1. (a) Reporting Hospitals shall submit event files, electronically in the file format for outpatient hospital bills defined by the American National Standards Institute (ANSI), commonly known as the ANSI ASC X12N form 837 Health Care Claims transaction for institutional claims. ANSI updates this format from time to time by issuing new versions.
2. (b) DSHS will make detailed specifications for these data elements available to submitters and to the public.

3. (c) In addition to the data elements contained in the ANSI 837 Institutional Guide, DSHS has specified the location where each the following data elements in this subsection shall be reported in the ANSI 837 Institutional format Guide. Data element content, format and locations may change as state legislative requirements or federal legislative changes (i.e., HIPAA).

   1. (1) Patient race - This data element shall be reported at Loop 2010BA or 2010CA in the segment DMG05 as a numeric value. Acceptable codes are 1 = American Indian/Eskimo/ Aleut, 2 = Asian or, Pacific Islander, 3 = Black, 4 = White and 5 = Other Race. In order to obtain this data, the hospital staff retrieves the patient's response from a written form or asks the patient, or the person speaking for the patient to classify the patient. If the patient, or person speaking for the patient, declines to answer, the hospital staff is to use its best judgment to make the correct classification based on available data.
   2. (2) Patient ethnicity - This data element shall be reported at Loop 2300 in the segment NTE02 as a numeric value. Acceptable codes are 1 = Hispanic or Latino Origin and 2 = Not of Hispanic or Latino Origin. In order to obtain this data, the hospital staff retrieves the patient's response from a written form or asks the patient, or the person speaking for the patient to classify the patient. If the patient, or person speaking for the patient, declines to answer, the hospital staff is to use its best judgment to make the correct classification based on available data.
   3. (3) Other E-codes - These additional E-codes (maximum of 9 other E-codes, a total of 10 E-codes may be submitted) shall be reported in the following ANSI X12N Form 837 locations: Loop 2300, segments, HI05-2, HI06-2, HI07-2, HI08-2, HI09-2, HI10-2, HI11-2 and HI12-2. (The first E-code is generally reported in Loop 2300 segment HI04-2).

   4. (4) THCIC Identification Number - This data element shall be submitted in data segment REF02 (Secondary Identification Number) of one of the followings Loops where the patient received the event services:

      1. (A) Loop 2010AA associated with the "Billing Provider"; or
      2. (B) Loop 2010AB associated with the "Pay-to provider"; or
      3. (C) Loop 2310E associated with the "Service Facility Provider".

4. (d) Reporting hospitals shall submit the required minimum data set for all patients for which an event claim is required by this subchapter. The required minimum data set includes the following data elements as listed in this subsection:

   1. (1) Patient Name:

      1. (A) Patient Last Name;
      2. (B) Patient First Name; and
      3. (C) Patient Middle Initial.

   2. (2) Patient Address:

      1. (A) Patient Address Line 1;
      2. (B) Patient Address Line 2 (if applicable);
      3. (C) Patient City;
      4. (D) Patient State;
      5. (E) Patient ZIP; and
      6. (F) Patient Country (if address is not in United States of America, or one of its territories).
   3. (3) Patient Birth Date;
   4. (4) Patient Sex;
   5. (5) Patient Race;
   6. (6) Patient Ethnicity;
   7. (7) Patient Social Security Number;
   8. (8) Patient Account Number;
   9. (9) Patient Medical Record Number;
   10. (10) Claim Filing Indicator Code (primary and secondary);
   11. (11) Payer Name - Primary and secondary (if applicable, for both);
   12. (12) National Plan Identifier - for primary and secondary (if applicable) payers (National Health Plan Identification number, if applicable and when assigned by the Federal Government);
   13. (13) Type of Bill;
   14. (14) Statement Dates;

   15. (15) Start of Care:

       1. (A) Start of Care Date; and
       2. (B) Start of Care Hour;
   16. (16) Patient (Discharge) Status;
   17. (17) Patient Discharge Hour;
   18. (18) Principal Diagnosis;
   19. (19) Patient's Reason for Visit;
   20. (20) External Cause of Injury (E-Code) up to 10 occurrences (if applicable);
   21. (21) Other Diagnosis Codes - up to 24 occurrences (all applicable);
   22. (22) Principal Procedure Code (if applicable);
   23. (23) Principal Procedure Date (if applicable);
   24. (24) Other Procedure Codes - up to 24 occurrences (if applicable);
   25. (25) Other Procedure Dates - up to 24 occurrences (if applicable);
   26. (26) Occurrence Code - up to 24 occurrences (if applicable);
   27. (27) Occurrence Code Associated Date - up to 24 occurrences (if applicable);
   28. (28) Value Code - up to 24 occurrences (if applicable);
   29. (29) Value Code Associated Amount - up to 24 occurrences (if applicable);
   30. (30) Condition Code - up to 24 occurrences (if applicable);

   31. (31) Attending Physician or Attending Practitioner Name:

       1. (A) Attending Practitioner Last Name;
       2. (B) Attending Practitioner First Name; and
       3. (C) Attending Practitioner Middle Initial.
   32. (32) Attending Practitioner Primary Identifier (National Provider Identifier, when HIPAA rule is implemented);
   33. (33) Attending Practitioner Secondary Identifier (Texas state license number or UPIN);

   34. (34) Operating Physician or Other Practitioner Name (if applicable):

       1. (A) Operating Physician or Other Practitioner Last Name;
       2. (B) Operating Physician or Other Practitioner First Name; and
       3. (C) Operating Physician or Other Practitioner Middle Initial.
   35. (35) Operating Physician or Other Practitioner Primary Identifier (National Provider Identifier, when HIPAA rule is implemented);
   36. (36) Operating Physician or Other Practitioner Secondary Identifier (Texas state license number or UPIN);
   37. (37) Total Claim Charges;

   38. (38) Revenue Service Line Details (up to 999 service lines) (all applicable);

       1. (A) Revenue Code;
       2. (B) Procedure Code;
       3. (C) HCPCS/HIPPS Procedure Modifier 1;
       4. (D) HCPCS/HIPPS Procedure Modifier 2;
       5. (E) HCPCS/HIPPS Procedure Modifier 3;
       6. (F) HCPCS/HIPPS Procedure Modifier 4;
       7. (G) Charge Amount;
       8. (H) Unit Code;
       9. (I) Unit Quantity;
       10. (J) Unit Rate; and
       11. (K) Non-covered Charge Amount.
   39. (39) Service Provider Name;
   40. (40) Service Provider Primary Identifier - Provider Federal Tax ID (EIN) or National Provider Identifier (when HIPAA rule is implemented);

   41. (41) Service Provider Address:

       1. (A) Service Provider Address Line 1;
       2. (B) Service Provider Address Line 2 (if applicable);
       3. (C) Service Provider City;
       4. (D) Service Provider State; and
       5. (E) Service Provider ZIP; and
   42. (42) Service Provider Secondary Identifier - THCIC 6-digit Hospital ID assigned to each facility.

Source Note:The provisions of this §421.67 adopted to be effective August 29, 2004, 29 TexReg 8123; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842.