1. (a) The Division prescribes standard electronic formats by adopting the following implementation guides for the medical billing transactions:

   1. (1) Billing:

      1. (A) Professional Billing--ANSI x12 837(P) Version 4010.
      2. (B) Institutional/Hospital Billing--ANSI x12 837(I) Version 4010.
      3. (C) Dental Billing--ANSI x12 837(D) Version 4010.
      4. (D) Pharmacy Billing--NCPDP Telecommunications Standard Version 5.1.

   2. (2) Acknowledgment:

      1. (A) Functional Acknowledgment--ANSI x12 997 Version 4010.
      2. (B) Detail Acknowledgment--ANSI x12 824 Version 4010.
   3. (3) Remittance--ANSI x12 835 Version 4010.
   4. (4) Reporting--IAIABC 837 Version 4010.
   5. (5) Documentation--ANSI x12 275 Version 4050.

2. (b) An implementation guide is a:

   1. (1) specification document for national standard electronic formats as defined in subsection (a) of this section and published by a national standard setting organization that defines data requirements, data transaction sets, and data mapping; or
   2. (2) published specification document that defines specific data requirements, data set transactions, data mapping, or data edits and is intended to accompany national standard implementation guides.

3. (c) Medical billing transactions must:

   1. (1) contain all fields required in the applicable format implementation guide as set forth in subsection (a) of this section and associated Division implementation guides; and
   2. (2) be populated with current and correct values defined in the applicable implementation guide as set forth in subsection (a) of this section and associated Division implementation guides.
4. (d) Insurance carriers and health care providers may exchange electronic data in a non-prescribed format by mutual agreement. All data elements required in the Division prescribed formats must be present in a mutually agreed upon format.

Source Note:The provisions of this §133.500 adopted to be effective August 10, 2006, 31 TexReg 6230.