28 Tex. Admin. Code § 21.2802 - Definitions
The following words and terms when used in this subchapter have the following meanings unless the context clearly indicates otherwise:
(1) Audit--A procedure
authorized by and described in §
21.2809 of this title (relating to
Audit Procedures) under which a managed care carrier (MCC) may investigate a
claim beyond the statutory claims payment period without incurring penalties
under §
21.2815 of this title (relating to
Failure to Meet the Statutory Claims Payment Period).
(2) Batch submission--A group of electronic
claims submitted for processing at the same time within a HIPAA standard ASC
X12N 837 Transaction Set and identified by a batch control number.
(3) Billed charges--The charges for medical
care or health care services included on a claim submitted by a physician or a
provider. For purposes of this subchapter, billed charges must comply with all
other applicable requirements of law, including Health and Safety Code §
311.0025,
Occupations Code §
105.002, and
Insurance Code Chapter 552.
(4)
CMS--The Centers for Medicare and Medicaid Services of the U.S. Department of
Health and Human Services.
(5)
Catastrophic event--An event, including an act of God, civil or military
authority, or public enemy; war, accident, fire, explosion, earthquake,
windstorm, flood, or organized labor stoppage, that cannot reasonably be
controlled or avoided and that causes an interruption in the claims submission
or processing activities of an entity for more than two consecutive business
days.
(6) Clean claim--
(A) For nonelectronic claims, a claim
submitted by a physician or a provider for medical care or health care services
rendered to an enrollee under a health care plan or to an insured under a
health insurance policy that includes:
(i)
the required data elements set out in §
21.2803(b) or (c)
of this title (relating to Elements of a Clean Claim); and
(ii) if applicable, the amount paid by the
primary plan or other valid coverage under §
21.2803(d) of
this title;
(B) For
electronic claims, a claim submitted by a physician or a provider for medical
care or health care services rendered to an enrollee under a health care plan
or to an insured under a health insurance policy using the ASC X12N 837 format
and in compliance with all applicable federal laws related to electronic health
care claims, including applicable implementation guides, companion guides, and
trading partner agreements.
(7) Condition code--The code utilized by CMS
to identify conditions that may affect processing of the claim.
(8) Contracted rate--Fee or reimbursement
amount for a preferred provider's services, treatments, or supplies as
established by agreement between the preferred provider and the MCC.
(9) Corrected claim--A claim containing
clarifying or additional information necessary to correct a previously
submitted claim.
(10) Deficient
claim--A submitted claim that does not comply with the requirements of §
21.2803(b), (c), or
(e) of this title.
(11) Diagnosis code--Numeric or alphanumeric
codes from the International Classification of Diseases (ICD-9-CM), Diagnostic
and Statistical Manual (DSM-IV), or their successors, valid at the time of
service.
(12) Duplicate claim--Any
claim submitted by a physician or a provider for the same health care service
provided to a particular individual on a particular date of service that was
included in a previously submitted claim. The term does not include:
(A) corrected claims; or
(B) claims submitted by a physician or a
provider at the request of the MCC.
(13) Exclusive provider carrier--An insurer
that issues an exclusive provider benefit plan as provided by Insurance Code
Chapter 1301.
(14) HMO--A health
maintenance organization as defined by Insurance Code §
843.002(14).
(15) HMO delivery network--As defined by
Insurance Code §
843.002(15).
(16) Institutional provider--An institution
providing health care services, including, but not limited to, hospitals, other
licensed inpatient centers, ambulatory surgical centers, skilled nursing
centers, and residential treatment centers.
(17) MCC or managed care carrier--An HMO, a
preferred provider carrier, or an exclusive provider carrier.
(18) NPI number--The National Provider
Identifier standard unique health identifier number for health care providers
assigned under 45 Code of Federal Regulations Part 162 Subpart D or a successor
rule.
(19) Occurrence span
code--The code used by the Centers for Medicare and Medicaid Services (CMS) to
define a specific event relating to the billing period.
(20) Patient control number--A unique
alphanumeric identifier assigned by the institutional provider to facilitate
retrieval of individual financial records and posting of payment.
(21) Patient financial responsibility--Any
portion of the contracted rate for which the patient is responsible under the
terms of the patient's health benefit plan.
(22) Patient discharge status code --The code
used by CMS to indicate the patient's status at the time of discharge or
billing.
(23) Physician--Anyone
licensed to practice medicine in this state.
(24) Place of service code--The code used by
CMS that identifies the place where the service was rendered.
(25) Point of Origin for Admission or Visit
code--The code used by CMS to indicate the source of an inpatient
admission.
(26) Preferred
provider--
(A) with regard to a preferred
provider carrier or an exclusive provider carrier, a preferred provider as
defined by Insurance Code §
1301.001;
and
(B) with regard to an HMO:
(i) a physician, as defined by Insurance Code
§
843.002, who is a
member of that HMO's delivery network; or
(ii) a provider, as defined by Insurance Code
§
843.002, who is a
member of that HMO's delivery network.
(27) Preferred provider carrier--An insurer
that issues a preferred provider benefit plan as provided by Insurance Code
Chapter 1301.
(28) Primary plan--As
defined in §
3.3506 of this title (relating to
Use of the Terms "Plan," "Primary Plan," "Secondary Plan," and "This Plan" in
Policies, Certificates, and Contracts), or in a successor rule adopted by the
commissioner.
(29) Procedure
code--Any alphanumeric code representing a service or treatment that is part of
a medical code set that is adopted by CMS as required by federal statute and
valid at the time of service. In the absence of an existing federal code, and
for nonelectronic claims only, this definition may also include local codes
developed specifically by Medicaid, Medicare, or an MCC to describe a specific
service or procedure.
(30)
Provider--Any practitioner, institutional provider, or other person or
organization that furnishes health care services and that is licensed or
otherwise authorized to practice in this state, other than a
physician.
(31) Revenue code--The
code assigned by CMS to each cost center for which a separate charge is
billed.
(32) Secondary plan--As
defined in §
3.3506 of this title, or in a
successor rule adopted by the commissioner.
(33) Statutory claims payment period--
(A) the 45 calendar days during which an MCC
must pay or deny a claim, in whole or in part, after receipt of a nonelectronic
clean claim under Insurance Code Chapters 843 and 1301, and any extended period
permitted under §
21.2804 of this title (relating to
Requests for Additional Information from Treating Provider) or §
21.2819 of this title (relating to
Catastrophic Event);
(B) the 30
calendar days during which an MCC must pay or deny a claim, in whole or in
part, after receipt of an electronically submitted clean claim under Insurance
Code Chapters 843 and 1301, and any extended period permitted under §
21.2804 or §
21.2819 of this title;
(C) the 21 calendar days during which an MCC
must pay a claim after affirmative adjudication of a claim for a prescription
benefit that is not electronically submitted under Insurance Code Chapters 843
and 1301 and §
21.2814 of this title (relating to
Adjudication of Prescription Benefits), and any extended period permitted under
§ 21.2804 or § 21.2819; or
(D) the
18 calendar days during which an MCC must make a claim payment after
affirmative adjudication of an electronically submitted claim for a
prescription benefit under Insurance Code Chapters 843 and 1301 and §
21.2814 of this title, and any
extended period permitted under §
21.2804 or §
21.2819 of this title.
(34) Subscriber--If individual
coverage, the individual who is the contract holder and is responsible for
payment of premiums to the MCC; or if group coverage, the individual who is the
certificate holder and whose employment or other membership status, except for
family dependency, is the basis for eligibility for enrollment in a group
health benefit plan issued by the MCC.
(35) Type of bill code--The three-digit
alphanumeric code used by CMS to identify the type of facility, the type of
care, and the sequence of the bill in a particular episode of care.
Notes
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