1. (a) Insurance carriers shall submit an '00' original medical EDI record for each action (initial processing, request for reconsideration, or subsequent orders) taken on an individual medical bill. Original medical EDI records shall be reported within 30 days after the date of the action. Each iteration of an '00' original medical EDI record must contain a different unique medical bill identification number. The amount paid on each action related to a medical bill must contain only the amount issued for that event and must not contain a cumulative amount reflecting all events related to an individual medical bill. Original medical EDI records on subsequent payment actions must contain a service adjustment reason code of 'W3' when a payment is made following a request for reconsideration or appeal and the service adjustment amount associated with this code value may be populated with zero.
2. (b) Insurance carriers shall submit an '01' cancel medical EDI record if the '00' original medical EDI record should not have been sent or contained the incorrect insurance carrier identification number. Cancel medical EDI records shall be reported within 30 days after the earliest date the insurance carrier discovered the reporting error. The '01' cancel medical EDI record must contain the same unique bill identification number as the '00' original medical EDI record that was previously submitted and accepted.
3. (c) Insurance carriers shall submit an '05' replacement medical EDI record when correcting data on a previously submitted medical EDI record. Replacement medical EDI records shall be submitted within 30 days after the earliest date the insurance carrier discovered the reporting error. The '05' replacement medical EDI record must contain the same unique bill identification number as the associated '00' original medical EDI record.

4. (d) Insurance carriers are responsible for the timely and accurate submission of medical EDI records. For the purpose of this section, a medical EDI record is considered to have been accurately submitted when the record:

   1. (1) received an Application Acknowledgment Code of accepted;
   2. (2) where applicable, contained the same data as the source medical bill and explanation of benefits; and
   3. (3) to the extent supported by the format, contained all appropriate modifiers, code qualifiers, and data elements necessary to identify health care services, charges and payments.
5. (e) Insurance carriers are responsible for correcting and resubmitting rejected medical EDI records within 30 days of the action that triggered the reporting requirement. The insurance carrier's receipt of a rejection does not modify, extend or otherwise change the date the transaction is required to be reported to the division. The resubmitted medical EDI record must contain the same unique bill identification number as the previously rejected medical EDI record.
6. (f) This section is effective September 1, 2011.

Source Note:The provisions of this §134.804 adopted to be effective September 1, 2011, 36 TexReg 4136.