or pharmacy processing agent; and

(2) the alternate billing form provides all information required on the Division form DWC-66.

(c) Dentists shall submit bills for dental services using the current American Dental Association claim form.

(d) (No change.)

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 February 4, 2008.

TRD-200800670

Norma Garcia

General Counsel

Texas Department of Insurance, Division of Workers' Compensation

Earliest possible date of adoption: March 16, 2008

For further information, please call: (512) 804-4715