receipt of medical bills submitted in accordance with
shall evaluate each bill's conformance with the criteria of a complete
electronic medical bill
(a) A payer shall
not reject medical bills that are complete, unless the bill is a duplicate
Upon receipt of an
incomplete medical bill, a payer
or its agent shall either:
1. Complete the bill by adding missing health
care provider identification or demographic information already known to the
payer within 15 business days; or,
2. Reject the incomplete bill, in accordance
with subsection .06(6).
(2) The received date of an electronic
medical bill is the date all of the contents of a complete electronic bill are
successfully received by the claims payer.
may contact the medical
provider to obtain the information necessary to make the bill complete.
Any request by the payer
or its agent for
additional documentation to pay a medical bill shall:
1. Be made by telephone or electronic
transmission unless the information cannot be sent by those media, in which
case the sender shall send the information by mail or personal
2. Be specific to the
bill or the bill's related episode of care;
3. Describe with specificity the clinical and
other information to be included in the response;
4. Be relevant and necessary for the
resolution of the bill;
5. Be for
information that is contained in or is in the process of being incorporated
into the injured employee's medical or billing record maintained by the health
care provider; and
6. Indicate the
specific reason for which the insurance carrier is requesting the
(b) If the
payer or its agent obtains the missing information and completes the bill to
the point that it can be adjudicated for payment, the payer shall document the
name and telephone number of the person who supplied the information.
(c) Health care providers and payers, or
their agents, shall maintain documentation of any pertinent internal or
external communications that are necessary to make the medical bill
shall not reject or deny a medical bill except as provided in subsection (1) of
this section. When rejecting or denying an electronic
medical bill, the payer
shall clearly identify the reason(s) for the bill's rejection or denial by
utilizing the appropriate codes in the standard transactions pursuant to
(5) The rejection of an
incomplete medical bill in accordance with this section fulfills the obligation
of the payer to provide to the health care provider or its agent information
related to the incompleteness of the bill.
Payers shall timely reject incomplete
bills or request additional information needed to reasonably determine the
(a) For bills submitted
electronically, the rejection of the entire bill or the rejection of specific
service lines included in the initial bill shall be sent to the submitter
within two business days of receipt.
(b) If bills are submitted in a batch
transmission, only the specific bills failing edits shall be
(c) If there is a
technical defect within the transmission itself that prevents the bills from
being accessed or processed, the transmission will be rejected with a TA1
and/or a 999 transaction, as appropriate.
(7) If a payer has reason to challenge the
coverage or amount of a specific line item on a bill, but has no reasonable
basis for objections to the remainder of the bill, the uncontested portion
shall be paid timely, as in subsection H below.
(8) Payment of all uncontested portions of a
complete medical bill shall be made to the provider within 30 calendar days of
receipt of the original bill, or receipt of additional information requested by
the payer allowed under the law.
(9) A payer shall not reject or deny a
medical bill except as provided in subsection (1). When rejecting or denying a
medical bill, the payer shall also communicate to the provider the reason(s)
for the medical bill's rejection or denial.
(10) The payer's failure to comply with any
requirements of this rule will result in an administrative violation in
accordance with 0800-02-17, 0800-02-18, 0800-02-19, 0800-02-01, or T.C.A.