1. (a) Applicability.

   1. (1) Electronic medical bill processing is the exclusive process to exchange medical bill data in accordance with §133.500 of this chapter (relating to Electronic Formats for Electronic Medical Bill Processing) for professional, institutional/hospital, pharmacy, and dental services.
   2. (2) Insurance carriers must be able to exchange electronic data by January 1, 2008 unless the insurance carrier is excepted from the process in accordance with paragraph (6) of this subsection.
   3. (3) Health care providers must be able to exchange electronic data by January 1, 2008 unless the health care provider is excepted from the process in accordance with paragraph (5) of this subsection.

   4. (4) Health care providers and insurance carriers may contract with other entities for electronic medical bill processing. Insurance carriers and health care providers are responsible for the acts or omissions of its agents executed in the performance of services for the insurance carrier or health care provider.

      1. (A) Health care provider agent is a person or entity that the health care provider contracts with or utilizes for the purpose of fulfilling the health care provider's obligations for electronic medical bill processing under the Texas Labor Code or Division rules.
      2. (B) Insurance carrier agent is a person or entity that the insurance carrier contracts with or utilizes for the purpose of providing claims service or fulfilling the insurance carrier's obligations for electronic medical bill processing under the Texas Labor Code or Division rules.

   5. (5) A health care provider is waived from the requirement to submit medical bills electronically to an insurance carrier if:

      1. (A) the health care provider employs 10 or fewer full time employees, and workers' compensation constitutes less than 10% of their practice; or
      2. (B) the health care provider requests and the Division approves a waiver. The Division will approve a request on a case-by-case basis and will base the decision on whether or not electronic billing causes an unreasonable financial burden on the health care provider.
   6. (6) An insurance carrier is waived from the requirement to receive medical bills electronically from health care providers on approval from the Division. The Division may grant an exception on a case-by-case basis if an insurance carrier establishes that electronic billing will result in an unreasonable financial burden.

2. (b) Electronic medical bill.

   1. (1) An electronic medical bill is a medical bill submitted electronically by a health care provider or an agent of the health care provider.

   2. (2) A complete electronic medical bill is an electronic medical bill that:

      1. (A) is submitted in accordance with this chapter, and

      2. (B) identifies the:

         1. (i) injured employee;
         2. (ii) employer;
         3. (iii) insurance carrier;
         4. (iv) health care provider; and
         5. (v) service, supply, or medication.
   3. (3) The received date of an electronic medical bill is the date the bill is electronically transmitted in accordance with §102.4(p) of this title (relating to General Rules for Non-Division Communication). An electronic medical bill is considered received if it meets the criteria of a complete electronic medical bill.

3. (c) Acknowledgment.

   1. (1) A Functional Acknowledgment is an electronic notification to the sender of an electronic file that the file has been received and:

      1. (A) accepted as a complete, correct file, or
      2. (B) rejected with a valid rejection code.

   2. (2) A Detail Acknowledgment is an electronic notification to the sender of an electronic transaction within an electronic file that the transaction has been received and:

      1. (A) accepted as a complete, correct submission, or
      2. (B) rejected with a valid rejection code.

   3. (3) An insurance carrier must acknowledge receipt of an electronic medical bill by returning a Detail Acknowledgment within one business day of receipt of the electronic submission.

      1. (A) Notification of a rejection is transmitted in a Detail Acknowledgment when an electronic medical bill does not meet the definition of a complete electronic medical bill or does not meet the edits defined in the applicable implementation guide or guides.
      2. (B) A health care provider may not submit a duplicate electronic medical bill earlier than 45 days from the date submitted if an insurance carrier has acknowledged acceptance of the original complete electronic medical bill. A health care provider may submit a corrected medical bill electronically to the insurance carrier after receiving notification of a rejection. The corrected medical bill is submitted as a new, original bill.

   4. (4) Acceptance of a complete medical bill is not an admission of liability by the insurance carrier. An insurance carrier may subsequently reject an accepted electronic medical bill if it is determined that the employer listed on the medical bill is not a policyholder of the insurance carrier.

      1. (A) The subsequent rejection must occur no later than 7 days from the date of receipt of the complete electronic medical bill.
      2. (B) The rejection transaction must clearly indicate the reason for the rejection is due to denial of liability.

4. (d) Electronic remittance notification.

   1. (1) An electronic remittance notification is an explanation of benefits (EOB), submitted electronically regarding payment or denial of a medical bill, recoupment request, or receipt of a refund.
   2. (2) An insurance carrier must provide an electronic remittance notification no later than 45 days after receipt of a complete electronic medical bill or within 5 days of generating a payment.

5. (e) Electronic documentation.

   1. (1) Electronic documentation consists of medical reports and/or records submitted electronically that are related to an electronic medical bill.

   2. (2) Complete electronic documentation related to an electronic medical bill:

      1. (A) is submitted by fax, electronic mail, or in an electronic format and

      2. (B) identifies the:

         1. (i) injured employee,
         2. (ii) insurance carrier,
         3. (iii) health care provider;
         4. (iv) related medical bill(s), and
         5. (v) date(s) of service.
   3. (3) When a health care provider submits electronic documentation related to an electronic medical bill, the documentation must be submitted within 7 days of submission of the electronic medical bill.

Source Note:The provisions of this §133.501 adopted to be effective August 10, 2006, 31 TexReg 6230.