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Compensation Claim Texas Clean Claim and eBill

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									                                                     Texas Clean Claim and eBill Companion Guide Revisions 08/12/2008
Note: Written feedback about the proposed changes can be emailed to TXComp.Help@tdi.state.tx.us. These proposed changes will be further discussed at a stakeholder
meeting prior to finalization. Please submit your feedback on or before Friday, September 5, 2008.

Type         Chapter      Page Item                                    Issue/Comments                                          Change Implemented

                                                                                                                                The format of the Companion Guides has
                                                                                                                                been modifed to an format which
                                                                                                                                highlights the areas where workers'
                                                                                                                                compensation implementation may be
                                                                                                                                considered different than the HIPAA
                                                                                                                                implementation, but still consistent with
                                                                       Version 2.0 of the Texas eBill Companion Guide           the ASC X12 standards. Where
                                                                       (Companion Guide) contained information which was information and instructions are clear in
                                                                       already contained in the national implementation         the ASC X12N Implementation Guides,
                                                                       guides (redundant information). The size of the          that information has been removed from
                                                                       document and the presentation made it difficult to       the Companion Guide. This approach will
                                                                       use and maintain (prone to typograpical or other         assist system vendors with quick
                                                                       clerical errors). In addition, certain statements in the identification of the workers'
                                                                       Companion Guide have been interpreted as requiring compensation implementation situational
                                                                       different standards than those contained in the          descriptions or distinctions necessary for
Global          All               Companion Guide Format               national implementation guides.                          successful implementation.

                                                                                                                               The proposed revisions excluded
                                                                                                                               information on data attributes that are
                                                                       Stakeholders have informed the TDI-DWC that             already clearly defined in the ASC X12N
                                                                       Version 2.0 of the Companion Guide contained            Implementation Guides. This
             Previous                                                  typographical errors regarding the data length or       presentation difference resolves these
General      837P/I/D             Typographical errors                 codes to be used.                                       types of clerical and typographical errors.

                                                                       Stakeholders have informed the TDI-DWC that             The proposed revisions excluded
                                                                       Version 2.0 of the Companion Guide contained            information which can be interpreted as
                                                                       "mandated" code values which would require              limiting the use of valid codes under the
                                                                       incorrect data to be submitted. For example, specific   ASC X12N Implementation Guides.
                                                                       code values were required for Medicare Assignment       Specific code values were included where
                                                                       Code, Provider Assignment Indicator, and the            those code values are the only ones to be
                                                                       Release of Information Code. These previously           used in the workers' compensation
                                                                       identified specific code values may or may not          implementation (for example, the code
             Previous                                                  represent the health care provider's information on a   'WC' to indicate that it is a workers'
General        P/I/D              "Mandated" Code Values               particular patient or medical bill.                     compensation medical bill).




Information Management Services                                               Page 1 of 28                                                        Proposed Revisions 20071212
Type         Chapter      Page Item                                      Issue/Comments                                           Change Implemented
                                                                                                                                  These Companion Guide tables and
                                                                                                                                  associated information have been
                                                                                                                                  removed. Since there are no known
                                                                                                                                  differences between the ASC X12N
                                                                                                                                  Implementation Guides and the workers'
                                                                                                                                  compensation implementation, system
                                                                                                                                  vendors should use the national
                                                                       Version 2.0 of the Companion Guide repeated the            standards in developing systems. The
                                                                       information contained in the ASC X12N                      text language and chapter on
                                                                       Implementation Guides where there were no                  attachments was retained in the current
                                                                       differences in the workers' compensation                   version since the submission of
                                                                       implementation. In addition, there were are some           attachments is not limited to the ASC
                                                                       statements in Version 2.0 of the Companion Guides          X12N 275 framework and stakeholders
             Previous             Companion Guide Tables for ISA, IEA, that do not conform with the syntactical rules which       have indicated an on-going need for this
General      837P/I/D             GS, GE, TA1, 275, 824, and 997.      serve as the foundation for the national standards.        additional information.

                                                                         Version 2.0 of the Companion Guide stated that the
                                                                         DRG Code is "(r)equired for inpatient admissions."
                                                                         Stakeholders have stated that not all admissions are
                                                                         acute care admissions reimbursable under a DRG
                                                                         framework. Inpatient rehabilitation and psychiatric
                                                                         admissions do not use DRG codes. Stakeholders
                                                                         have also pointed out that reimbursement under
                                                                         Certified Workers' Compensation Health Care
                                                                         Networks may or may not be DRG based, even for           The proposed revisions do not include
                                                                         acute care admissions. In addition, the ASC X12N         any additional instructions or
                                                                         Implementation Guides states that the DRG                "requirements" on the DRG information.
                                                                         information "is required when an inpatient hospital is   Accordingly, the information contained in
                                                                         under a DRG contract with a payer and the contract       the ASC X12N Implementation Guide will
                                                                         requires the provider to identify the DRG to the         guide system vendors and stakeholders
General   Previous 837I           Companion Guide Page 7.9, DRG          payer."                                                  regarding the use of this data segment.
                                                                         Version 2.0 of the Companion Guide contained an
                                                                         optional format that was presented as an ASC X12N
                                                                         837 format. The ASC X12N has not approved a              The "optional" format was removed. This
                                                                         pharmacy 837 transaction as part of their national       format was not adopted under 28 TAC
                                                                         standards. Stakeholders have raised concerns             §133.500. However, system vendors and
                                  Previous "optional" Pharmacy 837       about the need to submit bills in an "unofficial"        stakeholders may use mutually agreed
General     Pharmacy              Format                                 format.                                                  upon formats.




Information Management Services                                                 Page 2 of 28                                                        Proposed Revisions 20071212
Type         Chapter     Page Item                                        Issue/Comments                                         Change Implemented

                                                                          Appendix A contained discriptions and tables related
                                                                          to other electronic transactions sets maintained by
            Previous                                                      ASC X12N. These transactions are not mandated in
General     Appendix              Appendix A                              the workers' compensation implementation.            Appendix A was removed.
                                                                                                                               Links to the national code sets were
                                                                                                                               added into the appropriate section in the
                                                                                                                               new Chapter 3, eliminating the need for
            Previous                                                                                                           this Appendix (removed from current
General     Appendix              Appendix B                              Appendix B contained links to national code sets.    proposed Companion Guide).
                                                                                                                               Appendix C was removed from the
                                                                                                                               proposed version. TDI-DWC appreciates
            Previous                                                      Appendix C contained a glossary of terms, many of feedback on whether or not a glossary is
General     Appendix              Appendix C                              which are incorrect or in need of update.            needed for this document.

                                                                                                                                 Chapter 2 was modified to use the actual
                                                                                                                                 form labels. Workers' compensation
                                                                                                                                 usage information moved to comment
                                                                                                                                 column when applicable. Included
                                                                                                                                 information on the use of condition codes
                                                                                                                                 for resubmitted medical bills. DRG Code
                                                                                                                                 usage was modified and the field locator
                                                                          Use of workers' compensation field descriptions has changed to conform to national
                                                                          caused confusion on completion of forms. In            standards. Modified DWC-66 instructions
                                  Alignment with NUCC and NUBC            addition, NPI implementation and a new NCPDP           to accomodate other "agreed upon forms"
Clerical        2                 Instructions                            form is not clear.                                     and require use of the DAW code.
                                  Description of ASC X12 data structure   Redundant information that is contained in the         Removed language.
                                  standards and HIPAA Gap Analysis        national implementation guides or easily identified in
Clerical        3                                                         the new format of the Companion Guides.
                         3.2      References to versions                  Version 2.0 included a general reference to the ASC Added additional clarifying information
                                                                          X12N Implementation Guides.                            regarding the versions required for the
New             3                                                                                                                workers' compensation implementation.
                         3.3      Table layout                            The previous version contained information on data Table format was revised to remove
                                                                          attributes.                                            information that is readily available in the
New             3                                                                                                                ASC X12N Implementation Guides.
                         3.4      Property and Casualty Claim Number      The ASC X12 has issued an interpretation that the      Modified language to align with national
                                  (workers' compensation claim number     Property and Casualty (P&C) Claim Number is            standards -- the insurance carrier's
                                  assigned by the insurance carrier)      required on all P&C 837 transactions (see HIR 664). workers' compensation claim number is
                                                                          It is noted that the ASC X12N Implementation Guides required.
                                                                          states that the P&C Claim Number is "required on
                                                                          property and casualty claims."
New             3




Information Management Services                                                  Page 3 of 28                                                       Proposed Revisions 20071212
Type         Chapter     Page Item                                      Issue/Comments                                      Change Implemented
                         3.10 Claim Adjustment Reason Codes             The Claim Adjustment Reason Code Committee has      Included a map between the Texas
                                                                        adopted new codes for workers' compensation         "codes" and the approved national codes.
                                                                        implementation.                                     Included instruction for insurance carriers
                                                                                                                            to begin migrating to the use of the
New             3                                                                                                           national codes.
                         3.11 Claim Resubmission Code                   The National Uniform Billing Committee has adopted Added language to help inform system
                                                                        new condition codes to assist in the electronic     vendors and participants on the use of
                                                                        submission of requests for reconsideration and      these new codes in conjunction with the
                                                                        appeals. The National Uniform Claims Committee      Claim Resubmission Code.
                                                                        has approved their use for professional claims. The
                                                                        ASC X12N has approved the use of these codes in
                                                                        the appropriate segments in the 837 transactions.
                                                                        The prior Companion Guides does not include this
                                                                        information.
New             3
                         3.18 Reconsiderations/Appeals                  The National Uniform Billing Committee has adopted Added language to help inform system
                                                                        new condition codes to assist in the electronic     vendors and participants on the use of
                                                                        submission of requests for reconsideration and      these new codes.
                                                                        appeals. The National Uniform Claims Committee
                                                                        has approved their use for professional claims. The
                                                                        ASC X12N has approved the use of these codes in
                                                                        the appropriate segments in the 837 transactions.
                                                                        The prior Companion Guides does not include this
                                                                        information.
New             3
                                  Subscriber Address (2010BA)           The ASC X12N Implementation Guides require the         Deleted the workers' compensation
                                                                        subscriber address only when the patient is the same   specific usage instructions which would
                                                                        person as the subscriber. Version 2.0 of the Texas     make the subscriber address required on
                                                                        eBill Companion Guide required the subscriber's        all ASC X12N 837 transactions.
                                                                        address on all 837 transactions. Given the
                                                                        requirement to include the workers' compensation
                                                                        claim number, this Companion Guide requirement is
New           4, 5, 7                                                   no longer necessary.
                                  Property and Casualty Claim Number    The ASC X12 has issued an interpretation that the      Modified language to align with national
                                  (workers' compensation claim number   Property and Casualty (P&C) Claim Number is            standards -- the insurance carrier's
                                  assigned by the insurance carrier)    required on all P&C 837 transactions (see HIR 664).    workers' compensation claim number is
New           4, 5, 7                                                                                                          required.




Information Management Services                                                Page 4 of 28                                                      Proposed Revisions 20071212
Type         Chapter     Page Item                                       Issue/Comments                                         Change Implemented
                              Date of Accident (2300/DTP)                The ASC X12N Implementation Guides identify this       Deleted the workers' compensation
                                                                         field as situational. Version 2.0 of the Texas eBill   specific usage instructions which would
                                                                         Companion Guide required the date of accident on       make the date of injury required on all
                                                                         all 837 transactions. Given the requirement to         ASC X12N 837 transactions.
                                                                         include the workers' compensation claim number,
                                                                         this Companion Guide requirement is no longer
New           4, 5, 7                                                    necessary.
                         4.2      K3 Segment -- State Data Requirement                                                        Added K3 segment to capture condition
                                                                         Previous instructions did not include the K3 segment codes for duplicates and resubmissions.
                                                                         which made submissions of duplicates and             Required on/after January 1, 2009 for 837
New             4                                                        reconsiderations difficult to identify and process.  transactions.
                                                                                                                              Added language to inform stakeholders
                                                                                                                              about the new condition codes. Required
                                  2300/HI Health Care Condition          New condition codes are available for duplicates and on/after January 1, 2009 for 837
New             5         5.2     Information Codes                      appeals.                                             transactions.
                                                                         The NCPDP 5.1 format enables three different
                                                                         methods for submitting compound drug bills. Version Referenced the different methods and
                                                                         2.0 of the Texas eBill Companion Guide only          referred stakeholder to the rule
New             6         6.1     Compound Medications                   contained one method.                                requirements to ensure compliance.

                                                                         Version 2.0 of the Texas eBill Companion Guide
                                                                         instructued pharmacies to use a default NDC code
                                                                         for billing the compounding fee. In the NCPDP 5.1
                                                                         format, this is incorrect. Compounding fees are
                                                                         considered dispensing fees and separate from the     Revised instructions to align with national
New             6         6.2     Compounding Fee                        drug charges (which use NDC numbers).                standards.
                                                                                                                              Added language to inform stakeholders
                                                                                                                              about the new condition codes. Required
                                                                         New condition codes are available for duplicates and on/after January 1, 2009 for 837
New             7         7.2     2300/NTE Claim Note                    appeals.                                             transactions.
                                                                         Version 2.0 of the Texas eBill Companion Guide
                                                                         indicated that resubmission codes were not
                                                                         mandated in the workers' compensation
                                                                         implementation. 28 Texas Administrative Code
                                                                         (TAC) §133.500 adopted the ASC X12 835 format,
                                                                         which includes the use of remittance remark codes    Removed language to ensure remittance
New             8         8.1     Remittance Remark Codes                when applicable.                                     remark codes are used when applicable.

                                                                         The previous version contained Appendix C for code Code source reference was incorporated
New             8         8.1     Code Source Reference                  source references.                                 into the Remittance Advice Chapter.




Information Management Services                                                 Page 5 of 28                                                      Proposed Revisions 20071212
                                                    Texas Clean Claim and eBill Companion Guide Revisions 01/07/2008
           Note: Page numbers omitted due to restructing of documents

Type       Chapter       Page Item                                         Issue/Comments                                          Change Implemented
                                                                           Stakeholder indicates the use of numerous excel
                                                                           spreadsheets create some confusion on required          The new companion guide is structured in
                                                                           and optional transaction sets. Recommend                a Chapter format with the tables
Clerical   All                    Complexity of document use               incorporating into a single source document.            incorporated into the appropriate chapter.
                                                                           The new structure eliminates the need for a Table of
Clerical   Chapter 1              Table of Contents                        Contents.                                               Table of Contents deleted.
                                                                           Background did not provide statutory requirement for
                                                                           insurance carriers to receive medical bills
                                                                           electronically. Audience omitted name of
Clerical   Chapter 1              Texas History                            Washington Publishing Company.                          Information added.

                                                                           Guide references UCF as the Phamacy Claim Form.
                                                                           The Division is currently engaging in rulemaking
Paper      Chapter 2              General Opening                          activities to retain the DWC-066 for the time being.    Replaced UCF with DWC-066
                                                                                                                                   Modified language to state new form must
                                                                           Addresses NPI and form requirements in future           be used for claims submitted on/after July
Paper      Chapter 2              CMS-1500 first paragraph                 tense.                                                  1, 2007.
                                                                           The NUCC has indicated that not used fields should Change usage to "Optional" or include
                                  Fields 9, 12, 13, and 16, not used (CMS- be considered optional to avoid the rejection of        instructions that claims cannot be rejected
Paper      Chapter 2              1500)                                    otherwise complete claims                               if populated
                                                                           The IAIABC ProPay Subcommittee recommends
                                                                           modifing the requirements on taxonomy codes to
                                                                           align with HIPAA requirements. Other stakeholders
                                                                           pointed out that the current Division guides require    Modified condition to state: Required
                                                                           this every time the rendering provider is a health care when the rendering provider NPI is not
                                                                           provider even when the information can be derived submitted on the paper claim or when
Paper      Chapter 2              Taxonomy Code in 10d (CMS-1500)          from the NPI number.                                    required by CMS policy.
                                                                                                                                   Modify usage to "Situational" with the
Paper      Chapter 2              Claim Number in box 11                   Currently the claim number is optional                  condition "If known."
                                                                                                                                   Modified condition to cover situations
                                                                                                                                   where a provider may not be eligible for
Paper      Chapter 2              NPI instruction in 17b (CMS-1500)        Requires NPI if referring provider populated            an NPI.
Paper      Chapter 2              Field 23 Preauthorization Number         Conditional field without a condition                   Added condition.

                                                                                                                                   Added additional language to condition to
                                                                                                                                   address situations where a non-licensed
Paper      Chapter 2              NPI instruction in 24j (CMS-1500)        Requires NPI for rendering provider                     individual is the rendering provider.




Information Management Services                                                    Page 6 of 28                                                      Proposed Revisions 20071212
Type      Chapter        Page Item                                        Issue/Comments                                        Change Implemented
                                                                          The NUCC has indicated that not used fields should
                                                                          be considered optional to avoid the rejection of
Paper     Chapter 2               Field 26, not used (CMS-1500)           otherwise complete claims                             Changed usage to "Optional"
Paper     Chapter 2               NPI instruction in 32a (CMS-1500)       Requires NPI for providers and facilities             Changed usage to "Optional"
                                                                                                                                Modified usage to "Required" for claims
Paper     Chapter 2               NPI instruction in 33A (CMS-1500)       Requires NPI for providers                            filed on and after May 23, 2008.
                                                                                                                                Modify language to state new form must
                                                                          Addresses NPI and form requirements in future         be used for claims submitted on/after May
Paper     Chapter 2               UB-04 first paragraph                   tense.                                                23, 2007
                                                                          The NUBC has indicated that not used fields should
                                                                          be considered optional to avoid the rejection of
Paper     Chapter 2               Fields 15, 50, 51, 58, and 61, not used otherwise complete claims                             Changed usage to "Optional"
                                                                                                                                Changed usage to "Situational" if the
                                                                                                                                claim submitted on or after May 23, 2008
                                                                                                                                if billing provider is a health care provider
Paper     Chapter 2               NPI instruction in 56 (UB-04)           Requires NPI                                          eligible for a NPI.
Paper     Chapter 2               Field 63 Preauthorization Number        Conditional field without a condition                 Added condition.
                                                                                                                                Changed usage to "Situational" with
                                                                                                                                condition that ties requirement to CMS
Paper     Chapter 2               Field 67 ICD-9                          Current usage state "required" but it is situational. policy.

                                                                           Current required for admissions, observation says      Modify condition to state "Required for
Paper     Chapter 2               Admitting diagnosis code in 69           and emergency care and not required for outpatient     inpatient admissions"
                                                                           NUBC has stated that field 73 should be used to
Paper     Chapter 2               DRG in 75 (UB-04)                        report the DRG on institutional claims                 Require DRG to be reported in field 73
                                                                           Stakeholder raised questions on differences between
Paper     Chapter 2               Field 74 procedure codes/dates           prior instructions and CMS policy.                     Modified conditions to mirror CMS policy.
                                                                                                                                  Changed usage to "Situational" and
                                                                                                                                  added condition: "Required for claims
                                                                                                                                  submitted on and after May 23, 2008 if
                                                                                                                                  claim includes any services other than
                                  Attending Physician information          Requires attending physician information (won't be     nonscheduled transportation services.
                                  (NPI/Name/State License) in 76 (UB-      applicable for home health or nonscheduled             For home health claims, this will be the
Paper     Chapter 2               04)                                      transportation services)                               NPI of the referring physician."
                                                                                                                                  Changed condition to: "required for
                                                                                                                                  claims submitted on and after May 23,
                                                                                                                                  2008 if a surgical procedure code is listed
                                                                           Requires operating physician NPI when surgical         on the claim (e.g., surgical services
Paper     Chapter 2               NPI instruction in 77                    services provided                                      provided).
Paper     Chapter 2               NPI instruction in 78 (UB-04)            Requires other physician NPI                           Changed usage to "Optional"
Paper     Chapter 2               NPI instruction in 79 (UB-04)            Requires other physician NPI                           Changed usage to "Optional"




Information Management Services                                                   Page 7 of 28                                                      Proposed Revisions 20071212
Type      Chapter        Page Item                                        Issue/Comments                                            Change Implemented
                                                                          The IAIABC ProPay Subcommittee recommends
                                                                          modifing the requirements on taxonomy codes to
                                                                          align with HIPAA requirements. Other stakeholders
                                                                          pointed out that the current Division guides require      Modified condition to state: Required
                                                                          this every time the rendering provider is a health care   when the attending physician NPI is not
                                  Taxonomy Code in 80, 81A, 81b, 81c,     provider even when the information can be derived         submitted on the paper claim or when
Paper     Chapter 2               and 81d (UB-04)                         from the NPI number.                                      required per CMS policy.

                                                                          Stakeholders recommended retaining the use of the         Rulemaking in progress. Replaced UCF
                                                                          DWC-66 form instead of mandating the UCF for              instructions with DWC-066 instructions.
Paper     Chapter 2               NCPDP UCF Implementation                paper claims.                                             NPI implementation also addressed.
                                                                          Current instructions require the use of the NCPDP         Included instructions that the NPI will be
                                                                          number for the pharmacy and the DEA number for            required instead of the NCPDP or DEA
                                  DWC-66 Statement of Pharmacy            the physician. Health industry is currently moving to     number for claims submitted on and after
Paper     Chapter 2               Services: Provider Identification Codes requiring the NPI on and after May 23, 2008.              May 23, 2008.
                                                                          Stakeholder asked for additional information on
Paper     Chapter 2               ADA J515 First Paragraph                billing for professional services by dentists.            Additional info added.
                                                                          Suggestion to modify to optional similar to issue
Paper     Chapter 2               Not used fields (several)               raised by NUBC and NUCC.                                  Changed usage to "Optional"
Paper     Chapter 2               Field 2 Preauthorization                Conditional field without a condition                     Added condition.
                                                                                                                                    Changed condition to state required for
                                                                                                                                    claims submitted on and after May 23,
Paper     Chapter 2               Field 49 and 52 NPI Number              Requires NPI number.                                      2008 provider is eligible for an NPI.
                                                                                                                                    Modified condition to state: Populate
                                                                                                                                    Provider Taxonomy Code if the NPI
Paper     Chapter 2               Field 52A Taxonomy Code                 Currently required on all claims                          number is not provided in Field 49.
                                                                                                                                    Modified condition to state: Populate
                                                                                                                                    Provider Taxonomy Code if required per
Paper     Chapter 2               Field 56A Taxonomy Code                 Currently required on all claims                          CMS policy.
                                                                                                                                    Modified to "Situational" and added a little
Paper     Chapter 2               DWC-062 Field 15C Type of Service       Currently required without any description                description.
                                                                                                                                    Added the following language: or other
                                  Interchange Control (ISA/IEA) FEIN      Stakeholders indicated need for other ETINs based         mutually agreed upon identification
HIPAA     Chapter 4               requirement for ETIN                    on business model.                                        numbers
                                                                                                                                    Added the following language: or other
                                  Functional Group (GS/GE) FEIN           Stakeholders indicated need for other ETINs based         mutually agreed upon identification
HIPAA     Chapter 4               requirement for ETIN                    on business model.                                        numbers




Information Management Services                                                   Page 8 of 28                                                         Proposed Revisions 20071212
Type       Chapter       Page Item                                       Issue/Comments                                           Change Implemented
                                                                         Stakeholders have indicated issues with the
                                                                         statements that transactions containing "not used"
                                                                         data elements can be rejected by insurance carriers.
                                                                         Stakeholder indicated that if a transaction is           Modified the language to ensure that
                                                                         submitted consistent with the ANSI X12                   ANSI X12 compliant transactions are
                                                                         requirements, contain all data necessary to process      processed by insurance carriers if all
                                                                         the claim, the carrier should accept the transaction     other required data elements are
HIPAA      Chapter 5              HIPAA Not Used and W/C Not Used        and process the claim.                                   submitted.
                                                                         Other clarifications modified the HIPAA Gap              Updated the HIPAA Gap Analysis to
HIPAA      Chapter 5              HIPAA/WC Gap Analysis                  Analysis.                                                reflect changes in guides.
                                                                         Stakeholder indicated need to use other identification   Added the following language: or other
                                                                         numbers for paper ID and other purposes.                 mutually agreed upon identification
HIPAA      Chapter 5              Identification Numbers                                                                          numbers
                                                                         The IAIABC ProPay Subcommittee recommends                Modified instructions and components to
                                                                         modifing the instructions in this and other              incorporate IAIABC recommendation
                                                                         components of the guides. The purpose can be
                                                                         served by allowing an "other" code in the transaction
                                                                         and the "JX" codes to be the first two digits of the
                                                                         document ID. Current instructions require the use of
                                  PWK Information and attached           codes that are not contained in ANSI X12 4010.
HIPAA      Chapter 5              documentation
                                                                       Current language recommends using state reporting          Modified language to encourage carriers
                                                                       type edits which are not always applicable to bill         to consider bill processing issues and
Clerical   Chapter 5              Insurance carrier edits.             processing scenarios.                                      removed certain edits.
                                                                       Code set section did not address jurisdictional claim      Added.
Clerical   Chapter 5              Code sets                            adjustment reason codes.
                                                                       Stakeholder noted that this was a "not used" element       Deleted references to CLM19 and
                                                                       in ANSI X12 and HIPAA IG. Existing codes, and new          explained current HIPAA IG use of
                                                                       ones coming in December, are sufficient to convey          CLM05-03 and ICN/DCN number.
HIPAA      Chapter 5              Reconsideration Requests and Appeals information in CLM05.
                                                                       Current guides included language for rejecting claims      Modified language to ensure consistency
                                                                       that may not be considered consistent with Rule            with Rule requirements.
HIPAA      Chapter 5              Reconsideration Requests and Appeals 133.200.
                                                                       Stakeholder recommended adding Provider Type               Added License Type Codes.
                                                                       Prefix reference to Health Care Provider State
Clerical   Chapter 5              State License Number Section         License Number section.
                                                                                                                                  Deleted sentence. Instructions for NPI
                                                                        Language conveys requirement as broadly stated            numbers contained in form instructions for
                                  NPI Number. States required for Texas and stakeholders have inquired on differences             paper claims and in the companion
Clerical   Chapter 5              billing in 2007                       between electronic requirements and paper billing.        guides for electronic submissions.




Information Management Services                                                 Page 9 of 28                                                        Proposed Revisions 20071212
Type       Chapter       Page Item                                   Issue/Comments                                        Change Implemented
                                                                                                                           Included language to allow the provider to
                                                                     Stakeholders raised an issue regarding the need to populate 2300/CLM/CLM11-4 when the
                                                                     identify the jurisdiction of the claim for editing    claim is covered by a non-Texas
HIPAA      Chapter 5              Jurisdictional Identifier          purposes.                                             jurisdiction.
                                                                     The format provided was not presented in an           Included a NCPDP companion guide
                                                                     NCPDP 5.1 style. Information on NCPDP 5.1             following the format required by NCPDP
                                                                     segments and usage was either missing or difficult to 5.1.
NCPDP      Chapter 8              Format Guides                      understand.
                                                                     The Division has indicated that current rulemaking    References to the UCF have been
                                                                     initiatives are in progress to retain the DWC-066     removed.
Paper      Chapter 8              UCF References                     Statement of Pharmacy Services.
                                                                                                                           This language has been modified to
                                                                                                                           service date to ensure consistency with
                                                                                                                           the NCPDP 5.1 data names. In addition,
                                                                                                                           a conditional statement was added to
                                                                                                                           allow for other information to be
                                                                                                                           considered related to the date the
                                                                     The Billing Date section referred to the prescription transaction was submitted to the carrier.
Clerical   Chapter 8              Billing date clarification         date as the bill date.
                                                                     Several places referenced the name of the data        Data element numbers and transaction
                                                                     element, but not the data element number or           segments added.
Clerical   Chapter 8              Data element references            transaction segment.
                                                                     Stakeholders raised issues regarding the use of the Added additional language reflecting
                                                                     835 transaction and the sufficiency information in    Rules 133.500 and 133.501.
Clerical   Chapter 10             Second Paragraph                   Rule 133.240.
                                  Error in Claim Adjustment Reason   Reads “The Division accepts ANSI codes to were . . ” Correct text to read "that were".
Clerical   Chapter 10             Code section text.
                                                                     IAIABC ProPay SubCommittee recommends                    Need to follow-up on this comment
                                  Claim Adjustment Reason Code       removing stated to eliminate anything that imply that
Clerical   Chapter 10             Language                           these codes will change over time.
                                                                     The current version of the companion guides              Modified list and information to align with
                                                                     requires data elements to be populated on                Rule 133.501.
                                                                     attachments that are different than the list contained
Other      Chapter 12             Data element requirements          in Rule 133.501.
                                                                     The IAIABC ProPay Subcommittee recommends                Added appropriate language to this effect.
                                                                     modifing the instructions in this and other
                                                                     components of the guides. The purpose can be
                                                                     served by allowing an "other" code in the transaction
                                                                     and the "JX" codes to be the first two digits of the
                                                                     document ID. Current instructions require the use of
                                                                     codes that are not contained in ANSI X12 4010.
HIPAA      Chapter 12             Documentation requirements




Information Management Services                                            Page 10 of 28                                                         Proposed Revisions 20071212
Type      Chapter        Page Item                                      Issue/Comments                                         Change Implemented
                                                                        Current code value only includes 00 and omits code     Deleted defined code to allow standard
HIPAA     837 Prof                Loop TS BHT BHT02                     18 for reissue due to transmission problem.            codes to be submitted.
                                                                        Current code value only includes 02 and omits code     Added code 01.
                                  Loop 1000A Sender Information NM1     01 for individual health care provider (person).
HIPAA     837 Prof                Submitter Name NM102
                                  Loop 1000A Sender Information NM1     Data element not included in companion guides.         Added NM104
HIPAA     837 Prof                Submitter Name NM104
                                  Loop 1000A Sender Information NM1     Data element not included in companion guides.         Added NM105
HIPAA     837 Prof                Submitter Name NM105
                                  Loop 2000A PRV Billing Provider      IAIABC ProPay SubCommittee recommends                   Modified usage from "J" to "S" as defined
                                  Taxonomy Code                        removing the jurisdictional requirement for taxonomy    in the ANSI X12 guides. Amended
                                                                       codes. The HIPAA IG language adequately covers          required comment to reflect situational
HIPAA     837 Prof                                                     the conditions.                                         requirement.
                                  Loop 2010AA Billing Provider REF     Stakeholder indicates HIPAA conditions are              Modified usage from "J" to "S" as defined
HIPAA     837 Prof                State License                        sufficient and suggests changing the "J" to an "S"      in the ANSI X12 guides.
                                  Loop 2010AB Pay to Provider REF      Stakeholder indicates HIPAA conditions are              Modified usage from "J" to "S" as defined
HIPAA     837 Prof                State License                        sufficient and suggests changing the "J" to an "S"      in the ANSI X12 guides.
                                  Loop 2000B Subscriber Detail SBR     Stakeholder points out that under the HIPAA IG this     Modified usage from "J" to "S" as defined
                                  Subscriber Information Segment       data element is required if there is no group plan      in the ANSI X12 guides.
                                  SBR09 Claim Filing Indicator         number, which makes it required for w/c.
                                                                       Recommend changing to match HIPAA IG ("J" to
HIPAA     837 Prof                                                     "S")
                                  Loop 2010BB Payer Identification REF Stakeholder points out that there may be situations     Added situational data segment.
                                  Secondary Payer Identification       were the secondary Payer ID is needed. For
                                                                       example, if the payer ID in Loop 2010BB NM1
                                                                       segment is a TPA and the insurance carrier
                                                                       identification is needed to process the claim, the
                                                                       secondary ID may be needed.
HIPAA     837 Prof
                                  Loop 2000C Patient Information HL     Stakeholder points out that under the HIPAA IG this    Modified usage from "J" to "S" as defined
                                  Segment                               data element is required if there the patient is       in the ANSI X12 guides.
                                                                        different than the policyholder, which makes it
                                                                        required for w/c. Recommend changing to match
HIPAA     837 Prof                                                      HIPAA IG ("J" to "S")
                                  Loop 2000C Patient Information PAT    Companion Guides did not include situational data      Added situational data element.
HIPAA     837 Prof                Segment PAT05                         elements for date of death.
                                  Loop 2000C Patient Information PAT    Companion Guides did not include situational data      Added situational data element.
HIPAA     837 Prof                Segment PAT06                         elements for date of death.
                                  Loop 2010CA Patient Information NM    HIPAA IG shows this data element as situational, not   Modified HIPAA and wc usage from "R" to
HIPAA     837 Prof                Name NM108                            required as noted in companion guide.                  "S" as defined in ANSI X12 guides.
                                  Loop 2010CA Patient Information NM    HIPAA IG shows this data element as situational, not   Modified HIPAA and wc usage from "R" to
HIPAA     837 Prof                Name NM109                            required as noted in companion guide.                  "S" as defined in ANSI X12 guides.




Information Management Services                                                Page 11 of 28                                                     Proposed Revisions 20071212
Type       Chapter       Page Item                                      Issue/Comments                                         Change Implemented
                              2300 Claim Information CLM Segment        HIPAA IG shows this data element to be used when       Added situational data element.
                              CLM16 Provider Agreement Code             a non-participating provider is submitting a claim.
                                                                        This may be needed for access plans in network
                                                                        settings and should be allowed as situational.
HIPAA      837 Prof
                                  2300 Claim Information CLM Segment    Stakeholder noted that this was a "not used" element HIPAA "not used" data element deleted.
                                  CLM19 Bill Submission Reason Code     in ANSI X12 and HIPAA IG. Existing codes, and new
                                                                        ones coming in December, are sufficient to convey
HIPAA      837 Prof                                                     information in CLM05.
                                  2300 Claim Information CLM Segment    HIPAA IG includes a delay reason code situational    Added CLM20 to companion guides with
                                  CLM20 Delay Reason Code               data element.                                        "S" as defined in the ANSI X12 guides.
Question   837 Prof
                                  2300 Claim Information PWK Segment    IAIABC ProPay recommended change in approach           Modified usage from "J" to "S" as defined
HIPAA      837 Prof               PWC05                                 to align with HIPAA IG ("J" to "S")                    in the ANSI X12 guides.
                                  2300 Claim Information PWK Segment    IAIABC ProPay recommended change in approach           Modified usage from "J" to "S" as defined
HIPAA      837 Prof               PWC06                                 to align with HIPAA IG ("J" to "S")                    in the ANSI X12 guides.
                                  2300 Claim Information CN1 Contract   HIPAA IG shows this data element as situational, not   Modified HIPAA and wc usage from "R" to
HIPAA      837 Prof               Information Segment CN102             required as noted in companion guide.                  "S" as defined in ANSI X12 guides.
                                  2310A Referring Provider NM1          Companion Guides did not include situational data      Added NM107 as "S" as defined in ANSI
HIPAA      837 Prof               Provider Name Segment                 element for suffix.                                    X12 guides.
                                  2310A Referring Provider NM1          HIPAA IG shows this data element as situational, not   Modified HIPAA and wc usage from "R" to
HIPAA      837 Prof               Provider Name Segment NM108           required as noted in companion guide.                  "S" as defined in ANSI X12 guides.
                                  2310A Referring Provider NM1          HIPAA IG shows this data element as situational, not   Modified HIPAA and wc usage from "R" to
HIPAA      837 Prof               Provider Name Segment NM109           required as noted in companion guide.                  "S" as defined in ANSI X12 guides.
                                  Loop 2310A Referring Provider REF     Stakeholder indicates HIPAA conditions are             Modifed usage from "J" to "S" as defined
HIPAA      837 Prof               State License                         sufficient and suggests changing the "J" to an "S"     in the ANSI X12 guides.
                                  Loop 2310B Rendering Provider REF     Stakeholder indicates HIPAA conditions are             Modified usage from "J" to "S" as defined
HIPAA      837 Prof               State License                         sufficient and suggests changing the "J" to an "S"     in the ANSI X12 guides.
                                  Look 2310D NM1 Facility Service       Stakeholder indicates HIPAA conditions are             Modified usage from "R" to "S" as defined
HIPAA      837 Prof               Location Name NM103                   sufficient and suggests changing the "R" to an "S"     in the ANSI X12 guides.
                                  Loop 2310D NM1 Facility Service       Spreadsheet indicates HIPAA usage for this data        Modified HIPAA and wc usage from "R" to
                                  Location Name NM108 Identification    element is Required, HIPAA IG indicates segment is     "S" as defined in ANSI X12 guides.
HIPAA      837 Prof               Code Qualifier                        Situational.
                                  Loop 2310D NM1 Facility Service       Spreadsheet indicates HIPAA usage for this data        Modified HIPAA and wc usage from "R" to
                                  Location Name NM109 Identification    element is Required, HIPAA IG indicates segment is     "S" as defined in ANSI X12 guides.
HIPAA      837 Prof               Code                                  Situational.




Information Management Services                                               Page 12 of 28                                                     Proposed Revisions 20071212
Type      Chapter        Page Item                                       Issue/Comments                                          Change Implemented
                              Loop 2310B Rendering Provider PRV          Spreadsheet indicates HIPAA usage for this data         Deleted comment and modified usage to
                              Provider Specialty Code                    element is Required, but HIPAA IG indicates             situational as defined in the ANSI X12
                                                                         segment is Situational with the condition of when       guides.
                                                                         adjudication requires taxonomy code. Comment in
                                                                         Division guides and w/c usage shows it is Required.
                                                                         Stakeholders recommend changing usage to
HIPAA     837 Prof                                                       Situational and deleting comment.
                                  Loop 2410D Facility/Service Location   HIPAA IG shows segment is situational, but DWC          Modified usage from "J" to "S" consistent
                                  REF State License Number               companion guides show jurisdictionally situational      with the ANSI X12 guides.
HIPAA     837 Prof                                                       without a condition.
                                  Loop 2400 SV1 Professional Service     Companion Guide did not include the emergency           Added situational data element.
                                  SV109 Emergency Indicator              indicator. This indicator is important to prevent
                                                                         unnecessary denials of claims for lack of
HIPAA     837 Prof                                                       preauthorization.
                                  Loop 2400 SV5 Durable Medical          IAIABC ProPay SubCommittee recommends                   Modify usage from "N" to "S" and "R" as
                                  Equipment                              removing the not-used usage in order to align the       defined in the ANSI X12 guides
HIPAA     837 Prof                                                       companion guides with the HIPAA IG
                                  Loop 2400 Service Line Information     Stakeholder indicates that the SV5 segment is the       Modified w/c usage from "N" to "S" and
                                  SV5 DME                                segment used in the submission of DME items in the      "N" to "R" as defined in the ANSI X12
                                                                         industry. Failure to use this loop/segment is a         guides.
                                                                         significant deviation from the ANSI X12 standards.
HIPAA     837 Prof
                                  Loop 2410 Drug Identification          HIPAA IG shows that this segment can be repeated, Modified comment to recommendation to
                                                                         but note says w/c implementation does not repeat. help ensure consistency with HIPAA IG.
HIPAA     837 Prof
                                  Loop 2420A Rendering Line Provider     Companion guide did not include this situational data   Added situational data element.
HIPAA     837 Prof                NM Provider Name Segment NM105         element.
                                  Loop 2420A Rendering Line Provider     Companion guide did not include this situational data   Added situational data element.
HIPAA     837 Prof                NM Provider Name Segment NM107         element.
                                  Loop 2420A Rendering Line Provider     Stakeholder indicates that the HIPAA Condition          Modify usage from "J" to "S" as defined in
HIPAA     837 Prof                REF State License                      meets w/c needs for reporting.                          the ANSI X12 guides.
                                  Loop 2420A Rendering Line Provider     HIPAA IG allows different tax ID numbers,               Added code for either FEIN or SSN as
                                  REF Tax ID Number                      companion guide limits to Social Security Number.       defined in the ANSI X12 guides.
                                                                         Providers may have either a FEIN or SSN.
HIPAA     837 Prof
                                                                         Current code value only includes 00 and omits code Deleted defined code to allow standard
HIPAA     837 Dental              Loop TS BHT BHT02                      18 for reissue due to transmission problem.        codes to be submitted.
                                                                         Current code value only includes 02 and omits code Added code 01.
                                  Loop 1000A Sender Information NM1      01 for individual health care provider (person).
HIPAA     837 Dental              Submitter Name NM102
                                  Loop 1000A Sender Information NM1      Data element not included in companion guides.          Added NM104
HIPAA     837 Dental              Submitter Name NM104




Information Management Services                                                Page 13 of 28                                                       Proposed Revisions 20071212
Type       Chapter       Page Item                                       Issue/Comments                                         Change Implemented
                              Loop 1000A Sender Information NM1          Data element not included in companion guides.         Added NM105
HIPAA      837 Dental         Submitter Name NM105
                              Loop 2000A PRV Billing Provider            IAIABC ProPay SubCommittee recommends                  Modified usage from "J" to "S" as defined
                              Taxonomy Code                              removing the jurisdictional requirement for taxonomy   in the ANSI X12 guides. Amended
                                                                         codes. The HIPAA IG language adequately covers         required comment to reflect situational
HIPAA      837 Dental                                                    the conditions.                                        requirement.
                                  Loop 2000A Billing/Pay to Provider     Incorrect qualifier for Taxonomy Code referenced in    Corrected qualifier to "ZZ".
                                  Loop PRV Provider Taxonomy Code        field PRV02.
Clerical   837 Dental             Segment
                                  Loop 2010AA Billing Provider NM1       Data element not included in companion guides.       Added NM107 as "S" as defined in ANSI
HIPAA      837 Dental             Name NM107                                                                                  X12 guides.
                                  Loop 2010AA Billing Provider REF Tax Codes are not inclusive of those allowed in HIPAA      Deleted code values to allow appropriate
HIPAA      837 Dental             ID REF01                             implementation guides.                                 code to be used.
                                  Loop 2010AA Billing Provider REF     Stakeholder indicates HIPAA conditions are             Modified usage from "J" to "S" and
                                  Segment Dentist State License Number sufficient and suggests changing the "J" to an "S". In deleted second segment as defined in the
                                                                       addition, current spreadsheet indicates a              ANSI X12 guides. The code values used
                                                                       jurisdictional requirement for Texas and two different will define the license type, if needed.
HIPAA      837 Dental                                                  segments for the same type of data.
                                  Loop 2010AA Billing Provider PER     This data segment is not included in the HIPAA         Deleted segment.
HIPAA      837 Dental             Contact Information Segment          implementation guides.
                                  Loop 2010AB Pay to Provider NM1      Data element not included in companion guides.         Added NM107 as "S" as defined in ANSI
HIPAA      837 Dental             Name NM107                                                                                  X12 guides.
                                  Loop 2010AB Pay to Provider REF Tax Codes are not inclusive of those allowed in HIPAA       Deleted code values to allow appropriate
HIPAA      837 Dental             ID REF01                             implementation guides.                                 code to be used.
                                  Loop 2010AB Pay to Provider          Field REF01 was omitted from Excel spreadsheet.        Added field.
                                  Information REF State License Number
Clerical   837 Dental             Segment
                                  Loop 2010AB Pay to Provider REF      Stakeholder indicates HIPAA conditions are             Modified usage from "J" to "S" as defined
HIPAA      837 Dental             State License                        sufficient and suggests changing the "J" to an "S"     in the ANSI X12 guides.
                                  Loop 2010AB Pay to Provider PER                                                             Deleted segment.
                                  Contact Information Segment          Stakeholder recommends deletion of this data
                                                                       segment that is not used in the ANSI X12 837d
                                                                       transaction set. Spreadsheet shows segment is not
HIPAA      837 Dental                                                  used in HIPAA, but jurisdictionally required in w/c.
                                  Loop 2010BA N302 Employer Address                                                           Modified mapping to show source from
                                                                       Spreadsheet shows employer address coming from Box 12 (Policyholder name and address).
Clerical   837 Dental                                                  Box 7 on the ADA form (which is gender).
                                  Loop 2000B Subscriber Detail SBR     Stakeholder points out that under the HIPAA IG this Modified usage from "J" to "S" as defined
                                  Subscriber Information Segment       data element is required if there is no group plan     in the ANSI X12 guides.
                                  SBR09 Claim Filing Indicator         number, which makes it required for w/c.
                                                                       Recommend changing to match HIPAA IG ("J" to
HIPAA      837 Dental                                                  "S")




Information Management Services                                                 Page 14 of 28                                                     Proposed Revisions 20071212
Type      Chapter        Page Item                                 Issue/Comments                                             Change Implemented
                              Loop 2010BB Payer Identification REF Stakeholder points out that there may be situations        Added situational data segment.
                              Secondary Payer Identification       were the secondary Payer ID is needed. For
                                                                   example, if the payer ID in Loop 2010BB NM1
                                                                   segment is a TPA and the insurance carrier
                                                                   identification is needed to process the claim, the
                                                                   secondary ID may be needed.
HIPAA     837 Dental
                                  Loop 2000C Patient Information HL   Stakeholder points out that under the HIPAA IG this     Modified usage from "J" to "S" as defined
                                  Segment                             data element is required if there the patient is        in the ANSI X12 guides.
                                                                      different than the policyholder, which makes it
                                                                      required for w/c. Recommend changing to match
HIPAA     837 Dental                                                  HIPAA IG ("J" to "S")
                                  Loop 2010CA Patient Information NM1 HIPAA implementation guide shows this data              Modified usage from "R" to "S" as defined
                                  Name NM108                          element as situational, as opposed to the required      in the ANSI X12 guides and deleted code.
                                                                      usage listed in the companion guides. In addition,
                                                                      Code MI is for member identification, and SSN may
HIPAA     837 Dental                                                  be used in workers' compensation.
                                  Loop 2010CA Patient Information NM1 HIPAA implementation guide shows this data              Modified usage from "R" to "S" as defined
                                  Name NM109                          element as situational, as opposed to the required      in the ANSI X12 guides and changed
                                                                      usage listed in the companion guides. In addition,      name to identification code.
HIPAA     837 Dental                                                  data element name is incorrect.
                                  Loop 2300 Claim Information CLM     HIPAA implementation guide shows this data              Modified data type.
                                  Claim Segment CLM05-1               element as "AN" not "ID" as contained in companion
HIPAA     837 Dental                                                  guide.
                                  Loop 2300 Claim Information CLM     Companion Guide lists only "A" as a valid code          Deleted code value to allow appropriate
HIPAA     837 Dental              Claim Segment CLM07                 value, HIPAA IG allows other code values.               code to be used.
                                  Loop 2300 Claim Information CLM     Companion Guide lists only "I" as a valid code value,   Deleted code value to allow appropriate
                                  Claim Segment CLM09                 HIPAA IG shows only "Y" and "N" as valid code           code to be used.
HIPAA     837 Dental                                                  values.
                                  Loop 2300 Claim Information CLM                                                             Added CLM12 to companion guides with
                                  Claim Segment CLM12                 Situational data element omitted from companion         "S" as defined in the ANSI X12 guides.
HIPAA     837 Dental                                                  guides.
                                  Loop 2300 Claim Information CLM     Stakeholder noted that this was a "not used" element    Modified HIPAA usage from "N" to "S"
                                  Claim Segment CLM19                 in ANSI X12 and HIPAA IG. Additional investigation      and w/c usage from "J" to "S" and
                                                                      reveals that the CLM19 segment is a "situational"       modified code value as defined in the
                                                                      data element in the HIPAA IG, but does not contain      ANSI X12 guides.
                                                                      the code values for the usage contemplated in the
HIPAA     837 Dental                                                  companion guides.
                                  2300 Claim Information CLM Segment HIPAA IG includes a delay reason code situational        Added CLM20 to companion guides with
                                  CLM20 Delay Reason Code             data element.                                           "S" as defined in the ANSI X12 guides.
HIPAA     837 Dental




Information Management Services                                                Page 15 of 28                                                    Proposed Revisions 20071212
Type       Chapter       Page Item                                      Issue/Comments                                    Change Implemented
                              2300 Claim Information DTP Date of        Stakeholder indicates HIPAA conditions are        Modified usage from "J" to "S" as defined
HIPAA      837 Dental         Service                                   sufficient and suggests changing the "J" to an "S"in the ANSI X12 guides.
                              Loop 2300 DTP Date of Service                                                               Modified mapping to show source from
                                                                     Spreadsheet shows date of service coming from Box Box 24
Clerical   837 Dental                                                41 on the ADA form (which is date appliance placed).
                                  Loop 2300 Claim Information DN1                                                         Modified data type.
                                  Orthodontic Information DN101 and  These data elements show the data type as "N" as
Clerical   837 Dental             DN102                              opposed to "R" in the HIPAA IG
                                  2300 Claim Information PWK Segment IAIABC ProPay recommended change in approach Modified usage from "R" to "S" as defined
HIPAA      837 Dental             PWC05                              to align with HIPAA IG ("R" to "S")                  in the ANSI X12 guides.
                                  2300 Claim Information PWK Segment IAIABC ProPay recommended change in approach Modified usage from "R" to "S" as defined
HIPAA      837 Dental             PWC06                              to align with HIPAA IG ("R" to "S")                  in the ANSI X12 guides.
                                  2300 Claim Information AMT Amount  Stakeholder recommends removing the "not used"       Modify usage from "N" to "S" as defined
                                  Paid Segment                       workers' compensation usage, while generally not     in the ANSI X12 guides.
                                                                     found in workers' compensation, this will align with
HIPAA      837 Dental                                                HIPAA IG.
                                  Loop 2310A Referring Provider NM1  HIPAA IG shows additional code values used in        Deleted single code value to allow
HIPAA      837 Dental             Name NM101                         certain situations.                                  appropriate code to be used.
                                  Loop 2310A Referring Provider NM1  HIPAA IG shows additional code values used in        Deleted single code value to allow
                                  Name NM102                         certain situations.                                  appropriate code to be used and added
HIPAA      837 Dental                                                                                                     data element name.
                                  Loop 2310A Referring Provider NM1  Data element not included in companion guides.       Added NM107 as "S" as defined in ANSI
HIPAA      837 Dental             Name NM107                                                                              X12 guides.
                                  Loop 2310A Referring Provider NM1  HIPAA implementation guide shows this data           Modified usage from "R" to "S" as defined
                                  Name NM108                         element as situational, as opposed to the required   in the ANSI X12 guides and deleted code.
                                                                     usage listed in the companion guides. In addition,
HIPAA      837 Dental                                                companion guide only lists one code value.
                                  Loop 2310A Referring Provider NM1  HIPAA implementation guide shows this data           Modified usage from "R" to "S" as defined
                                  Name NM109                         element as situational, as opposed to the required   in the ANSI X12 guides and changed
                                                                     usage listed in the companion guides. In addition,   name to identification code.
HIPAA      837 Dental                                                data element name is incorrect.
                                  Loop 2310A Referring Provider REF  Stakeholder indicates HIPAA conditions are           Modified usage from "J" to "S" as defined
HIPAA      837 Dental             State License                      sufficient and suggests changing the "J" to an "S"   in the ANSI X12 guides.
                                  Loop 2310B Rendering Provider NM1 HIPAA IG shows additional code values used in         Deleted single code value to allow
                                  Name NM102                         certain situations.                                  appropriate code to be used and added
HIPAA      837 Dental                                                                                                     data element name.
                                  Loop 2310B Rendering Provider NM1 Data element not included in companion guides.        Added NM107 as "S" as defined in ANSI
HIPAA      837 Dental             Name NM107                                                                              X12 guides.
                                  Loop 2310B Rendering Provider NM1                                                       Deleted code to allow use of appropriate
HIPAA      837 Dental             Name NM108                         Companion guide only lists one code value.           code.
                                  Loop 2310B Rendering Provider NM1                                                       Changed name to identification code.
HIPAA      837 Dental             Name NM109                         Data name indicates only NPI to be used.




Information Management Services                                               Page 16 of 28                                                 Proposed Revisions 20071212
Type       Chapter       Page Item                                       Issue/Comments                                         Change Implemented
                              Loop 2310B Rendering Provider PRV          Spreadsheet indicates HIPAA usage for this data        Deleted comment and modified usage to
                              Provider Specialty Code                    element is Required, but HIPAA IG indicates            situational as defined in the ANSI X12
                                                                         segment is Situational with the condition of when      guides.
                                                                         adjudication requires taxonomy code. Comment in
                                                                         Division guides and w/c usage shows it is Required.
                                                                         Stakeholders recommend changing usage to
HIPAA      837 Dental                                                    Situational and deleting comment.
                                  Loop 2310B Rendering Provider REF      Stakeholder indicates HIPAA conditions are             Modified usage from "J" to "S" as defined
HIPAA      837 Dental             State License                          sufficient and suggests changing the "J" to an "S"     in the ANSI X12 guides.
                                  Loop 2310C NM1 Segment Individual      Stakeholder indicates HIPAA conditions are             Modified usage from "J" to "S" as defined
HIPAA      837 Dental             or Org Name                            sufficient and suggests changing the "J" to an "S"     in the ANSI X12 guides.
                                  Loop 2310C Facility/Service Location   Companion Guide shows HIPAA usage is "S" when          Modified usage from "S" to "R" as defined
HIPAA      837 Dental             NM1 Name NM103                         HIPAA IG shows usage is "R"                            in ANSI X12 guides.
                                  Loop 2310C Facility/Service Location                                                          Deleted segment.
                                  REF Segment State License Number       HIPAA Implementation Guide does not contain a
HIPAA      837 Dental                                                    REF Segment for the facility state license number.
                                  Loop 2310D Assisting Surgeon PRV       Comment in companion guides indicates this is          Deleted comment since the HIPAA
HIPAA      837 Dental             Provider Specialty Code                required.                                              defined condition is sufficient.
                                  Loop 2310D Assisting Surgeon REF       Companion guide shows jurisdictionally required with   Modified usage from "J" to "S" as defined
HIPAA      837 Dental             State License Number                   "J" but no defined Texas condition.                    in the ANSI X12 guides.
                                  Loop 2320 Other Subscriber Info SBR    SBR04 is defined as the Policy or Plan Name in the     Modified name.
                                  Other Subscriber Info SBR04            HIPAA IG, as a Group or Plan Name in the
Clerical   837 Dental                                                    Companion Guides.
                                  Loop 2320 Other Subscriber Info SBR                                                        Deleted SBR05.
HIPAA      837 Dental             Other Subscriber Info SBR05            HIPAA IG shows this is a "not used" data element.
                                  Loop 2320 Other Subscriber             Companion guide shows only allowed value is "WC" Deleted "WC" code value to allow
                                  Information SBR Segment SBR09          for workers' compensation, however, the other claim appropriate code to be used. Modified "J"
                                                                         referenced in this loop may not have been workers' to "S" as defined in the ANSI X12 guides.
                                                                         compensation. In addition, companion guide shows
                                                                         as "J" with comment that it is a required field.
HIPAA      837 Dental
                                  Loop 2330A Other Subscriber Name       Data element not included in companion guides.         Added NM107 as "S" as defined in ANSI
HIPAA      837 Dental             NM1 Name NM107                                                                                X12 guides.
                                  Loop 2400 Service Lines SV3 Dental     HIPAA IG shows data type is "ID" not "AN" as in        Corrected data type.
HIPAA      837 Dental             Service SV305                          companion guides.
                                  Loop 2400 Service Lines DTP Service    Companion guides show data/time/period qualifier as Corrected code value.
Clerical   837 Dental             Date DTP02                             "RD8", HIPAA IG shows "D8"
                                  Loop 2420A Rendering Line Provider     HIPAA IG shows additional code values used in       Deleted single code value to allow
                                  NM1 Name NM102                         certain situations.                                 appropriate code to be used and added
HIPAA      837 Dental                                                                                                        data element name.
                                  Loop 2420A Rendering Line Provider                                                         Deleted code value to allow appropriate
HIPAA      837 Dental             NM1 Name NM108                         Companion guide only lists one code value.          code to be used.




Information Management Services                                                Page 17 of 28                                                      Proposed Revisions 20071212
Type       Chapter       Page Item                                    Issue/Comments                                         Change Implemented
                              Loop 2420A Rendering Line Provider                                                             Corrected data element name.
HIPAA      837 Dental         NM1 Name NM109                          Data element name is incorrect.
                              Loop 2420A Rendering Line Provider                                                             Corrected data type.
HIPAA      837 Dental         PRV Specialty Code PRV02                Data type incorrect (lists "AN" not "ID").
                              Loop 2420A Rendering Line Provider      Stakeholder indicates that the HIPAA Condition         Modified usage from "J" to "S" as defined
HIPAA      837 Dental         REF State License                       meets w/c needs for reporting.                         in the ANSI X12 guides.
                              Loop 2420C Assistant Surgeon NM1        HIPAA IG shows this data element as required, not      Modified usage from "S" to "R" as defined
HIPAA      837 Dental         Name NM108                              situational as noted in companion guide.               in ANSI X12 guides.
                              Loop 2420C Assistant Surgeon NM1        HIPAA IG shows this data element as required, not      Modified usage from "S" to "R" as defined
HIPAA      837 Dental         Name NM109                              situational as noted in companion guide.               in ANSI X12 guides.
                              Loop 2420C Assistant Surgeon REF        Companion guide shows this segment as                  Modified usage from "J" to "S" as defined
HIPAA      837 Dental         State License Number                    jurisdictionally required without a Texas condition.   in the ANSI X12 guides.
                                                                      Current code value only includes 00 and omits code     Deleted defined code to allow standard
HIPAA      837 Inst               Loop TS BHT BHT02                   18 for reissue due to transmission problem.            codes to be submitted.
                                                                      Current code value only includes 02 and omits code     Added code 01.
                                  Loop 1000A Sender Information NM1   01 for individual health care provider (person).
HIPAA      837 Inst               Submitter Name NM102
                                  Loop 1000A Sender Information NM1   Data element not included in companion guides.         Added NM104
HIPAA      837 Inst               Submitter Name NM104
                                  Loop 1000A Sender Information NM1   Data element not included in companion guides.         Added NM105
HIPAA      837 Inst               Submitter Name NM105
                                  Loop 2000A PRV Billing Provider     IAIABC ProPay SubCommittee recommends                  Modified usage from "J" to "S" as defined
                                  Taxonomy Code                       removing the jurisdictional requirement for taxonomy   in the ANSI X12 guides. Amended
                                                                      codes. The HIPAA IG language adequately covers         required comment to reflect situational
HIPAA      837 Inst                                                   the conditions.                                        requirement.
                                  Loop 2010AA Billing Provider        Situational language was ambiguous.                    Modify language to indicate hospital
                                  Information Segment REF Provider                                                           Billing Provider State License Number is
                                  Identification Number                                                                      submitted if the billing entity is a health
                                                                                                                             care provider and if provider has a state
Clerical   837 Inst                                                                                                          license.
                                  Loop 2010AA Billing Provider REF    Stakeholder indicates HIPAA conditions are             Modified usage from "J" to "S" as defined
HIPAA      837 Inst               State License                       sufficient and suggests changing the "J" to an "S"     in the ANSI X12 guides.
                                  Loop 2010AB Pay to Provider REF     Stakeholder indicates HIPAA conditions are             Modified usage from "J" to "S" as defined
HIPAA      837 Inst               State License                       sufficient and suggests changing the "J" to an "S"     in the ANSI X12 guides.
                                  Loop 2000B Subscriber Detail SBR    Spreadsheet showed code value but not data             Added data element name.
                                  Subscriber Information Segment      element name.
Clerical   837 Inst               SBR01
                                  Loop 2000B Subscriber Detail SBR    SBR03 fields was inadvertently omitted from the 837I Added field.
Clerical   837 Inst               Subscriber Information Segment      Excel spreadsheet.




Information Management Services                                             Page 18 of 28                                                       Proposed Revisions 20071212
Type       Chapter       Page Item                                     Issue/Comments                                          Change Implemented
                              Loop 2000B Subscriber Detail SBR         Stakeholder points out that under the HIPAA IG this     Modified usage from "J" to "S" as defined
                              Subscriber Information Segment           data element is required if there is no group plan      in the ANSI X12 guides.
                              SBR04 Employer Name                      number, which makes it required for w/c.
                                                                       Recommend changing to match HIPAA IG ("J" to
HIPAA      837 Inst                                                    "S")
                                  Loop 2000B Subscriber Detail SBR     Stakeholder points out that under the HIPAA IG this     Modified usage from "J" to "S" as defined
                                  Subscriber Information Segment       data element is required if there is no group plan      in the ANSI X12 guides.
                                  SBR09 Claim Filing Indicator         number, which makes it required for w/c.
                                                                       Recommend changing to match HIPAA IG ("J" to
HIPAA      837 Inst                                                    "S")
                                  Loop 2010BC Payer Identification REF Stakeholder points out that there may be situations     Added situational data segment.
                                  Secondary Payer Identification       were the secondary Payer ID is needed. For
                                                                       example, if the payer ID in Loop 2010BC NM1
                                                                       segment is a TPA and the insurance carrier
                                                                       identification is needed to process the claim, the
                                                                       secondary ID may be needed.
HIPAA      837 Inst
                                  Loop 2000C Patient Information HL     Stakeholder points out that under the HIPAA IG this    Modified usage from "J" to "S" as defined
                                  Segment                               data element is required if there the patient is       in the ANSI X12 guides.
                                                                        different than the policyholder, which makes it
                                                                        required for w/c. Recommend changing to match
HIPAA      837 Inst                                                     HIPAA IG ("J" to "S")
                                  Loop 2010CA Patient Information NM    Sutuational data element NM107 omitted from            Added NM107 as "S" as defined in ANSI
HIPAA      837 Inst               Name NM107                            companion guides.                                      X12 guides.
                                  Loop 2010CA Patient Information NM    HIPAA IG shows this data element as situational, not   Modified HIPAA and wc usage from "R" to
HIPAA      837 Inst               Name NM108                            required as noted in companion guide.                  "S" as defined in ANSI X12 guides.
                                  Loop 2010CA Patient Information NM    HIPAA IG shows this data element as situational, not   Modified HIPAA and wc usage from "R" to
HIPAA      837 Inst               Name NM109                            required as noted in companion guide.                  "S" as defined in ANSI X12 guides.
                                  Loop 2010CA Patient Information N4    Companion guide contains typo showing N404 as          Corrected typo.
Clerical   837 Inst               City State Zip                        N403.
                                  2300 Claim Information CLM Segment    Stakeholder noted that this was a "not used" element   HIPAA "not used" data element deleted.
                                  CLM19 Bill Submission Reason Code     in ANSI X12 and HIPAA IG. Existing codes, and new
                                                                        ones coming in December, are sufficient to convey
HIPAA      837 Inst                                                     information in CLM05.
                                  2300 Claim Information CLM Segment    HIPAA IG includes a delay reason code situational      Added CLM20 to companion guides with
                                  CLM20 Delay Reason Code               data element.                                          "S" as defined in the ANSI X12 guides.
HIPAA      837 Inst
                                  2300 Claim Information PWK Segment    IAIABC ProPay recommended change in approach           Modified usage from "R" to "S" as defined
HIPAA      837 Inst               PWC05                                 to align with HIPAA IG ("R" to "S")                    in the ANSI X12 guides.
                                  2300 Claim Information PWK Segment    IAIABC ProPay recommended change in approach           Modified usage from "R" to "S" as defined
HIPAA      837 Inst               PWC06                                 to align with HIPAA IG ("R" to "S")                    in the ANSI X12 guides.




Information Management Services                                                Page 19 of 28                                                     Proposed Revisions 20071212
Type       Chapter       Page Item                                Issue/Comments                                               Change Implemented
                              2300 Claim Information REF Segment Companion Guide placed segment in different                   Moved to same location as HIPAA IG.
                              Original Reference Number (ICN/DCN) location than HIPAA IG.
Clerical   837 Inst
                                  2300 Claim Information REF Segment   Stakeholder indicates HIPAA conditions are              Modified usage from "J" to "S" as defined
HIPAA      837 Inst               Medical Record Number                sufficient and suggests changing the "J" to an "S"      in the ANSI X12 guides.
                                  2300 Claim Information HI Segment    Stakeholder indicates HIPAA conditions are              Modified usage from "J" to "S" as defined
                                  DRG Information                      sufficient and suggests changing the "J" to an "S"      in the ANSI X12 guides and added
                                                                                                                               comment that it is required for inpatient
HIPAA      837 Inst                                                                                                            admissions.
                                  2300 Claim Information HI Segment    Stakeholder indicates HIPAA conditions are              Modified usage from "J" to "S" as defined
HIPAA      837 Inst               Occurance Codes and Dates            sufficient and suggests changing the "J" to an "S"      in the ANSI X12 guides.
                                  2300 Claim Information QTY Segment   Stakeholder recommends changing the w/c "not            Modified usage from "N" to "S" as defined
                                  Covered Days                         used" usage to the HIPAA "S" usage. This will           in the ANSI X12 guides.
                                                                       prevent bills from being rejected that are otherwise
HIPAA      837 Inst                                                    complete.
                                  2300 Claim Information QTY Segment   Stakeholder recommends changing the w/c "not            Modified usage from "N" to "S" as defined
                                  Non Covered Days                     used" usage to the HIPAA "S" usage. This will           in the ANSI X12 guides.
                                                                       prevent bills from being rejected that are otherwise
HIPAA      837 Inst                                                    complete.
                                  2300 Claim Information QTY Segment   Stakeholder recommends changing the w/c "not            Modified usage from "N" to "S" as defined
                                  Co Insured Days                      used" usage to the HIPAA "S" usage. This will           in the ANSI X12 guides.
                                                                       prevent bills from being rejected that are otherwise
HIPAA      837 Inst                                                    complete.
                                  2300 Claim Information QTY Segment   Stakeholder recommends changing the w/c "not            Modified usage from "N" to "S" as defined
                                  Lifetime Reserved Days               used" usage to the HIPAA "S" usage. This will           in the ANSI X12 guides.
                                                                       prevent bills from being rejected that are otherwise
HIPAA      837 Inst                                                    complete.
                                  Loop 2310 Attending Provider         Companion guide only lists person as an option and      Deleted code value to allow appropriate
                                  Information NM1 Individual Name      HIPAA IG allows person or organization.                 code to be used.
HIPAA      837 Inst               NM102 Entity Type Qualifier
                                  Loop 2310 Attending Provider         Stakeholder points out that HIPAA usage dictates        Modified usage from "J" to "S" as defined
                                  Information NM1 Individual Name      this as required for hospital admissions, which meets   in the ANSI X12 guides.
                                  NM104                                w/c usage needs. Recommend changing from "J" to
HIPAA      837 Inst                                                    "S".
                                  Loop 2310 Attending Provider         Companion guide lists this data element as "Title"      Modified name of data element as defined
                                  Information NM1 Individual Name      and HIPAA IG shows this data element as "Name           in the ANSI X12 guides.
Clerical   837 Inst               NM107                                Suffix".
                                  Loop 2310A Attending Provider                                                                Modified usage from "J" to "S" as defined
                                  Information REF Segment State        Stakeholder indicates HIPAA conditions are              in the ANSI X12 guides.
HIPAA      837 Inst               License Number                       sufficient and suggests changing the "J" to an "S"




Information Management Services                                              Page 20 of 28                                                       Proposed Revisions 20071212
Type      Chapter        Page Item                                        Issue/Comments                                          Change Implemented
                              Loop 2310B Operating Physician PRV                                                                  Deleted non-standard segment.
                              Segment Provider Specialty Code             This segment is not contained in the HIPAA
HIPAA     837 Inst                                                        implementation guide.
                                  Loop 2310B Operating Physician REF      Stakeholder indicates HIPAA conditions are              Modified usage from "J" to "S" as defined
HIPAA     837 Inst                Segment State License Number            sufficient and suggests changing the "J" to an "S"      in the ANSI X12 guides.
                                  Loop 2310C Other Provider Name NM1      Companion Guide allows use of "ZZ" which is not         Deleted code value.
HIPAA     837 Inst                Name NM101                              contained in HIPAA implementation guide.
                                  Loop 2310C Other Provider Name NM1      Companion guide only lists person as an option and      Deleted code value to allow appropriate
HIPAA     837 Inst                Name NM102                              HIPAA IG allows person or organization.                 code to be used.
                                  Loop 2310C Other Provider Name NM1      HIPAA implementation guide usage is situational.        Modified usage from "R" to "S" as defined
HIPAA     837 Inst                Name NM104                              Companion guides show as required.                      in the ANSI X12 guides.
                                  Loop 2310C Other Provider PRV           This segment is not contained in the HIPAA              Deleted non-standard segment.
HIPAA     837 Inst                Segment Provider Specialty Code         implementation guide.
                                  Loop 2310C Other Provider REF           Stakeholder indicates HIPAA conditions are              Modified usage from "J" to "S" as defined
HIPAA     837 Inst                Segment State License Number            sufficient and suggests changing the "J" to an "S"      in the ANSI X12 guides.
                                  Loop 2310D                              Loop 2310D does not exist in the HIPAA                  Deleted loop.
HIPAA     837 Inst                                                        implementation guide.
                                  Loop 2310E Facility/Service Location    Stakeholder indicates HIPAA condition requires this     Modified usage from "J" to "S" as defined
                                  NM1 Individual Name NM108               loop only when location is different than billing       in the ANSI X12 guides.
                                                                          provider or pay-to-provider loops. HIPAA condition
HIPAA     837 Inst                                                        meets w/c needs, modify from "J" to "S"
                                  Loop 2310E Facility/Service Location    Stakeholder indicates HIPAA condition requires this     Modified usage from "J" to "S" as defined
                                  NM1 Individual Name NM109               loop only when location is different than billing       in the ANSI X12 guides.
                                                                          provider or pay-to-provider loops. HIPAA condition
HIPAA     837 Inst                                                        meets w/c needs, modify from "J" to "S"
                                  Loop 2310E Facility/Service REF State   Current companion guide shows as "J" without a          Modified usage from "J" to "S" as defined
                                  License Number                          Texas specific condition.                               in the ANSI X12 guides and added
                                                                                                                                  condition if the facility is a licensed health
HIPAA     837 Inst                                                                                                                care facility.
                                  Loop 2310F Referring Provider           Stakeholder indicates ANSI X12 4010 does not            Deleted loop.
                                                                          contain this loop, but the guides present it as a
                                                                          situational application in the implementation guides.
                                                                          This loop is not supported in the ANSI X12 4010A1
HIPAA     837 Inst                                                        version.
                                  Loop 2320 Other Subscriber              HIPAA implementation guide shows this data              Deleted HIPAA "not used" data element.
                                  Information SBR Segment SBR08           element is "not used". Companion guide shows it
HIPAA     837 Inst                                                        jurisdictionally required.
                                  Loop 2320 Other Subscriber              HIPAA implementation guide shows this data              Deleted HIPAA "not used" data element.
                                  Information SBR Segment SBR09           element is situational but companion guide shows it
HIPAA     837 Inst                                                        jurisdictionally required.




Information Management Services                                                 Page 21 of 28                                                         Proposed Revisions 20071212
Type       Chapter       Page Item                                       Issue/Comments                                           Change Implemented
                              Loop 2320 Other Subscriber                 Companion guide shows only allowed value is "WC"         Deleted "WC" code value to allow
                              Information SBR Segment SBR09              for workers' compensation, however, the other claim      appropriate code to be used.
                                                                         referenced in this loop may not have been workers'
HIPAA      837 Inst                                                      compensation.
                                  Loop 2320 Other Subscriber AMT         This segment in the HIPAA implementation guide is        Modified segement as defined in the
                                  Coordination of Benefits (COB) Payer the Payer Prior Payment with some differences in           ANSI X12 guides.
HIPAA      837 Inst               Paid Amount                            code value.
                                  Loop 2320 Other Subscriber AMT         This segment is not contained in the HIPAA               Deleted non-standard (per HIPAA) data
                                  Coordination of Benefits (COB) Patient implementation guide.                                    segment.
HIPAA      837 Inst               Paid Amount
                                  Loop 2330A Other Subscriber Name       This situational data element was not contained in       Added data element and usage as
HIPAA      837 Inst               NM Name NM 107                         the companion guides.                                    defined in the ANSI X12 guides.
                                  Loop 2330A Other Subscriber REF        The HIPAA implementation guides permit several           Modified name in companion guide and
                                  Secondary Information                  codes and identification numbers to be used. The         deleted code value to allow appropriate
                                                                         companion guide restricts usage to Social Security       codes and identification numbers to be
                                                                         Number, which may not be applicable in all               used as defined in the ANSI X12 guides.
HIPAA      837 Inst                                                      situations.
                                  Loop 2400 Service Line Information     Stakeholder indicates that the HIPAA Condition           Modified usage from "J" to "S" as defined
                                  DTP Service Date                       requires this on outpaitent claims when revenue,         in the ANSI X12 guides.
                                                                         procedure or other codes are reported in the SV2
                                                                         segement. This condition meets w/c needs for
HIPAA      837 Inst                                                      reporting.
                                  Loop 2410 Drug Identification CTP      Condition in description segment contains incorrect      Deleted condition, HIPAA implementation
                                  Drug Pricing CTP03                     reference to SV102.                                      guides contain sufficient instructions.
Clerical   837 Inst
                                  Loop 2410 Drug Identification CTP      Condition in description segment contains incorrect      Deleted condition, HIPAA implementation
                                  Drug Pricing CTP03                     reference to SV104.                                      guides contain sufficient instructions.
Clerical   837 Inst
                                  Loop 2410 Drug Identification CTP      Stakeholder indicates that the spreadsheet shows         Modify usage from "S" to "R" as defined
                                  Drug Pricing CTP03-CTP05               data elements are situational, but the situation is at   in the ANSI X12 guides.
HIPAA      837 Inst                                                      the segment level, not the data element level.
                                                                         Current code value only includes 00 and omits code       Deleted defined code to allow standard
HIPAA      837 Rx                 Loop TS BHT BHT02                      18 for reissue due to transmission problem.              codes to be submitted.
                                                                         Companion guide only listed code "2" for company,        Deleted defined code to allow standard
                                  Loop 1000A Sender Information NM1      HIPAA allows individuals and organizations to submit     codes to be submitted.
HIPAA      837 Rx                 Name NM102                             transactions.
                                  Loop 1000A Sender Information NM1      NM104 and NM105 not contained in companion               Added data elements.
HIPAA      837 Rx                 Name NM104 and NM105                   guides but do exist in HIPAA IG.
                                  Loop 2000A PRV Billing Provider        IAIABC ProPay SubCommittee recommends                    Modified usage from "J" to "S" as defined
                                  Taxonomy Code                          removing the jurisdictional requirement for taxonomy     in the ANSI X12 guides. Deleted required
                                                                         codes. The HIPAA IG language adequately covers           comment.
HIPAA      837 Rx                                                        the conditions.




Information Management Services                                                 Page 22 of 28                                                       Proposed Revisions 20071212
Type       Chapter       Page Item                                      Issue/Comments                                         Change Implemented
                              Loop 2010AA Billing Provider              Spreadsheet indicates data element is Situational,     Modified usage to Required.
                              Information NM108 Identification Code     HIPAA IG indicates segment is Required.
Clerical   837 Rx             Qualifier
                              Loop 2010AA Billing Provider              Spreadsheet indicates data element is Situational,     Modified usage to Required.
                              Information NM109 Identification Code     HIPAA IG indicates segment is Required.
Clerical   837 Rx
                                  Loop 2010AA Billing Provider REF     Companion guides show usage as "J" and HIPAA IG         Modified usage from "J" to "S" as defined
HIPAA      837 Rx                 State License                        shows usage as "S"                                      in the ANSI X12 guides.
                                  Loop 2010AA Billing Provider PER     Companion guides show usage as "J" and HIPAA IG         Modified usage from "J" to "S" as defined
HIPAA      837 Rx                 Contact Information Segment          shows usage as "S"                                      in the ANSI X12 guides.
                                  Loop 2010AB Pay to Provider REF      Companion guides show usage as "J" and HIPAA IG         Modified usage from "J" to "S" as defined
HIPAA      837 Rx                 State License                        shows usage as "S"                                      in the ANSI X12 guides.
                                  Loop 2000B Subscriber Detail SBR     Stakeholder points out that under the HIPAA IG this     Modified usage from "J" to "S" as defined
                                  Subscriber Information Segment       data element is required if there is no group plan      in the ANSI X12 guides.
                                  SBR09 Claim Filing Indicator         number, which makes it required for w/c.
                                                                       Recommend changing to match HIPAA IG ("J" to
HIPAA      837 Rx                                                      "S")
                                  Loop 2010BB Payer Identification REF Stakeholder points out that there may be situations     Added situational data segment.
                                  Secondary Payer Identification       were the secondary Payer ID is needed. For
                                                                       example, if the payer ID in Loop 2010BB NM1
                                                                       segment is a TPA and the insurance carrier
                                                                       identification is needed to process the claim, the
                                                                       secondary ID may be needed.
HIPAA      837 Rx
                                  Loop 2000C Patient Information HL     Stakeholder points out that under the HIPAA IG this    Modified usage from "J" to "S" as defined
                                  Segment                               data element is required if there the patient is       in the ANSI X12 guides.
                                                                        different than the policyholder, which makes it
                                                                        required for w/c. Recommend changing to match
HIPAA      837 Rx                                                       HIPAA IG ("J" to "S")
                                  Loop 2100CA Patient Information       Spreadsheet shows patient information as 2100CA,       Modified loop to 2010CA
Clerical   837 Rx                                                       the proper loop is 2010CA
                                  Loop 2010CA Patient Information NM    HIPAA IG shows this data element as situational, not   Modified HIPAA and wc usage from "R" to
HIPAA      837 Rx                 Name NM108                            required as noted in companion guide.                  "S" as defined in ANSI X12 guides.
                                  Loop 2010CA Patient Information NM    HIPAA IG shows this data element as situational, not   Modified HIPAA and wc usage from "R" to
HIPAA      837 Rx                 Name NM109                            required as noted in companion guide.                  "S" as defined in ANSI X12 guides.
                                  2300 Claim Information CLM Segment    HIPAA IG shows this data element to be used when       Added situational data element.
                                  CLM16 Provider Agreement Code         a non-participating provider is submitting a claim.
                                                                        This may be needed for access plans in network
                                                                        settings and should be allowed as situational.
HIPAA      837 Rx




Information Management Services                                               Page 23 of 28                                                      Proposed Revisions 20071212
Type       Chapter       Page Item                                         Issue/Comments                                         Change Implemented
                              2300 Claim Information CLM Segment           Stakeholder noted that this was a "not used" element   HIPAA "not used" data element deleted.
                              CLM19 Bill Submission Reason Code            in ANSI X12 and HIPAA IG. Existing codes, and new
                                                                           ones coming in December, are sufficient to convey
HIPAA      837 Rx                                                          information in CLM05.
                                  2300 Claim Information CLM Segment       HIPAA IG includes a delay reason code situational      Added CLM20 to companion guides with
                                  CLM20 Delay Reason Code                  data element.                                          "S" as defined in the ANSI X12 guides.
HIPAA      837 Rx
                                  2300 Claim Information PWK Segment       IAIABC ProPay recommended change in approach           Modified usage from "J" to "S" as defined
HIPAA      837 Rx                 PWC05                                    to align with HIPAA IG ("J" to "S")                    in the ANSI X12 guides.
                                  2300 Claim Information PWK Segment       IAIABC ProPay recommended change in approach           Modified usage from "J" to "S" as defined
HIPAA      837 Rx                 PWC06                                    to align with HIPAA IG ("J" to "S")                    in the ANSI X12 guides.
                                  2300 Claim Information CN1 Contract      HIPAA IG shows this data element as situational, not   Modified HIPAA and wc usage from "R" to
HIPAA      837 Rx                 Information Segment CN102                required as noted in companion guide.                  "S" as defined in ANSI X12 guides.
                                  2300 Claim Information AMT Amount        Patient amount paid shows "J" instead of "S" as        Modified usage from "J" to "S" as defined
                                  Paid Segment                             defined in the HIPAA guides. This is a situational     in the ANSI X12 guides.
HIPAA      837 Rx                                                          field that is only populated when it is applicable.
                                  Loop 2310 Facility/Service Location      Comments referring to "in REF Segment"                 Removed comments.
Clerical   837 Rx                 Information NM1 Name Segment
                                  Loop 2310D NM1 Facility Service          Spreadsheet indicates HIPAA usage for this data        Modified HIPAA and wc usage from "R" to
                                  Location Name NM108 Identification       element is Required, HIPAA IG indicates segment is     "S" as defined in ANSI X12 guides.
HIPAA      837 Rx                 Code Qualifier                           Situational.
                                  Loop 2310D NM1 Facility Service          Spreadsheet indicates HIPAA usage for this data        Modified HIPAA and wc usage from "R" to
                                  Location Name NM109 Identification       element is Required, HIPAA IG indicates segment is     "S" as defined in ANSI X12 guides.
HIPAA      837 Rx                 Code                                     Situational.
                                  Loop 2410 Drug Identification LIN Item   Spreadsheet indicates data element is Required,        Modified HIPAA and workers'
                                  Identification Segment                   HIPAA IG indicates segment is Situational.             compensation usage to situational -- the
                                                                                                                                  HIPAA implementation notes show that
                                                                                                                                  this is required when NDC is needed,
                                                                                                                                  which would make it "required" for any RX
HIPAA      837 Rx                                                                                                                 transaction.
                                  Loop 2410 Drug Identification REF        Spreadsheet indicates segment is Required, HIPAA       Modified HIPAA and workers'
                                  Prescription Number Segment              IG indicates segment is Situational.                   compensation usage to situational -- the
                                                                                                                                  HIPAA implementation notes show that
                                                                                                                                  this is required when drug dispensing is
                                                                                                                                  done with an assigned RX number.
HIPAA      837 Rx
                                  Loop 2410 Service Payment                Stakeholder noted this includes an invalid             Modified to "ZZ"
                                  Information REF Segment Prescription     code…change "XZ" to "ZZ"
Clerical   837 Rx                 Number REF02
                                  Loop 2420E Ordering Provider Name        Spreadsheet indicates HIPAA usage for this data        Modified HIPAA usage to required.
                                  N104 First Name                          element is Situational, HIPAA IG indicates segment
Clerical   837 Rx                                                          is Required.




Information Management Services                                                  Page 24 of 28                                                       Proposed Revisions 20071212
Type      Chapter        Page Item                                    Issue/Comments                                            Change Implemented
                              Loop 2420E Ordering Provider Name       Spreadsheet indicates HIPAA usage for this data           Modified usage to situational.
                              N108 Identification Code Qualifier and  element is Required, HIPAA IG indicates segment is
HIPAA     837 Rx              NM109                                   Situational.
                              Loop TS BPR Financial Information       HIPAA IG usage is "R", companion guide shows as           Modified usage from "S" to "R" as defined
HIPAA     835                 BPR16                                   "S"                                                       in ANSI X12 guides.
                              Loop TS DTM Production Date             HIPAA IG usage is "S", companion guide shows as           Modified usage from "R" to "S" as defined
HIPAA     835                 Segment                                 "R"                                                       in the ANSI X12 guides.
                              Loop 1000A Payer Identification N1      Stakeholder indicates HIPAA condition requires if the     Modified usage from "R" to "S" as defined
                              Payer Name                              National Plan ID isn't populated, which basically         in the ANSI X12 guides.
HIPAA     835                                                         makes it required for w/c submissions.
                                  Loop 1000A Payer Identification REF Stakeholder indicates HIPAA condition requires if the     Modified usage from "J" to "S" as defined
                                  Payer Identification                National Plan ID is implemented, which basically          in the ANSI X12 guides.
                                                                      makes it required for w/c submissions with the same
HIPAA     835                                                         conditions.
                                  Loop 1000B Payee Identification NI  Stakeholder indicates that HIPAA requires this only       Modified usage from "R" to "S" as defined
                                  Payee Name                          when NPI is not submitted in the N104 field.              in the ANSI X12 guides.
                                                                      Otherwise, it isn't required to be sent in the 835 (NPI
HIPAA     835                                                         provides same information).
                                  Loop 1000B Payee Identification REF Stakeholder indicates HIPAA condition sufficent for       Modified usage from "J" to "S" as defined
HIPAA     835                     State License Number                w/c usage.                                                in the ANSI X12 guides.
                                  Loop 2100 Bill Payment Information  Stakeholder indicates HIPAA condition sufficent for       Modified usage from "R" to "S" as defined
                                  NM1 Insured Name NM108 and NM109 w/c usage. It is required when the patient isn't the         in the ANSI X12 guides.
HIPAA     835                                                         insured.
                                  Loop 2100 Bill Payment Information  Stakeholder indicates HIPAA condition sufficent for       Modified usage from "R" to "S" as defined
                                  NM1 Insured Name NM103              w/c usage. It is required when the patient isn't the      in the ANSI X12 guides.
HIPAA     835                     Organization Name                   insured.
                                  Loop 2100 Bill Payment Information  HIPAA IG usage shows as "S", but companion guide          Modified usage from "R" to "S" as defined
HIPAA     835                     NM1 Service Provider Name NM103     shows usage as "R".                                       in the ANSI X12 guides.
                                  Loop 2100 Bill Payment Information  HIPAA IG usage shows as multiple code values, but         Added "FI" to the code list in the
                                  NM1 Service Provider Name NM108     companion guides only list State License or NPI.          companion guides.
                                                                      HIPAA IG advises preference for use of the "FI"
HIPAA     835                                                         Federal Tax Identification Number.
                                  2100 Bill Payment Information REF   Stakeholder indicates we currently list this as a         Modified code from "Y4" to "F8" and
                                  Reference Identification (workers'  jurisdiction requirement with the use of a "Y4" code.     modified usage from "J" to "S" as defined
                                  compensation claim no.)             Questions use of the code and indicates it is             in the ANSI X12 guides.
HIPAA     835                                                         situational in the HIPAA IG.
                                  2100 Bill Payment Information DTM   Stakeholder indicates this is not used in HIPAA IG        Deleted HIPAA "not used" data segment.
                                  Date of Accident                    and questions the need to include the date of injury
                                                                      on 835 transactions when other data elements (such
                                                                      as dates of service) provide sufficient data to match
                                                                      remittance advice to original claim.
HIPAA     835




Information Management Services                                                 Page 25 of 28                                                     Proposed Revisions 20071212
Type       Chapter       Page Item                                       Issue/Comments                                       Change Implemented
                              2100 Bill Payment Information DTM Bill     Stakeholder indicates HIPAA IG allows this to be     Modify usage from "J" to "S" as defined in
HIPAA      835                Received Date                              submitted and provides some conditions.              the ANSI X12 guides.
                              2100 Bill Payment Information PER Bill     Stakeholder indicates HIPAA IG outlines conditions   Modify usage from "J" to "S" as defined in
                              Contact Infromation                        which would make it applicable and suggests          the ANSI X12 guides.
HIPAA      835                                                           changing "J" to "S".
                                  2100 Bill Payment Information PER Bill Stakeholder indicates HIPAA IG outlines conditions   Modify usage from "R" to "S" as defined
                                  Contact Infromation PER03              which would make it applicable and suggests          in the ANSI X12 guides. Also removed
                                                                         changing "R" to "S".                                 code value to allow appropriate code to
HIPAA      835                                                                                                                be used.
                                  2100 Bill Payment Information PER Bill Stakeholder indicates HIPAA IG outlines conditions   Modify usage from "R" to "S" as defined
                                  Contact Infromation PER04              which would make it applicable and suggests          in the ANSI X12 guides.
HIPAA      835                                                           changing "R" to "S".
                                  2110 Service Payment Inormation REF Stakeholder recommends using the CLP01 to return Removed segment to align with HIPAA
                                  Prescription Number                    the prescription number instead of this ANSI X12        IG.
                                                                         "not used" segment. Even if the Rx number is not
                                                                         sent in the CLP01 field, the receiving entity should be
                                                                         able to match the paid amount on a claim with the
                                                                         other identification elements without deviating from
                                                                         the ANSI X12 format.
HIPAA      835
Clerical   Acks                   Multiple in Acknowledgment Formats     Segment usage not listed.                            Added segment usage.
                                  997 TS ST Transaction Set Header       The data elements did not contain the data element   Added data element numbers.
Clerical   Acks                                                          number.




Information Management Services                                                Page 26 of 28                                                    Proposed Revisions 20071212
                                             Texas Clean Claim and eBill Companion Guide Revision Tracking 06/21/20

Chapter      Page    Issue                                   Comments
837D                 Loop 2300 REF Original Reference        Inadvertently omitted
Excel                Number (ICN/DCN) Segments are
                     missing
837D                 Loop 2320 AMT Coordination of           Payer loop referenced Patient
Excel                Benefits Payer Paid Amount Field
837I Excel           Loop 2320 AMT Coordination of           Payer loop referenced Patient
                     Benefits Payer Paid Amount Field
837I Excel           Loop 2300 REF Prior Authorization       Inadvertently omitted
                     Number Segment is missing
837I Excel           Loop 2300 REF Medical Record            Inadvertently omitted
                     Number Segment is missing
837P                 Loop 2300 REF Original Reference        Inadvertently omitted
Excel                Number (ICN/DCN) Segments are
                     missing
837P                 Loop 2320 AMT Coordination of           Payer loop referenced Patient
Excel                Benefits Payer Paid Amount Field
Chapter 2 8          CMS-1500 Instructions                   Boxes 11b Employer' Name and 11c Insurance
                                                             Plan Name omitted
Chapter 2 21,22      ADA revised form to support NPI and     Add fields
                     taxonomy codes.
Chapter 5 32         Loop 2300 CLM Claim Information         Omitted reference in Gap Analysis
                     Segment CLM19 field
Chapter 5 46         Incorrect reference to Chapter 7        Reference should state Chapter 8
                     Companion Guide Pharmacy
Chapter 5 47         Change AP to 30
Chapter 5 30, 47     Qualifier AP is used for                Correct value is 30
                     Appeal/Reconsideration transactions
                     where valid value is defined as 30

Chapter 5 41, 48     Reconsideration instructions does not   Language appears to require the same PWK
                     provide specific direction on PWK       segment on the reconsideration that was on the
                     Segment                                 original bill
Chapter 7 50         SBR08 Employment Status Code            Reference in Companion Guide Excel removed,
                                                             SBR08 no longer required
Chapter      59      Use of the term "header" of a           Remove the term header
12                   document caused confusion with the
                     use of header in electronic
                     transactions
Chapter      60      Methods of exchanging electronic        Companion Guide did not include language to
12                   documentation and HL7 formats           indicate a participant is not required to support
                                                             all three methods or direction on the use of HL7
                                                             attachment formats
Multiple     Mult.   Incorrect reference to ANSI format      Reference should state 004010A1
                     version 00410A1
Revision Tracking 06/21/2007

            Resolution
            Added to spreadsheet, line 289


            Corrected reference, line 411

            Corrected reference, line 681

            Added to spreadsheet, line 268

            Added to spreadsheet, line 272

            Added to spreadsheet, line 290


            Corrected reference, line 415

            Added to CMS-1500 instructions

            Added field 52A for Billing Provider and 56A for Rendering
            Provider taxonomy Codes.
            Added to Gap Analysis

            Corrected reference


            Replaced all AP occurrences with 30



            Change language to indicate PWK Segment information may be
            different on the reconsideration transaction

            Removed reference in Companion Guide Word document

            Instructions changed to read "top part of each pager of the
            document, left justified"


            Added language to clarify issue



            Corrected multiple references

								
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