1. (a) A medical EDI transmission shall not exceed a file size of 1.5 megabytes. A transaction set shall not contain more than 100 medical EDI records in a claimant hierarchical loop.
2. (b) Insurance carriers shall submit medical EDI transactions using Secure File Transfer Protocol (SFTP). All alphabetic characters used in the SFTP file name must be lower case and the file must be compressed/zipped. Files that do not comply with these requirements or the naming convention may be rejected and placed in appropriate failure folders. Insurance carriers must monitor these folders for file failures and make corrections in accordance with §134.804(e) of this title (relating to Reporting Requirements).

3. (c) SFTP files must comply with the following naming convention:

   1. (1) Two digit alphanumeric state indicator of 'tx';
   2. (2) Nine digit trading partner Federal Employer Identification Number (FEIN);
   3. (3) Nine digit trading partner postal code;
   4. (4) Nine digit insurance carrier FEIN or 'xxxxxxxxx' if the file contains medical EDI transactions from different insurance carriers;
   5. (5) Three digit record type '837';
   6. (6) One character Test/Production indicator ('t' or 'p');
   7. (7) Eight digit date file sent 'CCYYMMDD';
   8. (8) Six digit time file sent 'HHMMSS';
   9. (9) One character standard extension delimiter of '.'; and
   10. (10) Three digit alphanumeric standard file extension of 'zip' or 'txt'.
4. (d) The transaction types accepted by the division include '00' original, '01' cancel, and '05' replacement.

5. (e) Insurance carriers are required to use the following delimiters:

   1. (1) Date Element Separator--'*' asterisk;
   2. (2) Sub-element Separator--':' colon; and
   3. (3) Segment Terminator--'~' tilde.

6. (f) In addition to the requirements adopted under §134.803 of this title (relating to Reporting Standards), state reporting of medical EDI transactions shall comply with the following formatting requirements:

   1. (1) Loop 2400 Service Line Information shall not contain more than one type of service. Only one of the following data segments may be contained in an iteration of this loop: SV1 Professional Service, SV2 Institutional Service, SV3 Dental Service or SV4 Pharmacy Service.
   2. (2) When reporting compound medications, Loop 2400 Service Line Information SV4 Pharmacy Drug Service shall include a separate line for each reimbursable component of the compound medication. The compounding fee must be reported using a default NDC number equal to '99999999999' as a separate service line.

   3. (3) When reporting pharmacy medical EDI records, the following data element definition clarifications apply:

      1. (A) DN501 Total Charge Per Bill is the total amount charged by the pharmacy or pharmacy processing agent;
      2. (B) DN511 Date Insurer Received Bill is the date the insurance carrier received the bill;
      3. (C) DN512 Date Insurer Paid Bill is the date the insurance carrier paid the pharmacy or pharmacy processing agent;
      4. (D) DN638 Rendering Bill Provider Last/Group Name is the name of the dispensing pharmacy;
      5. (E) DN690 Referring Provider Last/Group Name is the last name of the prescribing doctor; and
      6. (F) DN691 Referring Provider First Name is the first name of the prescribing doctor.
7. (g) This section is effective September 1, 2011.

Source Note:The provisions of this §134.807 adopted to be effective September 1, 2011, 36 TexReg 4136.