The Texas Division of Workers' Compensation published a Proposed Clarification to the Texas eBill Companion Guide.  Texas and California are simultaneously creating eBill initiatives requiring carriers to accept medical bills electronically. 

The proposed payment companion guide is in conjunction with the Health Insurance Portability and Accountability Act (HIPPA), accredited standards committee (ASC X12N 837) and the National Council for Prescription Drug Programs (NCPD) National Standard Implementation Guides.  Texas requires electronic billing as of January 1, 2008.  Although some waivers were previously granted, the author does not expect many waivers to be granted in the future. 

Providers submit their bills directly or through their billing agent using the ASC X12N 837 professional, institutional, or dental transaction data format.  Carriers use the 835 acknowledgment to report explanation of payments, reductions, and denials to the provider.  The Division chose not to regulate the health care provider, agents, clearinghouses or software solutions.  Therefore, there continues to be a connectivity issue between many providers (and their agents) and the insurance carriers (and their agents).  Of course, providers and insurance carriers are responsible for the errors and omissions of their agents. 

The proposed 2.01 version modified paper form instructions to align with national instructions, reformatted the eBill companion guides to highlight workers’ compensation applications, remove redundant information which can be found the in the ASC X12 Implementation Guides, and added K3 segment in the 837P transaction and minor clerical corrections.  Medical bills will identify insurance carriers and their agents through the use of the FEIN or other mutually agreeable identification number.  Centers for Medicare and Medicaid Services administers a national provider identification number (NPI) that is unique to each provider.  Unfortunately, there is no similar unique carrier identifier information.  To date, the clearinghouses have yet to agree on a standard unique numbering system for every payor even though there are less carriers than providers.  Not every clearinghouse has a relationship with every carrier and two clearinghouses can have different or unique numbers for each carrier. 

The most important document carriers should review is the Texas Clean Claim and Electronic Medical Billing and Payment Companion Guides dated August 12, 2008 which contains the table specifically listing the issue and the change implemented for that issue.  Many of the changes concern reconsideration and/or appeals.  New updated information is provided and carriers are to review those changes.

The second issue involves documentation.  Division rules allow health care providers to submit documentation supporting the medical bill by facsimile, email, or electronic means using the prescribed format or a mutually agreed upon format.  Providers can use ANSI 275 format.  However, providers and some of their software solutions and agents do not have updated systems that allow electronic documentation submission.  The medical provider must send the bills within seven days of submitting the electronic medical bill.  However, they can submit the medical bill to any entity or agent and the Division presumes the carrier’s receipt.  Therefore, the Division is placing the burden upon carriers to find the medical bill submitted by various means and link it to the electronic bill for consideration of payment.  Other states will require health care providers to submit the medical bill using the 275 or other prescribed format. 

The PWK segment will include a report type code, report transmission code, attachment control qualifier and the unique attachment control number.  The Division believes the combination of these data elements is sufficient to allow a carrier to appropriately match the attachment with the electronic medical bill. 

The Division has created additional claim adjustment reason codes unique to Texas claims.  Please see the following table: