1. (a) Facilities shall submit event files, electronically in the file format for outpatient 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 or ANSI ASC X12N form 837 Health Care Claims transaction for professional claims. ANSI updates these formats from time to time by issuing new versions and the United States Department of Health and Human Services adopts regulations regarding HIPAA that update the version allowed for claim submissions.
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 and the ANSI 837 Professional Guide, DSHS has specified the location where each of the following data elements in this subsection shall be reported in the ANSI 837 Institutional Guide format and the ANSI 837 Professional Guide format. Data element content, format and locations may change as state legislative requirements, or federal legislative or regulation requirements change (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 facility 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 facility 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 facility 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 facility 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 (if applicable) in the following ANSI 837 Institutional Guide 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). E-codes may be submitted in the ANSI 837 Professional Guide in the following locations Loop 2300, data fields: HI02-2, HI03-2, HI04-2, HI05-2, HI06-2, HI07-2 or HI08-2 if applicable preceded by "BN" qualifying code in the respective data field HI02-1, HI03-1, HI04-1, HI05-1, HI06-1, HI07-1 or HI08-1.

   4. (4) THCIC Identification Number - This data element shall be submitted in data segment REF02 (Secondary Identification Number) of one of the following 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 (ANSI 837 Institutional Guide) or Loop 2310D (ANSI 837 Professional Guide) associated with the "Service Facility Provider".

4. (d) Facilities shall submit the required minimum data set in the following modified ANSI 837 Institutional Guide format for all patients that are uninsured or considered self-pay or covered by third party payers in which the payer requires the claim be submitted in an ANSI 837 Institutional Guide format or CMS-1450 format for which an event claim is required by this subchapter. The required minimum data set for the modified (as specified in subsection (c) of this section) ANSI 837 Institutional Guide format 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 (Facility Type Code plus Claim Frequency Code);
   14. (14) Statement Dates;
   15. (15) Principal Diagnosis;
   16. (16) Patient's Reason for Visit;
   17. (17) External Cause of Injury (E-Code) up to 10 occurrences (if applicable);
   18. (18) Other Diagnosis Codes - up to 24 occurrences (all applicable);
   19. (19) Occurrence Code - up to 24 occurrences (if applicable);
   20. (20) Occurrence Code Associated Date - up to 24 occurrences (if applicable);
   21. (21) Value Code - up to 24 occurrences (if applicable);
   22. (22) Value Code Associated Amount - up to 24 occurrences (if applicable);
   23. (23) Condition Code - up to 24 occurrences (if applicable);
   24. (24) Related Cause Code - up to 3 occurrences (if applicable);

   25. (25) Other Provider or Other Health Professional Name (if applicable):

       1. (A) Other Provider or Other Health Professional Last Name;
       2. (B) Other Provider or Other Health Professional First Name; and
       3. (C) Other Provider or Other Health Professional Middle Initial.
   26. (26) Other Provider or Other Health Professional Primary Identifier (National Provider Identifier) (if applicable);
   27. (27) Other Provider or Other Health Professional Secondary Identifier (Texas state license number) (if applicable);

   28. (28) Operating Physician or Other Health Professional Name (if applicable):

       1. (A) Operating Physician or Other Health Professional Last Name;
       2. (B) Operating Physician or Other Health Professional First Name; and
       3. (C) Operating Physician or Other Health Professional Middle Initial.
   29. (29) Operating Physician or Other Health Professional Primary Identifier (National Provider Identifier) (if applicable);
   30. (30) Operating Physician or Other Health Professional Secondary Identifier (Texas state license number) (if applicable);
   31. (31) Total Claim Charges;

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

       1. (A) Revenue Code;
       2. (B) Procedure Code;
       3. (C) HCPCS Procedure Modifier 1 (applicable to each submitted Procedure code);
       4. (D) HCPCS Procedure Modifier 2 (applicable to each submitted Procedure code);
       5. (E) HCPCS Procedure Modifier 3 (applicable to each submitted Procedure code);
       6. (F) HCPCS Procedure Modifier 4 (applicable to each submitted Procedure code);
       7. (G) Charge Amount;
       8. (H) Unit Code;
       9. (I) Unit Quantity;
       10. (J) Unit Rate; and
       11. (K) Non-covered Charge Amount.
   33. (33) Service Provider Name;
   34. (34) Service Provider Primary Identifier - Provider Federal Tax ID (EIN) or National Provider Identifier;

   35. (35) 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
   36. (36) Service Provider Secondary Identifier - THCIC 6-digit facility ID assigned to each facility.

5. (e) Facilities shall submit the following required minimum data set in the following modified ANSI 837 Professional Guide format for all patients for which an event claim is required by a third party payer to be in the ANSI 837 Professional Guide format or CMS-1500 format and required to be submitted under this subchapter. At a facility's option, a facility may choose to submit the required data set listed in subsection (d) of this section. The required minimum data set for the modified (as specified in subsection (c) of this section) ANSI 837 Professional Guide format 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 (if applicable);
   10. (10) Claim Filing Indicator Code (Payer Source - primary and secondary (if applicable for secondary payer source);
   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 (Facility Type Code plus Claim Frequency Code);
   14. (14) Service Date;
   15. (15) Principal Diagnosis;
   16. (16) Other Diagnosis Codes - up to 7 occurrences (all applicable);
   17. (17) Related Cause Code - up to 3 occurrences (if applicable);

   18. (18) Procedure Codes - up to 50 occurrences (all applicable):

       1. (A) HCPCS Procedure Modifier 1 (applicable to each submitted Procedure code);
       2. (B) HCPCS Procedure Modifier 2 (applicable to each submitted Procedure code);
       3. (C) HCPCS Procedure Modifier 3 (applicable to each submitted Procedure code);
       4. (D) HCPCS Procedure Modifier 4 (applicable to each submitted Procedure code);
       5. (E) Charge Amount;
       6. (F) Unit Code; and
       7. (G) Unit Quantity;

   19. (19) Rendering Provider or Rendering Other Health Professional Name (Up to 2 occurrences):

       1. (A) Rendering Provider or Rendering Other Health Professional Last Name;
       2. (B) Rendering Provider or Rendering Other Health Professional First Name; and
       3. (C) Rendering Provider or Rendering Other Health Professional Middle Initial;
   20. (20) Rendering Provider or Rendering Other Health Professional Primary Identifier (National Provider Identifier) (Up to 2 occurrences);
   21. (21) Rendering Provider or Rendering Other Health Professional Secondary Identifier (Texas state license number) (if primary identifier not available) (Up to 2 occurrences);
   22. (22) Total Claim Charges;
   23. (23) Service Provider Name;
   24. (24) Service Provider Primary Identifier--Provider Federal Tax ID (EIN) or National Provider Identifier;

   25. (25) 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;
   26. (26) Service Provider Secondary Identifier--THCIC 6-digit Hospital ID assigned to each facility.

6. (f) Facilities shall submit the required minimum data set to DSHS for each patient who has one or more of the following revenue codes for services rendered to the patient in the facility.

   1. (1) 0321 Radiology--Diagnostic Angiocardiology;
   2. (2) 0322 Radiology--Diagnostic Arthrography;
   3. (3) 0323 Radiology--Diagnostic Arteriography;
   4. (4) 0329 Radiology--Diagnostic Other Radiology - Diagnostic;
   5. (5) 0330 Radiology--Therapeutic General Classification;
   6. (6) 0333 Radiology--Therapeutic Radiation Therapy;
   7. (7) 0339 Radiology--Therapeutic Other Radiology - Therapeutic;
   8. (8) 0340 Nuclear Medicine General Classification;
   9. (9) 0341 Nuclear Medicine Diagnostic;
   10. (10) 0342 Nuclear Medicine Therapeutic;
   11. (11) 0343 Nuclear Medicine Diagnostic Pharmaceuticals;
   12. (12) 0344 Nuclear Medicine Therapeutic Pharmaceuticals;
   13. (13) 0349 Nuclear Medicine Other Nuclear Medicine;
   14. (14) 0350 Computed Tomography (CT) Scan General Classification;
   15. (15) 0351 Computed Tomography (CT)--Head Scan;
   16. (16) 0352 Computed Tomography (CT)--Body Scan;
   17. (17) 0359 Computed Tomography (CT)--Other;
   18. (18) 0360 Operating Room Services General Classification;
   19. (19) 0361 Operating Room Services Minor Surgery;
   20. (20) 0369 Operating Room Services Other Operating Room Services;
   21. (21) 0400 Other Imaging Services General Classification;
   22. (22) 0401 Other Imaging Services Diagnostic Mammography;
   23. (23) 0403 Other Imaging Services Screening Mammography;
   24. (24) 0404 Other Imaging Services Positron Emission Tomography (PET);
   25. (25) 0409 Other Imaging Services Other Imaging Services;
   26. (26) 0481 Cardiology Cardiac Catheterization Lab;
   27. (27) 0483 Cardiology Echocardiology;
   28. (28) 0489 Cardiology Other Cardiology Services;
   29. (29) 0490 Ambulatory Surgical Care General Classification;
   30. (30) 0499 Ambulatory Surgical Care Other Ambulatory Surgical;
   31. (31) 0500 Outpatient Services General Classification;
   32. (32) 0509 Outpatient Services Other Outpatient;
   33. (33) 0610 Magnetic Resonance Technology General Classification;
   34. (34) 0611 Magnetic Resonance Technology Magnetic Resonance Imaging (MRI)--Brain/Brainstem;
   35. (35) 0612 Magnetic Resonance Technology Magnetic Resonance Imaging (MRI)-- Spinal Cord/Spine;
   36. (36) 0614 Magnetic Resonance Technology Magnetic Resonance Imaging (MRI)-- Other;
   37. (37) 0615 Magnetic Resonance Technology Magnetic Resonance Angiography (MRA)--Head and Neck;
   38. (38) 0616 Magnetic Resonance Technology Magnetic Resonance Angiography (MRA)--Lower Extremities;
   39. (39) 0618 Magnetic Resonance Technology Magnetic Resonance Angiography (MRA)--Other;
   40. (40) 0619 Magnetic Resonance Technology Other Magnetic Resonance Technology;
   41. (41) 0760 Specialty Room--Treatment/Observation Room General Classification;
   42. (42) 0761 Specialty Room--Treatment Room;
   43. (43) 0762 Specialty Room--Observation Room; and
   44. (44) 0769 Specialty Room--Other Specialty Room.
7. (g) This section is effective 90 calendar days after being published in the Texas Register. The department will not implement or enforce this section until July 1, 2009, at the earliest.

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; amended to be effective February 26, 2009, 33 TexReg 9694.