The following words and terms when used in this subchapter shall have the following meanings:

1. (1) Audit--A procedure authorized and described in §21.2809 of this title (relating to Audit Procedures) under which an HMO or preferred provider carrier may investigate a claim beyond the statutory claims payment period without incurring penalties under §21.2815 of this title (relating to Failure to Meet the Statutory Claims Payment Period).
2. (2) Billed charges--The charges for medical care or health care services included on a claim submitted by a physician or provider. For purposes of this subchapter, billed charges must comply with all other applicable requirements of law, including Texas Health and Safety Code §311.0025, Texas Occupations Code §105.002, and Texas Insurance Code Art. 21.79F.
3. (3) CMS--The Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services.
4. (4) Catastrophic Event--An event, including acts of God, civil or military authority, acts of public enemy, war, accidents, fires, explosions, earthquake, windstorm, flood or organized labor stoppages, that cannot reasonably be controlled or avoided and that causes an interruption in the claims submission or processing activities of an entity for more than two consecutive business days.

5. (5) Clean claim--

   1. (A) For non-electronic claims, a claim submitted by a physician or provider for medical care or health care services rendered to an enrollee under a health care plan or to an insured under a health insurance policy that includes:

      1. (i) the required data elements set forth in §21.2803(b) or (c) of this title (relating to Elements of a Clean Claim); and
      2. (ii) if applicable, the amount paid by the primary plan or other valid coverage pursuant to §21.2803(d) of this title (relating to Elements of a Clean Claim);
   2. (B) For electronic claims, a claim submitted by a physician or provider for medical care or health care services rendered to an enrollee under a health care plan or to an insured under a health insurance policy using the ASC X12N 837 format and in compliance with all applicable federal laws related to electronic health care claims, including applicable implementation guides, companion guides and trading partner agreements.
6. (6) Condition code--The code utilized by CMS to identify conditions that may affect processing of the claim.
7. (7) Contracted rate--Fee or reimbursement amount for a preferred provider's services, treatments, or supplies as established by agreement between the preferred provider and the HMO or preferred provider carrier.
8. (8) Corrected Claim--A claim containing clarifying or additional information necessary to correct a previously submitted claim.
9. (9) Deficient claim--A submitted claim that does not comply with the requirements of §21.2803(b), (c) or (e) of this title.
10. (10) Diagnosis code--Numeric or alphanumeric codes from the International Classification of Diseases (ICD-9-CM), Diagnostic and Statistical Manual (DSM-IV), or their successors, valid at the time of service.
11. (11) Duplicate Claim--Any claim submitted by a physician or provider for the same health care service provided to a particular individual on a particular date of service that was included in a previously submitted claim. The term does not include corrected claims, or claims submitted by a physician or provider at the request of the HMO or preferred provider carrier.
12. (12) HMO--A health maintenance organization as defined by Insurance Code §843.002(14).
13. (13) HMO delivery network--As defined by Insurance Code §843.002(15).
14. (14) Institutional provider--An institution providing health care services, including but not limited to hospitals, other licensed inpatient centers, ambulatory surgical centers, skilled nursing centers and residential treatment centers.
15. (15) Occurrence span code--The code utilized by CMS to define a specific event relating to the billing period.
16. (16) Patient control number--A unique alphanumeric identifier assigned by the institutional provider to facilitate retrieval of individual financial records and posting of payment.
17. (17) Patient-status-at-discharge code--The code utilized by CMS to indicate the patient's status at time of discharge or billing.
18. (18) Physician--Anyone licensed to practice medicine in this state.
19. (19) Place of service code--The codes utilized by CMS that identify the place at which the service was rendered.

20. (20) Preferred provider--

    1. (A) with regard to a preferred provider carrier, a preferred provider as defined by Insurance Code Article 3.70-3C, §1(10) (Preferred Provider Benefit Plans) or Article 3.70-3C, §1(1) (Use of Advanced Practice Nurses and Physician Assistants by Preferred Provider Plans).

    2. (B) with regard to an HMO,

       1. (i) a physician, as defined by Insurance Code §843.002(22), who is a member of that HMO's delivery network; or
       2. (ii) a provider, as defined by Insurance Code §843.002(24), who is a member of that HMO's delivery network.
21. (21) Preferred provider carrier--An insurer that issues a preferred provider benefit plan as provided by Insurance Code Article 3.70-3C, Section 2 (Preferred Provider Benefit Plans).
22. (22) Primary plan--As defined in §3.3506 of this title (relating to Use of the Terms "Plan," "Primary Plan," "Secondary Plan," and "This Plan" in Policies, Certificates and Contracts).
23. (23) Procedure code--Any alphanumeric code representing a service or treatment that is part of a medical code set that is adopted by CMS as required by federal statute and valid at the time of service. In the absence of an existing federal code, and for non-electronic claims only, this definition may also include local codes developed specifically by Medicaid, Medicare, an HMO, or a preferred provider carrier to describe a specific service or procedure.
24. (24) Provider--any practitioner, institutional provider, or other person or organization that furnishes health care services and that is licensed or otherwise authorized to practice in this state, other than a physician.
25. (25) Revenue code--The code assigned by CMS to each cost center for which a separate charge is billed.
26. (26) Secondary plan--As defined in §3.3506 of this title.
27. (27) Source of admission code--The code utilized by CMS to indicate the source of an inpatient admission.

28. (28) Statutory claims payment period--

    1. (A) the 45-calendar-day period in which an HMO or preferred provider carrier shall make claim payment or denial, in whole or in part, after receipt of a non-electronic clean claim pursuant to Insurance Code Article 3.70-3C, §3A (Preferred Provider Benefit Plans) and Chapter 843;
    2. (B) the 30-calendar-day period in which an HMO or preferred provider carrier shall make claim payment or denial, in whole or in part, after receipt of an electronically submitted clean claim pursuant to Insurance Code Article 3.70-3C, §3A (Preferred Provider Benefit Plans) and Chapter 843; or
    3. (C) the 21-calendar-day period in which an HMO or preferred provider carrier shall make claim payment after affirmative adjudication of an electronically submitted clean claim for a prescription benefit pursuant to Insurance Code Article 3.70-3C, §3A(f) (Preferred Provider Benefit Plans) and §843.339, and §21.2814 of this title (relating to Electronic Adjudication of Prescription Benefits).
29. (29) Subscriber--If individual coverage, the individual who is the contract holder and is responsible for payment of premiums to the HMO or preferred provider carrier; or if group coverage, the individual who is the certificate holder and whose employment or other membership status, except for family dependency, is the basis for eligibility for enrollment in a group health benefit plan issued by the HMO or the preferred provider carrier.
30. (30) Type of bill code--The three-digit alphanumeric code utilized by CMS to identify the type of facility, the type of care, and the sequence of the bill in a particular episode of care.

Source Note:The provisions of this §21.2802 adopted to be effective May 23, 2000, 25 TexReg 4543; amended to be effective October 5, 2003, 28 TexReg 8647; amended to be effective February 1, 2004, 29 TexReg 1001.