Texas Department of Insurance Division of Workers‟ Compensation Texas Medical State Reporting Electronic Data Interchange EDI

Document Sample
Texas Department of Insurance Division of Workers‟ Compensation Texas Medical State Reporting Electronic Data Interchange EDI Powered By Docstoc
					            Texas Department of Insurance
          Division of Workers‟ Compensation




             Texas Medical State Reporting
            Electronic Data Interchange (EDI)
                  Implementation Guide

                                    December 2007
                                     Version 1.0




Texas Department of Insurance                       Information Management Services
Division of Workers’ Compensation                                      Page 1 of 91
Texas Department of Insurance       Information Management Services
Division of Workers’ Compensation                      Page 2 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)                                                        TABLE OF CONTENTS




TABLE OF CONTENTS


SECTION 1               EDI– AN OVERVIEW ......................................................................................... 7
SECTION 2 – SUBMITTER PROFILE INFORMATION ....................................................... 14
SECTION 3 – ANSI FILE STRUCTURE .................................................................................. 18
SECTION 4 – TEST TRANSMISSION GUIDELINES ........................................................... 38
SECTION 5 – MEDICAL EDI TERMINOLOGY ..................................................................... 42
SECTION 6 – TEXAS REPORTING CRITERIA ..................................................................... 71
SECTION 7 – REFERENCE TABLES ...................................................................................... 72
SECTION 8 – ACKNOWLEDGMENTS/TRAFFIC REPORTS............................................... 74
FAQS ............................................................................................................................................ 84
Appendix A – SFTP Naming Convention ................................................................................... 88
Appendix B – Scenarios ............................................................................................................... 91




Texas Department of Insurance                                                                           Information Management Services
Division of Workers’ Compensation                                                                                          Page 3 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)                   TABLE OF CONTENTS




                                     This page is meant to be blank.




Texas Department of Insurance                                          Information Management Services
Division of Workers’ Compensation                                                         Page 4 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)      SECTION 1 – AN OVERVIEW



SECTION 1 –

ELECTRIONIC DATA INTERCHANGE–AN OVERVIEW
Background

Rules and Regulations
        Texas Workers’ Compensation Act

        Division Rules

Division Processing Actions & Production Schedule
        Division Processing Actions

        Division Production Schedule

Where To Get Help




Texas Department of Insurance                                   Information Management Services
Division of Workers’ Compensation                                                  Page 5 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)      SECTION 1 – AN OVERVIEW




This page is meant to be blank




Texas Department of Insurance                                   Information Management Services
Division of Workers’ Compensation                                                  Page 6 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)                            SECTION 1 – AN OVERVIEW




SECTION 1                  EDI– AN OVERVIEW
Background
The goal for Electronic Data Interchange (EDI) for workers‟ compensation data is improved transmission of
information from its source, such as the health care provider, to insurance carriers, and from the insurance carriers to
state and federal workers‟ compensation regulatory agencies. EDI standards contribute to reduced administrative
paperwork, improved accuracy, faster turnaround for payment of benefits, uniform reporting, and better overall
monitoring of safety factors and payment data.

The International Association of Industrial Accident Boards and Commissions (IAIABC) includes in its membership
numerous state regulatory agencies responsible for administering workers‟ compensation systems. The IAIABC
EDI Implementation Guide for Medical Bill Payment Records
(http://iaiabc.org/i4a/pages/index.cfm?pageid=3349), an adaptation of ANSI 837, details the processes and data
elements for health care claims reporting in the workers‟ compensation environment and extends also to ANSI 835
medical billing data. This IAIABC documentation is the primary resource for Texas Medical EDI 837 information

The American National Standards Institute (ANSI) coordinates the formal development and use of voluntary
standards in a wide range of business areas. Its Accredited Standards Committee, Property and Casualty Task
Group, has published EDI standards (ANSI X12N 837 4010) that address the submission of medical billing and
payment transactions to regulatory agencies. In addition, the Health Care Task Group has published implementation
guides for the submission, acknowledgements, and other transactions related to health care billing and payment
processes.

Prior to 2005, the Texas Workers‟ Compensation Commission required medical billing and payment data to be
submitted in a proprietary format which was not scalable, flexible, or allowed the transmission of all types of health
care services. Since that time, the Texas Department of Insurance, Division of Workers‟ Compensation, has
implemented the IAIABC EDI State Reporting Release 1 standards (ANSI X12N 837); moving Texas workers‟
compensation away from the prior Texas-specific formats and conforming to nationally recognized and accepted
standards. The Division is currently using Secure File Transfer Protocol (SFTP) for Trading Partners to submit
Medical EDI files.

Rules and Regulations
Texas Workers’ Compensation Act
In the Act (http://www.tdi.state.tx.us/wc/act/act.html) items of particular interest for reporting and EDI are:
Chapter 413. Medical Review
   Subchapter A. General Provisions
Chapter 415. Administrative Violations
   Subchapter A. Prohibited Acts

Texas Labor Code §415.002 provides that the failure to comply with a rule may result in an administrative violation.
Under Texas Labor Code §415.021, the administrative penalty shall not exceed $25,000 per day per occurrence with
each day of noncompliance constituting a separate violation. Repeated administrative violations may result in the
issuance of a cease and desist order. In addition, failure to maintain compliance with EDI standards and protocols
may result in the revocation of the trading partner‟s production submission status.

Division Rules
In the Rules (http://www.tdi.state.tx.us/wc/rules/tableofcontents/ruletoc.html) some items of particular interest for
reporting and EDI include:
Chapter 21. Trade Practices


Texas Department of Insurance                                                        Information Management Services
Division of Workers’ Compensation                                                                       Page 7 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)                            SECTION 1 – AN OVERVIEW


Chapter 102. Practices and Procedures -- General Provisions
   Rule 102.5. General Rules for Written Communications To and From the Division
Chapter 134. Benefits: Guidelines for Medical Services, Charges, and Payments
   Rule 134.802. Insurance Carrier Medical Electronic Data Interchange to the Division

Transaction Types
All actions by an insurance carrier that result in the payment or denial of healthcare services are required to be
reported to the Division. In addition, insurance carrier receipt of refunds from a healthcare provider is also required
to be reported to the Division. These requirements also apply to carrier actions as a result of a request for
reconsideration or an appeal of a previous denial (carriers should be certain to use the appropriate claim adjustment
reason code to identify these situations – “W3” or “W4”). Insurance carriers and their trading partners are required
to report these actions within thirty (30) days of the date the action is taken.
The transaction types accepted by the Division on these actions include Original, Cancel, and Replace (00, 01, and
05). Within each transaction type there are data elements that are Mandatory, Conditional or Optional. The Data
Elements in the Reference Tables section of the guide contains the required data element for each transactions type
and indicates if the field is Mandatory, Conditional or Optional.

Excluded Transaction Types
Insurance carriers are not required to report medical billing and payment information if the date of injury occurred
before January 1, 1991.
Administrative actions related to notification to a health care provider about duplicate submissions on bills that have
previously been processed are not required to be reported. For example, a health care provider submits a bill and
before the insurance carrier takes action on the bill, the provider submits a duplicate bill that was not rejected by the
insurance carrier on initial intake processing. The insurance carrier tenders payment on the first received bill, but
sends an explanation of benefits on the second “duplicate” bill indicating that payment had already been processed.
The insurance carrier would be required to report the payment of the initial bill, but not the identification and action
associated with the subsequently filed duplicate bill.
In addition, insurance carriers are not required to report medical billing and payment information for situations
where the health care is rendered outside the United States of America. Country codes for foreign countries are not
contained in the Division‟s database and any transactions containing these codes will be rejected and not processed.

Division Processing Actions & Production Schedule
Division Processing Actions
For a new Trading Partner to actively submit claims EDI data into production, they will need to obtain a copy of the
IAIABC standards and the Texas Medical EDI Implementation Guide. Next, the Trading Partner will need to
submit a complete EDI Trading Partner Profile (DWC-EDI-01), and submit the application to the EDI/TXCOMP
Help Desk. The Trading Partner must also complete and submit the EDI Transmission Profile and the EDI Trading
Partner Insurer/Claim Administrator ID List, which are included in the same form. The EDI/TXCOMP Help Desk
will set-up and assist in the testing process. Once testing is complete and the Trading Partner is approved for
production, the Trading Partner will be able to electronically submit required claims data to the Division. An
acknowledgment will be sent back to the Trading Partner. The acknowledgment will identify any errors that need to
be corrected.
The Texas Medical EDI 837 application processes SFTP transmissions sent by Trading Partners who have been
approved by TDI to send medical data to TDI. The Texas Medical EDI 837 application follows the ANSI
Implementation Guides issued by the IAIABC (IAIABC 837) to interpret transactions received in this format. For
more information, see the IAIABC website (http://www.iaiabc.org/i4a/pages/index.cfm?pageid=1,
http://iaiabc.org/i4a/pages/index.cfm?pageid=3349).

A Trading Partner may transmit either Test or Production data to TDI, and the Trading Partner must set the
Test/Production Indicator in the ISA envelope appropriately for each transmission.


Texas Department of Insurance                                                        Information Management Services
Division of Workers’ Compensation                                                                       Page 8 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)                              SECTION 1 – AN OVERVIEW



A Texas Medical EDI 837 Transaction Set (batch) consists of an ST header segment, one or more detail records
(transactions; medical bills), and an SE trailer segment. If the batch does not contain all three components, the batch
is rejected. A Transaction Set may contain multiple transactions (a batch may contain multiple bills).

The Texas Medical EDI 837 application first checks every inbound file for structural validation. If not valid, may be
unable to process and send a 997 Reject. TDI will perform no further processing of that file. A Trading Partner
must monitor its SFTP directories and error reports.

If the Texas Medical EDI 837 application has passed the structural validity of an inbound file, the application then
checks the individual transactions (bills). If any transaction in the file is rejected, the Transaction Set that contains
that transaction fails; and the application sends the Trading Partner a 997 Functional Acknowledgment that (1)
identifies the Transaction Sets that failed, and (2) rejects the file. TDI will perform no further processing of that
file; the Trading Partner must correct and resubmit the entire content of the file.

If the Medical EDI application accepts all transactions for processing, the application then validates each field (“data
element”) in the transaction using the edit rules. Each data element must meet the defined edits and validation rules
included in this implementation guide. After processing, the application sends the Trading Partner an 824 Detail
Acknowledgment with information about the results of the processing. If a data element fails to pass any edit
validation, then the Medical EDI application will stop all editing and processing of that data element and will
produce the appropriate error message in the 824 Detail Acknowledgment.

Division Production Schedule
Except for maintenance operations during certain weekend hours, the Division‟s environment for incoming medical
billing/payment transaction processing is available for transmissions on a 24/7 basis. However, the Division has
scheduled jobs which run for outgoing transactions which function Monday through Friday, with exception of
holidays and when the Division offices are closed. Outgoing processing usually occurs at: 8:00 a.m., 10:00 a.m.,
1:00 p.m. and 4:00 p.m. In order to avoid picking up incomplete files, trading partners should avoid picking up any
outbound files (824, 997) for 30 minutes after the scheduled start of the Divisions processing schedule.
In order to ensure adequate space on the SFTP server, the Division recommends that insurance carriers delete
transaction files that have already been processed. The Division will delete batches approximately thirty days after
the files are placed in the inbound or outbound folders. As such, insurance carriers are encouraged to actively
monitor production operations and schedules, identify any issues or defects, and quickly notify the TxComp Help
Desk.

Monitoring
In addition to the traffic reports discussed later in these guides, the Division will be developing various reports
related to timeliness of reporting and the accuracy of reporting. These reports will be used to monitor both trading
partner and insurance carrier performance on the data reporting requirements. The responsibility of accurate
reporting resides with the trading partner and the insurance carrier. These entities must be familiar with billing,
payment, and coding standards to ensure accuracy and should not rely simply on the edits implemented by the
Division to determine whether or not they are accurately reporting their data. If potential problems are identified,
the EDI/TXCOMP Help Desk will provide this information to the trading partner and insurance carrier to help
resolve potential issues or seek clarification. In addition, certain findings will be referred to our System Monitoring
staff to determine if further investigative or audit actions are necessary. In addition to timeliness and general
accuracy evaluations, the Division intends on reviewing the percentage of default codes used by individual trading
partners or insurance carriers. If the reports demonstrate that any individual entity is using default codes in a fashion
that exceeds other entities, it is likely that a more expansive audit will be conducted.


Where To Get Help


Texas Department of Insurance                                                          Information Management Services
Division of Workers’ Compensation                                                                         Page 9 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)                SECTION 1 – AN OVERVIEW


EDI/TXCOMP Help-Desk
Texas Department of Insurance/Division of Workers‟ Compensation
(888) 489-2667
txcomp.help@tdi.state.tx.us

The Division
Division of Workers‟ Compensation
Home Page – http://www.tdi.state.tx.us/wc/indexwc.html
EDI Guides – http://www.tdi.state.tx.us/wc/edi/index.html
TXCOMP – https://txcomp.tdi.state.tx.us/TXCOMPWeb/common/home.jsp

IAIABC
International Association of Industrial Accident Boards and Commissions
http://www.iaiabc.org
5610 Medical Circle, Suite 24
Madison, WI, 53719-1295 USA
Telephone: (608) 663-6355
Fax: (608) 663-1546

ANSI
American National Standards Institute
http://www.ansi.org
Email: info@ansi.org
Phone: 212.642.4980
Fax: 212.302.1286
Mailing Address:
ANSI Attn: Customer Service Department
25 W 43rd Street, 4th Floor
New York, NY, 10036




Texas Department of Insurance                                             Information Management Services
Division of Workers’ Compensation                                                           Page 10 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)      SECTION 1 – AN OVERVIEW




This page is meant to be blank




Texas Department of Insurance                                   Information Management Services
Division of Workers’ Compensation                                                 Page 11 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)   SECTION 2 - SUBMITTER PROFILE INFO




SECTION 2 – SUBMITTER PROFILE INFORMATION
EDI Trading Partner Profile


Transmissions Method


Previously Rejected Transactions




Texas Department of Insurance                                          Information Management Services
Division of Workers’ Compensation                                                        Page 12 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)   SECTION 2 - SUBMITTER PROFILE INFO




This page is meant to be blank.




Texas Department of Insurance                                          Information Management Services
Division of Workers’ Compensation                                                        Page 13 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)              SECTION 2 - SUBMITTER PROFILE INFO



 SECTION 2 – SUBMITTER PROFILE INFORMATION
EDI Trading Partner Profile
The Trading Partner profile information is submitted to the Division of Workers‟ Compensation on the EDI Trading
Partner Profile (DWC-EDI-01, http://www.tdi.state.tx.us/forms/dwc/edi01.doc). The profile is required to be
completed by entities intending to send Claim and/or Medical data to the Division using the EDI process.
Information contained on the profile defines the Trading Partner‟s type of business, contact information, sender
specifications, and receiver specifications. In addition, the profile identifies the insurance carriers for whom the
trading partner will be submitting EDI data. Trading Partners must include the insurer customer identification
number for workers‟ compensation carriers as listed in the TXCOMP Claims System. This will also ensure that the
trading partner is using the appropriate FEIN for individual insurance carriers.
Trading Partners are responsible for keeping their profiles up-to-date. If the list of insurance carriers changes after
the trading partner is approved for production and no other changes in the profile are necessary, the trading partner
may send an updated EDI-01 form with the revisions to the EDI Trading Partner Insurer/Claim Administrator ID
List, (page three of the DWC-EDI-01 form). Note: The EDI/TXCOMP Help Desk must be notified if any part of
the Trading Partner profile changes prior to submitting any new data to prevent files from being rejected. If the
transmission mode or specifications are changed, required re-testing of some or all types of transactions may be
required.
The EDI/TXCOMP Help Desk will notify trading partners that they are approved for production submissions after
successful completion of EDI data testing.

Transmissions Method
The Division will accept transmissions through a Secure File Transfer Protocol (STFP). The Data within the file
request may contain confidential or sensitive information that must be safeguarded during transmission to or from
the Trading Partner. For this reason, all file transfers will be exchanged using SFTP.
The initial EDI-01 form submitted by a trading partner is used set up the trading partner SFTP access, directory
profile and points of contact. The trading partner will use SFTP client software that is appropriate for their operating
system environment and can successfully interface with the Division environment. Inbound and outbound naming
conventions can be found in Appendix A.
Files are expected to be placed on the SFTP server by trading partners no later than 5:00 p.m. each business day to
ensure they are deemed received by Division that business day. The Division will place acknowledgements for
completely processed batches on the SFTP server the following day.



Previously Rejected Transactions
All identified errors, corrections, missing data, and changes must be re-transmitted to the Division in order to
maintain accurate/updated information. Rejected reports are not loaded to the Division‟s reporting database.
Therefore, to satisfy filing requirements, rejected reports must be corrected, re-transmitted, and accepted by the
Division.
The Division recognizes that the adjudication processes for compensability and extent of injury occasionally takes a
significant period of time prior to final resolution. As such, certain code values (HCPCS, NDC, etc…) may no
longer be valid at the time the medical billing and payment transactions are submitted to the Division. In order to
accommodate this exception, the Division will retain certain default values that insurance carriers may use in these
limited circumstances. The insurance carrier must ensure that the non-default codes that rejected were valid codes
for the date of service prior to using the default values.




Texas Department of Insurance                                                        Information Management Services
Division of Workers’ Compensation                                                                      Page 14 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)   SECTION 2 - SUBMITTER PROFILE INFO




This page is meant to be blank.




Texas Department of Insurance                                          Information Management Services
Division of Workers’ Compensation                                                        Page 15 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)   SECTION 4 – TEST TRANS. GUIDELINES




SECTION 3 – ANSI FILE STRUCTURE
Overview

File Structure Overview

ISA Envelope

ANSI X12 v4010 Envelope Segments With Texas Comments

EDI 837 Transaction Set

Acknowledgement Files




Texas Department of Insurance                                          Information Management Services
Division of Workers’ Compensation                                                        Page 16 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)   SECTION 4 – TEST TRANS. GUIDELINES




This page is meant to be blank




Texas Department of Insurance                                          Information Management Services
Division of Workers’ Compensation                                                        Page 17 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)              SECTION 4 – TEST TRANS. GUIDELINES




SECTION 3 – ANSI FILE STRUCTURE
Overview
Trading Partners are required to use the IAIABC standards to transmit EDI Claims Data to meet mandatory and
conditional requirements in accordance with Texas Department of Insurance Division of Workers‟ Compensation
(Division) EDI data elements and validation rules. These requirements supplement the IAIABC EDI
Implementation Guide Release 1 for the transmission of medical billing and payment data.

All EDI files use a defined American National Standards Institute (ANSI) file structure. This Texas Companion
Guide is a Texas-specific version of the 837, 997, and 824 information from the IAIABC EDI instructions.

Each text file contains at least three defined, nested components: one Interchange Control Statement (ISA defined
by a header segment and a trailer segment), one Functional Group (FG defined by a header segment and a trailer
segment), and one or more Transaction Sets within the Functional Group (each TS defined by a header segment and
a trailer segment).

TDI requires that all Transaction Sets in a single file contain information from only a single Insurance
Carrier. This enables TDI to track Trading Partner submission rates for an Insurance Carrier for Trading Partner
validation.

TDI suggests that a Trading Partner initially include only one Transaction Set (batch) per EDI 837 test file
submitted. As the Trading Partner becomes more accustomed to using the ANSI file structure, the Trading Partner
can work with TDI and include multiple Transaction Sets in a single submission.

When TDI receives an EDI 837 file that the TDI system can read, TDI performs initial processing of the file and
sends a 997 Functional Acknowledgment to the original sender.

If the file passes the initial checks, TDI sends a 997-Accept message. TDI will process the file and later (typically
within 24 hours) will send an 824-Detail Acknowledgment identifying the transactions that were processed and the
transactions that failed. If any Transaction Set fails, the Trading Partner must correct the failed Transaction Sets and
resubmit the contents of the original EDI 837 file.

If the file does not pass the initial checks, TDI sends a 997-Reject message. TDI will not process the file any further
and will send no additional messages. The Trading Partner must review and interpret the 997-Reject messages,
correct the errors, and resubmit the entire EDI 837 file.

When TDI receives an EDI 837 file that the TDI system cannot read, TDI moves the file to an error log directory.
TDI staff must review the file, identify the Trading Partner, and work with the Trading Partner to correct and
resubmit the file.




File Structure Overview
An ANSI file is made up of sets of data in a structured text file.

The smallest piece of data is the Data Element, which represents a single field or value. As an example, the data
element that represents the Employer Last Name is assigned a specific data element number (DN 43).

The Data Elements are arranged in a defined structure to represent a Segment. As an example, the Geographical
Location segment includes the data elements for city, state code, postal code, and country code.



Texas Department of Insurance                                                       Information Management Services
Division of Workers’ Compensation                                                                     Page 18 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)             SECTION 4 – TEST TRANS. GUIDELINES


Sets of Segments make up Loops. As an example, Loop ID Employer Named Insured Information includes name,
address, geographical location, identification number, and contact number segments.

Every 837 file must contain at least one Transaction Set. The set of Loops in a Transaction Set may provide
information for a single medical bill or many bills. The data elements, segments, and loops required depend on the
types of bills that the file contains.

A File is the entire submission. Every 837 file for the current Texas implementation must contain a defined set of
data elements, segments, and loops required in the file. The file includes one ISA header and trailer, one Functional
Group header and trailer, and the Transaction Sets (pairs of headers and trailers and the medical billing data included
between them).




ISA Envelope
Every ANSI EDI file is identified by elements that define an ISA envelope. The ISA envelope provides information
that identifies:
      the sender,
      the receiver, and
      critical identifying information on the file (the type of data contained in the file; time sent; date sent;
          tracking number, …).

The ISA envelope includes the ISA, GS, GE, and IEA segments shown below.


ISA Envelope:
ISA (Interchange Control header segment)
         GS (Functional Group header segment)

         Transaction Set or Sets: ST/SE pairs (header segment and trailer segment and the medical billing
         data content between those segments). An 837 Transaction Set also is called a Batch.
         Optional Transaction Set 2: ST/SE
         Optional Transaction Set 3: . . .

         GE (trailer segment; end of the Functional Group)
IEA (trailer segment; end of the ISA Envelope; end of the file)


The ISA envelope for an inbound EDI 837 file being sent to TDI provides information that identifies:
     the sender: the Trading Partner submitting the file,
     the receiver: TDI (DWC), and
     identifying information that defines the file as a specific EDI 837 file.

TDI uses the Federal Employer ID Number (FEIN) as the identifier for the sender and the receiver of an EDI file.
The Trading Partner FEIN for the Texas EDI system is the FEIN that was filed when the Trading Partner submitted
the Form EDI-01, EDI Trading Partner Application and Profile. The TDI FEIN is 746000119. Each number is
formatted as nine continuous digits.

The ISA envelope for the outbound 997 and 824 Acknowledgments from TDI to the Trading Partner includes the
same data elements, but the information in the Transaction Sets tells whether the data in each Transaction Set in the
837 was read. For the 997 and the 824, the ISA envelope identifies:
     the sender (TDI),
     the receiver (the original Trading Partner/sender of the 837), and
     identifying information relating the response to the original inbound 837 file.


Texas Department of Insurance                                                      Information Management Services
Division of Workers’ Compensation                                                                    Page 19 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)                SECTION 4 – TEST TRANS. GUIDELINES


Required Delimiters
For Texas Medical EDI Transactions, insurance carrier trading partners are required to use the following delimiters:

        Data element separator -- * (asterisk). Separates the data elements in a segment

         Example: ST*837*82341
         For an 837 file, header for the Transaction Set with Control Number 82341
         If an optional field is blank, do not insert a space; the file will contain two asterisks next to one another.

        Sub-element separator – : (colon). Separates sub-elements in the same data element, such as code
         modifiers.

         Example: HI*BK:820*BF:873.9
         Principal diagnosis code is 820, admitting diagnosis code is 873.9 (modifiers associate the use of the
         diagnosis codes).

        Segment Terminator -- ~ (tilde). Indicates the end of a segment. In an EDI file, do not follow a tilde by a
         line space (space-bar space) or line break character.

         Example: SE*56*82341~
         Transaction Set trailer; Transaction Set 82341 contains 56 segments.


Functional Errors
The two basic types of file failure are functional and structural. EDI 837 files that fail functional validation will
not generate a 997 Acknowledgment. A Trading Partner must monitor its SFTP mailboxes to determine whether an
expected 997 was not received. Files that fail functional validation, or the resulting error logs, must be reviewed
against the ISA envelope segments to determine the error for each file. A Trading Partner may find it beneficial to
view these files with a hex editor to locate hidden or missing characters in the envelope segments.

Common functional problems include:
    Missing segment terminators (~)
    Line breaks (carriage returns) or line spaces (space-bar spaces) between segments.
    Not enough characters in the ISA06 and ISA08 segments. The Interchange Sender ID (Trading Partner
      ZIP) and Receiver ID (TDI ZIP) segments specify that the field length is exactly 15 characters, although
      the data required (ZIP) is only 9 digits. Include space-bar spaces to fill the remainder of the segment.
    Invalid ISA14: Acknowledgment Requested should always be 0 (zero).
    Inappropriate ISA15: Usage Indicator should be „t‟ for Test, „p‟ for Production.




Texas Department of Insurance                                                         Information Management Services
Division of Workers’ Compensation                                                                       Page 20 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)                        SECTION 4 – TEST TRANS. GUIDELINES




ANSI X12 v4010 Envelope Segments With Texas Comments
ANSI Version 1.0, 04/19/05

IMPLEMENTATION
                         INTERCHANGE CONTROL HEADER
Purpose:                To start and identify an interchange of zero or more functional groups and interchange-
                        related control segments

Notes:                  1. The ISA is a fixed record length segment and all positions within each of the data
                        elements must be filled. The first element separator defines the element separator to be
                        used through the entire interchange. The segment terminator used after the ISA defines the
                        segment terminator to be used throughout the entire interchange.
                        2. Spaces in the example are represented by “.” for clarity.

Example:                ISA* 00* ..........*00*……….* ZZ*76533224…….* ZZ*746000119......*030923*1901*U*
                         00401*123456789* 0* T* :~
ELEMENT SUMMARY
USAGE               REF. DES.   DATA ELEMENT     NAME                                                                      ATTRIBUTES


MUST USE            ISA01         I01          Authorization Information Qualifier                                        M    ID      2/2
                                               Code to identify the type of information in the Authorization Information

                                               CODE       DEFINITION
                                               00         NO AUTHORIZATION INFORMATION PRESENT

MUST USE            ISA02         I02          Authorization Information                                                  M    AN      10/10
                                               Information used for additional identification or authorization of the interchange sender or
                                               the data in the interchange; the type of information is set by the Authorization Information
                                               Qualifier (I01)

                                                          INSERT SPACES

MUST USE            ISA03         I03          Security Information Qualifier                                             M    ID      2/2
                                               Code to identify the type of information in the Security Information. Since EDI837
                                               transactions are sent through SFTP, Security Information is not necessary.

                                               CODE DEFINITION
                                               00         NO SECURITY INFORMATION PRESENT

MUST USE            ISA04         I04          Security Information                                                       M    AN      10/10
                                               This is used for identifying the security information about the interchange sender or the data
                                               in the interchange; the type of information is set by the Security Information Qualifier (I03)

                                                          INSERT SPACES

MUST USE            ISA05         I05          Interchange ID Qualifier                                                   M    ID      2/2
                                               Qualifier to designate the system/method of code structure used to designate the sender or
                                               receiver ID element being qualified
                                               THIS ID QUALIFIES THE SENDER IN ISA06.
                                               CODE       DEFINITION
                                               ZZ         MUTUALLY DEFINED

MUST USE            ISA06         I06          Interchange Sender ID                                                      M    AN      15/15
                                               Identification code published by the sender for other parties to use as the receiver ID to
                                               route data to them; the sender always codes this value in the sender ID element
                                               CODE            DEFINITION




Texas Department of Insurance                                                                    Information Management Services
Division of Workers’ Compensation                                                                                  Page 21 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)                 SECTION 4 – TEST TRANS. GUIDELINES


                                        FEIN      9 DIGIT TRADING PARTNER FEIN AS FILED IN THE EDI-01 FORM PLUS
                                                  SPACES; OR TDI FEIN (746000119) PLUS SPACES


MUST USE            ISA07      I05      Interchange ID Qualifier                                                  M     ID     2/2
                                        Qualifier to designate the system/method of code structure used to designate the sender or
                                        receiver ID element being qualified
                                        THIS ID QUALIFIES THE RECEIVER IN ISA08.
                                        CODE      DEFINITION
                                        ZZ        MUTUALLY DEFINED

MUST USE            ISA08      I07      Interchange Receiver ID                                                   M     AN     15/15
                                        Identification code published by the receiver of the data. When sending, it is used by the
                                        sender as their sending ID, thus other parties sending to them will use this as a receiving ID
                                        to route data to them.
                                        CODE        DEFINITION
                                        FEIN      TDI FEIN (746000119) PLUS SPACES; or 9 DIGIT TRADING PARTNER
                                                  FEIN AS FILED IN THE EDI-01 FORM PLUS SPACES

MUST USE            ISA09      I08      Interchange Date                                                          M     DT     6/6
                                        Date of the interchange
                                        The date format is YYMMDD and is provided by the sender.

MUST USE            ISA10      I09      Interchange Time                                                          M     TM 4/4
                                        Time of the interchange
                                        The time format is HHMM and is provided by the sender.


MUST USE            ISA11      I10      Interchange Control Standards Identifier                                  M     ID     1/1
                                        Code to identify the agency responsible for the control standard used by the message that is
                                        enclosed by the interchange header and trailer
                                        CODE      DEFINITION
                                        U         U.S. EDI COMMUNITY OF ASC X12

MUST USE            ISA12      I11      Interchange Control Version Number                                        M     ID     5/5
                                        This version number covers the interchange control segments
                                        CODE      DEFINITION
                                        00401     APPROVED VERSION

MUST USE            ISA13      I12      Interchange Control Number                                                M     N0     9/9
                                        A control number assigned by the interchange sender

                                        The Interchange Control Number, ISA13, must be identical to the associated
                                        Interchange Trailer IEA02.


MUST USE            ISA14      I13      Acknowledgment Requested                                                  M     ID     1/1
                                        Code sent by the sender to request an interchange acknowledgment (TA1)

                                        CODE      DEFINITION
                                        0          NO ACKNOWLEDGMENT REQUESTED

                                        Note: A file that is sent to TDI that can be read will automatically receive a
                                                997 acknowledgement.

MUST USE            ISA15      I14      Usage Indicator                                                           M     ID     1/1
                                        Code to indicate whether data enclosed by this interchange envelope is test, production or
                                        information
                                        CODE      DEFINITION
                                        P         PRODUCTION DATA
                                        T         TEST DATA


Texas Department of Insurance                                                             Information Management Services
Division of Workers’ Compensation                                                                           Page 22 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)                SECTION 4 – TEST TRANS. GUIDELINES



MUST USE            ISA16      I15      Component Element Separator                                             M            1/1
                                        Type is not applicable; the component element separator is a delimiter and not a data
                                        element; this field provides the delimiter used to separate component data elements within a
                                        composite data structure; this value must be different than the data element separator and
                                        the segment terminator

                                        : - COLON




Texas Department of Insurance                                                            Information Management Services
Division of Workers’ Compensation                                                                          Page 23 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)                      SECTION 4 – TEST TRANS. GUIDELINES


IMPLEMENTATION
                         INTERCHANGE CONTROL TRAILER
Purpose:                To define the end of an interchange of zero or more functional groups and interchange-
                        related control segments

Example:                IEA*1*123456789~                    End of ISA Envelope; indicates one Functional Group
                         processed
ELEMENT SUMMARY
USAGE               REF. DES.   DATA ELEMENT     NAME                                                                  ATTRIBUTES


MUST USE            IEA01         I16          Number of Included Functional Groups                                    M   N0   1/5
                                               A count of the number of functional groups included in an interchange

                                               TDI requires that there be only one Functional Group in an interchange.

MUST USE            IEA02         I12          Interchange Control Number                                              M   N0   9/9
                                               A control number assigned by the interchange sender

                                               Number must match number in ISA13




Texas Department of Insurance                                                                 Information Management Services
Division of Workers’ Compensation                                                                               Page 24 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)                         SECTION 4 – TEST TRANS. GUIDELINES


IMPLEMENTATION
                         FUNCTIONAL GROUP HEADER
Purpose:                To indicate the beginning of a functional group and to provide control information

Example:                GS*HC*765332244……*746000119……….* 20030923* 1901* 000000001*X*004010~
                        Beginning segment, Functional Group

ELEMENT SUMMARY
USAGE               REF. DES.   DATA ELEMENT       NAME                                                                   ATTRIBUTES


MUST USE            GS01          479          Functional Identifier Code                                                M     ID     2/2
                                               Code identifying a group of application related transaction sets
                                               CODE       DEFINITION
                                               HC         HEALTH CARE CLAIM (837)

MUST USE            GS02          142          Application Sender’s Code                                                 M     AN     2/15
                                               Code identifying party sending transmission; codes agreed to by trading partners
                                               CODE           DEFINITION
                                               ZIP        9 DIGIT TRADING PARTNER ZIP CODE PLUS SPACES; OR 9 DIGIT TDI
                                                          ZIP CODE (787441609) PLUS SPACES

                                               This is the same ID as in ISA06.

MUST USE            GS03          124          Application Receiver’s Code                                               M     AN     2/15
                                               Code identifying party receiving transmission. Codes agreed to by trading partners
                                               CODE         DEFINITION
                                               ZIP        9 DIGIT TDI ZIP CODE (787441609) PLUS SPACES; OR 9 DIGIT
                                                          TRADING PARTNER ZIP CODE PLUS SPACES

MUST USE            GS04          373          Date                                                                      M     DT     8/8
                                               Date expressed as CCYYMMDD
                                               SEMANTIC: GS04 is the group date.

                                               Use this date for the functional group creation date.

MUST USE            GS05          337          Time                                                                      M     TM 4/8
                                               Time expressed in 24-hour clock time as follows: HHMM, where H = hours (00-23), M =
                                               minutes (00-59).
                                               SEMANTIC: GS05 is the group time.

                                               Use this time for the creation time.


MUST USE            GS06          28           Group Control Number                                                      M     N0     1/9
                                               Assigned number originated and maintained by the sender
                                               SEMANTIC: The data interchange control number GS06 in this header must be identical to
                                               the same data element in the associated functional group trailer, GE02.


MUST USE            GS07          455          Responsible Agency Code                                                   M     ID     1/2
                                               Code used in conjunction with Data Element 480 to identify the issuer of the standard
                                               CODE         DEFINITION
                                               X            ACCREDITED STANDARDS COMMITTEE X12

MUST USE            GS08          480          Version / Release / Industry Identifier Code                              M     AN     1/12
                                               Code indicating the version, release, sub release, and industry identifier of the EDI standard
                                               being used, including the GS and GE segments; if code in DE455 in GS segment is X, then
                                               in DE 480 positions 1-3 are the version number; positions 4-6 are the release and sub
                                               release, level of the version; and positions 7-12 are the industry or trade association
                                               identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other
                                               formats are allowed



Texas Department of Insurance                                                                    Information Management Services
Division of Workers’ Compensation                                                                                  Page 25 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)          SECTION 4 – TEST TRANS. GUIDELINES


                                        CODE              DEFINITION
                                        004010 ANSI RELEASE 004010




Texas Department of Insurance                                                 Information Management Services
Division of Workers’ Compensation                                                               Page 26 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)                       SECTION 4 – TEST TRANS. GUIDELINES


IMPLEMENTATION
                         FUNCTIONAL GROUP TRAILER
Purpose:                To indicate the end of a functional group and to provide control information

Example:                GE*1*000000001~ End of Functional Group; indicates one transaction set in Functional
                        Group 000000001
ELEMENT SUMMARY
USAGE               REF. DES.   DATA ELEMENT     NAME                                                                   ATTRIBUTES


MUST USE            GE01          97           Number of Transaction Sets Included                                     M     N0    1/6
                                               Total number of transaction sets included in the functional group or interchange
                                               (transmission) group terminated by the trailer containing this data element

                                               A transaction set is defined by one ST/SE pair


MUST USE            GE02          28           Group Control Number                                                    M     N0    1/9
                                               Assigned number originated and maintained by the sender

                                               SEMANTIC: The data interchange control number GE02 in this trailer must be identical to the
                                               same data element in the associated functional group header, GS06.

                                               Must match the number in GS06




Texas Department of Insurance                                                                   Information Management Services
Division of Workers’ Compensation                                                                                 Page 27 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)             SECTION 4 – TEST TRANS. GUIDELINES




EDI 837 Transaction Set
The EDI 837 file structure of a Transaction Set tracks information under the Insurance Carrier (IC), the Employer
(EM), and the Claimant (CL).

A Hierarchical Level (HL) statement identifies the category of participant: „IC‟, „EM‟, or „CL‟ in a relationship
comparable to a three-level outline.
     A higher level is a „Parent.‟
     A lower level is a „Child‟ of the last prior Parent.
The 837 submission always must contain at least one IC, one EM, and one CL Hierarchical Level.

The Hierarchical Levels are numbered consecutively in one continuous sequence. The level number itself does not
identify the category of participant.

Like an outline, each Hierarchical Level controls the content that follows it until there is another Hierarchical Level
introduction at the same level or a Parent level.
      An IC Hierarchical Level „Parent‟ controls the content that follows it until there is another IC Hierarchical
         Level statement. (Any EM or CL statement introduced refers to that Insurance Carrier.)
      An EM Hierarchical Level „Parent‟ controls all CL level statements until there is another EM or IC
         statement. An EM is the „Child‟ of the last prior IC.
      A CL Hierarchical Level is the „Child‟ of the last prior EM and also belongs to the last IC.
The last Hierarchical Level must be a CL.

There is never a Hierarchical Level with no content following. Each Parent must have at least one Child; if not,
there is no need to include the Parent in the 837 submission.

For each Claimant (CL) there is one or more Claims (medical bills). Each Claim includes detailed information
about the services being billed; and there can be multiple Claims submitted for a Claimant.

The 837 hierarchical structure enables Trading Partners to report medical bills for multiple Insurance Carriers,
Employers, and Claimants in a single file; each file must contain at least one Insurance Carrier, one Employer, one
Claimant, one Bill, and one Line Item.
      If there is no Claimant, there is no way to assign the Claim.
      If there is no Claim (billing information), there is no need to include the Claimant in the 837 submission.
Once a Claimant Hierarchical Level is included in the 837 submission, all Claims and bills are treated as belonging
to that Claimant until another Claimant, Employer, or Insurance Carrier is included.


Transaction Set Examples
An example of the Transaction Set structure contains loops such as the following.

Transaction Set Header segment (ST)
Sender Information for the Trading Partner
Receiver Information for TDI
         Insurance Carrier 1 –     Hierarchical Level 1 (Parent)

         Employer 1 for this Insurance Carrier - Hierarchical Level 2 (Employer is a Child to the last Carrier listed
                and a Parent to the Claimant or Claimants that follow)

         Claimant 1 for this Employer - Hierarchical Level 3 (Claimant is a Child to the last Employer listed)
         Billing (Claim, „CLM‟ A Claim is attached to a Claimant, and thus to the Employer and the Insurance
         Carrier. Each CLM contains one or more Line Items, „LX,‟ to define the charges that are requested to be
         paid.)


Texas Department of Insurance                                                       Information Management Services
Division of Workers’ Compensation                                                                     Page 28 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)               SECTION 4 – TEST TRANS. GUIDELINES


                                                Bill Data
                                                Provider Data
                                                Network Data
                                                Line Item Data, „LX‟
                                                Service Adjustment Line Data
         Billing (repeat for each bill for this Claimant)

         Next Claimant (Claimant 2 for this Employer) - Hierarchical Level 4 (Claimant is a Child to the last
         Employer listed)
         Billing for this Claimant

         Next Claimant (Claimant 3 for this Employer) - Hierarchical Level 5 (Claimant is a Child to the last
         Employer listed)
         Billing for this Claimant

         Next Employer (Employer 2 for this Insurance Carrier) - Hierarchical Level 6 (Employer is a Child to the
         last Carrier listed and a Parent to the Claimant or Claimants that follow)

         Next Claimant (Claimant 1 for this Employer) - Hierarchical Level 7 (Claimant is a Child to the last
         Employer listed)
         Billing for this Claimant

         Insurance Carrier 2 -Hierarchical Level 8 (Parent). There must be at least one Employer (hl*9*) and one
         Claimant (hl*10*) for this Insurance Carrier. NOTE: Because of TDI requirements for submission
         success rates, Texas prefers that a file include information for only one Insurance Carrier.
         Transaction Set Trailer (ST)

The following is a different representation of the same hierarchical looping within a Transaction Set (everything
from one ST statement through its following SE statement). Remember, Hierarchical Levels are numbered
continuously, and the IC, EM, or CL designation identifies the information contained in the Hierarchical Level.

 HL ID #                    Parent ID #       Description                                            Child Code
 1                          NA                1st Carrier
                                                                                                     1=Yes
                            1                 1st Employer of 1st Carrier
        2                                                                                            1=Yes
                   3        2                 Claimant 1 of 1st Employer under 1st Carrier
                                                                                                     0=No
                   4        2                 Claimant 2 of 1st Employer under 1st Carrier
                                                                                                     0=No
            5               1                 2nd Employer of 1st Carrier
                                                                                                     1=Yes
                   6        5                 Claimant 1 of 2nd Employer under 1st Carrier
                                                                                                     0=No
                   7        5                 Claimant 2
                                                                                                     0=No
 8                          NA                2nd Carrier
                                                                                                     1=Yes
            9               8                 1st Employer of 2nd Carrier
                                                                                                     1=Yes
                   10       9                 Claimant 1 of 1st Employer under 2nd Carrier
                                                                                                     0=No




Texas Department of Insurance                                                      Information Management Services
Division of Workers’ Compensation                                                                    Page 29 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)            SECTION 4 – TEST TRANS. GUIDELINES




Sample EDI 837 File
The following is an example of a complete EDI 837 file containing the minimum required structure – ISA Envelope
(header & trailer), Functional Group (header & trailer), Transaction Set (header & trailer), 1 Carrier, 1 Employer, 1
Claimant, 1 Bill, and 1 Line Item. To enhance readability, line breaks have been added after the segment
terminators (~) to show the structure of the file. A file submitted in this manner would fail structural validation.

ISA*00*      *00*      *ZZ*765332244    *ZZ*746000119  *030923*1901*U*00401*123456789*0*T*:~
         BEGINNING SEGMENT, ISA ENVELOPE
GS*HC*765332244*746000119*20030923*1901*000000001*X*004010~
         BEGINNING SEGMENT, FUNCTIONAL GROUP HEADER
ST*837*82341~ BEGINNING SEGMENT, TRANSACTION SET (BATCH)
BHT*0080*00*54321*20030923*1900~
NM1*10*2******FI*765332244~ SENDER LOOP
N4***752341234~
NM1*40*2******FI*746000119~ RECEIVER LOOP
N4***787441609~
HL*1**20*1~     BEGINNING SEGMENT, CARRIER LOOP – Hierarchical Level 1
DTP*582*RD8*20030802-20030915~
NM1*CA*2*Texas Insurance Company*****FI*765332244~
N4***752341234~
NM1*CX*2*Texas Insurance Company*****FI*765332244~
N4***752341234~
HL*2*1*EM*1~ BEGINNING SEGMENT, EMPLOYER LOOP - Hierarchical Level 2
NM1*36*2*Bagels Etc.~
N3*234 Main Street~
N4*Dallas*TX*72314*USA~
REF*IG*147643A472~
PER*IC**WP*2144721462~
HL*3*2*CL*0~ BEGINNING SEGMENT, CLAIMANT LOOP - Hierarchical Level 3
DTP*558*D8*20020918~
NM1*CC*1*Davidson*Darlene****34*224173272~
N3*5720 Green Dr.~
N4*Dallas*TX*72309*USA~
DMG*D8*19690604*F*I~
REF*Y1*14000714D~
PER*CT**TE*2148365527~
CLM*99999*575.02**DM*12:B*Y**********Y***00~        BEGINNING SEGMENT, CLAIM (BILLING
DATA)
DTP*050*D8*20030906~
DTP*434*D8*20030903~
DTP*666*D8*20030910~
AMT*TP*572~
REF*DD*4564656~
REF*EJ*470077~
REF*2I*10000001~
HI*BK:820*BF:873.9~
NM1*85*2*Austin Billing Co.*****FI*345678912~       BEGINNING SEGMENT, PROVIDER DATA
N3*23 Dove Street~
N4*Austin*TX*78200*USA~
REF*G1*0011~
NM1*82*2*Medical Supplies, Inc.~
REF*0B*DMTX~
NM1*61*2*Medical Supplies, Inc.~


Texas Department of Insurance                                                      Information Management Services
Division of Workers’ Compensation                                                                    Page 30 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)          SECTION 4 – TEST TRANS. GUIDELINES


N3*2700 Medical Drive~
N4*Dallas*TX*72311*USA~
NM1*DN*1*Boudreaux*James*A*****34*GP~
REF*0B*MDJ1234TX~
LX*1~ BEGINNING SEGMENT, LINE ITEM DATA
SV1*HC:A4320*25.02*UN*6*12**2~
DTP*472*RD8*20030824-20030824~
SVD*XX*22~
CAS*CO*131*3.02*0*45*0*0~ SERVICE ADJUSTMENT LINE DATA
CLM Another Claim for this Claimant would start here.
HL*4* Another Hierarchical Level would start here. See Note below.
SE*56*82341~ END OF TRANSACTION SET (BATCH)
GE*1*000000001~                                   END OF FUNCTIONAL GROUP; indicates 1 Transaction Set
IEA*1*123456789~       END OF ISA ENVELOPE; indicates 1 Functional Group processed

NOTE: HL*4 could introduce a new Claimant (still the child of the last Employer at HL 2); a new Employer (still
the child of the last Insurance Carrier at HL 1); or a new Insurance Carrier. Each new parent Hierarchical Level
must have appropriate children levels.




Texas Department of Insurance                                                   Information Management Services
Division of Workers’ Compensation                                                                 Page 31 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)               SECTION 4 – TEST TRANS. GUIDELINES




Acknowledgment Files
The two possible acknowledgments generated in response to an 837 transmission are, 1) 997 Functional
Acknowledgment, and 2) 824 Detail Acknowledgment, also identified by ANSI as the Application Advice.

The 997 response to an 837 is an acknowledgment by TDI to the Trading Partner indicating:
     The 837 file has been received by the TDI system,
     The TDI system was able to identify the sender and intended receiver,
     The TDI system validated the file structure to be an 837 file, and
     The TDI system accepted or reject the file based on results of the structural validation

The 824 is an acknowledgment to the Trading Partner indicating the results of the data content edits specific to the
Texas Medical EDI 837 application. The bills inside the file are accepted or rejected based on the results of the data
content edits.

837 files that fail functional or structural validation will not generate an 824 Detail Acknowledgment.
837 files that contain multiple transaction sets (ST/SE) within one file will generate an 824 only if all of the
transaction sets (ST/SE) pass structural validation.


997 Acknowledgment File Format

The examples below include ISA and FG header and trailer segments for a 997 Acknowledgment.

Within the ISA envelope (ISA and FG segments), the following segments are included in the current Texas
implementation of the 997:

ST - Transaction Set Header: Contains the acknowledgment type (997) and a unique number assigned by TDI, the
originator of the acknowledgment file.
                   Example: ST*997*1234

AK1 - Functional Group Response Header: Contains the Functional ID and Group Control Number cited in the
GS segment of the originating 837 file.
                 Example: AK1*000000001

AK2 - Transaction Set Response Header: Contains the Transaction Set ID and Transaction Set Control Number
cited in the ST segment of the originating 837 file.
                   Example: AK2*837*82341

AK5 - Transaction Set Response Trailer: Contains the status of the Transaction Set (whether the corresponding
AK2 segment was accepted or rejected). If the Transaction Set was rejected, the AK5 identifies up to 5 syntax
errors at the transaction level.
                    Example: AK5*A~

AK9 - Functional Group Response Trailer: Contains the status of the entire file (accepted or rejected), the total
number of transaction sets included (from the GE segment in the originating 837 file).
                 Examples:          AK9*A*1*1*1
                                    AK9*R*15*14*1

SE - Transaction Set Trailer: Contains the number of segments in the Transaction Set and a unique number
assigned by the originator of the acknowledgment file
                  Example: SE*27*1234




Texas Department of Insurance                                                        Information Management Services
Division of Workers’ Compensation                                                                      Page 32 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)          SECTION 4 – TEST TRANS. GUIDELINES




997 Examples
The 997 examples below indicate whether an 837 will or will not generate an 824. The actual 997 file contains no
line breaks, and there is no spacebar space that follows a segment terminator (tilde).


Example 1: 997-Accept

      File with Single ST/SE Transaction Set: 837 Passed Structural Validation –824 Will Be Generated
ISA*00*       *00*      *ZZ*746000119     *ZZ*765332244
*060405*0859*U*00401*000000639*0*T*:~GS*FA*746000119*765332244*20060405*085903*6390001*X*00
4010~ST*997*0001~AK1*HC*1~AK2*837*82341~AK5*A~AK9*A*1*1*1~SE*6*0001~GE*1*6390001~IEA*1
*000000639~


Example 2: 997-Reject

      File with Single ST/SE Transaction Set: 837 Failed Structural Validation – No 824 Will Be Generated
ISA*00*       *00*      *ZZ*746000119     *ZZ*765332244
*060405*0909*U*00401*000000641*0*T*:~GS*FA*746000119*765332244*20060405*090933*6410001*X*00
4010~ST*997*0001~AK1*HC*1~AK2*837*62341~AK5*R*4*4~AK9*R*1*1*0~SE*6*0001~GE*1*6410001~I
EA*1*000000641~


Example 3: 997-Reject

      File with Multiple ST/SE Transaction Sets, 1Structural Failure: No 824 Will Be Generated
ISA*00*       *00*      *ZZ*746000119     *ZZ*765332244
*060405*0909*U*00401*000000641*0*T*:~GS*FA*746000119*765332244*20060405*090933*6410001*X*00
4010~ST*997*0001~AK1*HC*1~AK2*837*000000001~AK5*R*5*5~AK2*837*000000002~AK5*A~AK2*837
*000000003~AK5*A~AK2*837*000000004~AK5*A~AK9*R*4*4*3~SE*12*0001~GE*1*6410001~IEA*1*000
000641~




Texas Department of Insurance                                                   Information Management Services
Division of Workers’ Compensation                                                                 Page 33 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)             SECTION 4 – TEST TRANS. GUIDELINES




824 Acknowledgment File Format

The examples below include ISA and FG header and trailer segments for an 824 Detail Acknowledgment.

Within the ISA envelope (ISA and FG segments), and for each Transaction Set, the following segments are included
in the current Texas implementation of the 824:

OTI - Original Transaction Identification: Used to identify the edited Transaction Set, and the level at which the
results of the edit are reported: Batch or Transaction level. Within each file, there will be 1 OTI segment for each
Batch/Transaction Set (ST/SE), and 1 OTI segment for each Transaction (Bill) within the batch. Valid
acknowledgment codes for Texas are:
BA Batch Accepted
TA Transaction Accepted
TR Transaction Rejected
       NOTE: TDI does not use the ANSI option TE, Transaction Accepted with Errors.

      For the current Texas implementation, all errors are reported at the transaction level

      Examples: OTI*BA*55*54321***20030923*1900***837~    BATCH ID-Batch Accepted
        DTM*009*20060307*0752~       824 PROCESSED DATE/TIME STAMP
                   OTI*TR*55*R2005***20030923*1900***837~                 BILL ID-Bill Rejected

         LQ - Industry Code: Contains element error code. The full list of error codes are listed by DN and Data
         Element Name in the IAIABC Medical Bill Payment Implementation Guide, Section 4 Data Elements List
         and Edit Matrix. Some of the most common codes include:
                  001 – Mandatory field not present
                  028 – Must be numeric
                  030 – Must be A-Z, 0-9, or spaces
                  039 – No match on database
                  058 – Code/ID invalid

         RED - Related Data: Contains a copy of the bad data and number (DN) of the element in error. Contains
         supplemental information such as the billing line number where the error occurs. The following Code List
         Qualifier Codes are used to indicate either invalid data or supplemental information:
                  GJ – Reject Indicator Code: Used in this segment to indicate bad data and the DN of the element
                  in error
                  A9 – Supplemental Data: Used to indicate the DN associated with supplemental information.

         Example 1 – Invalid code occurred in DN 522:
            LQ*FZ*058~                                                                     “058 – Code/ID invalid”
            RED*820**IB**GJ*522~                                                        BAD DATA = 820; DN #522

         Example 2:
            LQ*FZ*001~                                                          “001 – Mandatory field not present”
            RED*1**IB**A9*547~                       DN 547 = Line Number; error occurred in billing line number 1
            RED*1* *IB**GJ*552~                    Blank space between asterisk 2 and 3 indicates no data in DN 552

Any bills rejected in an 824 acknowledgment must be corrected and resubmitted to TDI.




Texas Department of Insurance                                                      Information Management Services
Division of Workers’ Compensation                                                                    Page 34 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)             SECTION 4 – TEST TRANS. GUIDELINES




824 Examples
Following are examples of 824 files indicating the status of the system edits. An actual 824 file contains no line
breaks, and there is no line space that follows a segment terminator (tilde).

Example 1 – One Transaction Rejected With Reject Indicator Code
ISA*00*      *00*     *ZZ*746000119     *ZZ*765332244
*060601*1105*U*00401*000000681*0*T*:~GS*AG*746000119*765332244*20060601*110507*6810001*X*00
4010~ST*824*0001~BGN*11*MED01*20030923*1900~N1*10**FI*746000119~N4***787441609~N1*40**FI*
765332244~N4***752341234~OTI*BA*55*54321***20030923*1900***837~DTM*009*20060601*110437~
OTI*TR*55*4564656***20030923*1900***837~DTM*009*20060601*110437~LM*IB~LQ*FZ*039~RED*765
332244**IB**GJ*6~SE*14*0001~GE*1*6810001~IEA*1*000000681~

Example 2 – Multiple Transactions Rejected
ISA*00*      *00*      *ZZ*746000119      *ZZ*202036689
*060523*1056*U*00401*000000139*0*T*:~GS*AG*746000119*202036689*20060523*105652*1390001*X*00
4010~ST*824*0001~BGN*11*MED01*20060309*1652~N1*10**FI*746000119~N4***787047491~N1*40**FI*
202036689~N4***606613600~OTI*BA*55*2***20060309*1652***837~DTM*009*20060523*105639~OTI*
TA*55*0088766860***20060309*1652***837~DTM*009*20060523*105639~OTI*TA*55*0090466521***200
60309*1652***837~DTM*009*20060523*105639~OTI*TR*55*0090726341***20060309*1652***837~DTM*0
09*20060523*105639~LM*IB~LQ*FZ*001~RED*
**IB**GJ*516~LQ*FZ*058~RED*836.20**IB**GJ*522~OTI*TA*55*0090596462***20060309*1652***837~
DTM*009*20060523*105639~OTI*TA*55*0090577423***20060309*1652***837~DTM*009*20060523*10563
9~OTI*TR*55*0083943162***20060309*1652***837~DTM*009*20060523*105639~LM*IB~LQ*FZ*001~RE
D* **IB**GJ*516~LQ*FZ*001~RED*1**IB**A9*547~RED*
**IB**GJ*557~LQ*FZ*001~RED*1**IB**A9*547~RED*
**IB**GJ*731~LQ*FZ*001~RED*1**IB**A9*547~RED*
**IB**GJ*732~SE*38*0001~GE*1*1390001~IEA*1*000000139~




Texas Department of Insurance                                                      Information Management Services
Division of Workers’ Compensation                                                                    Page 35 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)   SECTION 4 – TEST TRANS. GUIDELINES



SECTION 4 – TEST TRANSMISSION GUIDELINES
STEP 1 Complete EDI Trading Partner Application and Profile

STEP 2 Transmission Mode Set Up

STEP 3 Test Criteria

STEP 4 Prepare Initial Test File

STEP 5 Submit Test Data to DWC

STEP 6 Acknowledgments
STEP 7 Correct Errors/Submit Remaining Test Files

STEP 8 Production Approvals




Texas Department of Insurance                                          Information Management Services
Division of Workers’ Compensation                                                        Page 36 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)   SECTION 4 – TEST TRANS. GUIDELINES




This page is meant to be blank




Texas Department of Insurance                                          Information Management Services
Division of Workers’ Compensation                                                        Page 37 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)                SECTION 4 – TEST TRANS. GUIDELINES




SECTION 4 – TEST TRANSMISSION GUIDELINES
Trading Partners are required to use the IAIABC standards to transmit EDI Claims Data to meet mandatory and
conditional requirements in accordance with Texas Department of Insurance Division of Workers‟ Compensation
(Division) EDI data elements and validation rules. These requirements supplement the IAIABC EDI
Implementation Guide Release 1 for the transmission of medical billing and payment data (EDI837).
Note: Refer to the Reference Tables section of the guide for current events, code lists, element, and edits from the
IAIABC standard used by the Division to eliminate the need for re-transmissions because of the additional Texas
validation edits and requirements.

STEP 1 Complete EDI Trading Partner Application and Profile
An EDI Trading Partner Application and Profile (EDI-01) is required to be complete and submit to the
EDI/TXCOMP Help Desk. The EDI-01 is needed to initiate and begin the testing process. The EDI-01 may be
obtained from the Divisions web site (http://www.tdi.state.tx.us/forms/dwc/edi01.doc). The EDI/TXCOMP Help
Desk can also assist in providing a copy and questions regarding completion of the form.
The Division must be notified of any changes to the Trading Partner’s profile. The Trading Partner is
responsible for keeping Profiles up-to-date. If the transmission mode or specifications are changed, required re-
testing of some or all types of transactions may be required.
Note: A Trading Partner may serve more than one carrier or group.

STEP 2 Transmission Mode Set Up
The Division will accept ANSI X12 transmissions through a Secure File Transfer Protocol (STFP). The trading
partner will use SFTP client software that is appropriate for their operating system environment and can successfully
interface with the Division environment.
The initial EDI-01 form submitted by a trading partner is used set up the trading partner SFTP access, directory
profile and points of contact. An automated email will be generated and sent to the contact person, notifying the
Trading Partner of their SFTP identification number, password and directory information.

STEP 3 Test Criteria
The Trading Partner should submit at least 10% of their projected monthly bill volume for each type of bill, not to
exceed 100 bills for each bill type. Each test file should contain examples of the scenarios that are provided for the
bill type, and other normal processing scenarios anticipated by the trading partner. Trading partners that do not
intend to submit all bill types must submit the minimum number of bills for each bill type that they intend to submit.
The trading partner must include all transaction types during the testing phase; Original, Cancel, and Replace (00,
01, and 05). In addition, the trading partner needs to send bills associated with appeals or requests for
reconsiderations (00). These test files will be analyzed for format and data quality for each bill type.

STEP 4 Prepare Initial Test File
Select files containing live data which meet the test criteria, and create a batch to submit for testing. It is essential
that the Trading Partner contact the EDI/TXCOMP Help Desk prior to submitting test data at (888)489-2667.
The batch format includes the Interchange Header, one or more Functional Groups, one or more Transaction
Segments, and appropriate ending records (Transaction End, Functional Group End, and Interchange End).

The Division recommends you extract or create a previously submitted and processed EDI837 record with the
appropriate header and trailer records to initially submit. As a last alternative, due to no data available, the Trading
Partner may create realistic dummy data to submit for testing.




Texas Department of Insurance                                                          Information Management Services
Division of Workers’ Compensation                                                                        Page 38 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)               SECTION 4 – TEST TRANS. GUIDELINES


Note: Test data will not be loaded into the production database. Live data will need to be transmitted when
approved for production.

STEP 5 Submit Test Data to DWC
Contact the EDI/TXCOMP Help Desk (888-489-2667) once your initial test files are ready to transmit. Each
Trading Partner is assigned a representative to assist you through the testing process.

The EDI/TXCOMP Help Desk representative will give you the approval to submit your batch(s).

STEP 6 Acknowledgments
After the batch is received and processed by the Division, an electronic acknowledgment will be transmitted to the
Trading Partner. The acknowledgment will notify the Trading Partner of a successful transmission, accepted with
errors transmission. If the batch was not successful, error codes in the acknowledgment will identify the elements
within the transaction with errors or the reason for rejected transactions.

STEP 7 Correct Errors/Submit Remaining Test Files
At this time, the carrier is required to correct any error and resubmit the transaction until successfully processed.
Please refer to the Reference Tables section for a description of error and rejected codes.

Once the initial test files are processed successfully, the remaining transaction types and scenarios required for
testing may be submitted.

Note: The trading partner is responsible for ensuring the appropriate sequencing of transactions based on the
transaction type.

STEP 8 Production Approvals
Upon completion of successful transmissions of all required maintenance type codes, the EDI/TXCOMP Help Desk
representative will then complete the evaluation of test data received. When available, the EDI Help Desk intends on
providing feedback regarding the quality and accuracy of the data.

After the evaluation is complete, an electronic notice by email will be sent informing the Trading Partner of test
completion and approval to transmit data into production.

The Trading Partner is now ready for the production environment, and will need to note the following information:
        The header record should be changed to show “p” for the test/production indicator.
        The insurance carriers/Trading Partners are responsible for timely resubmissions of errors identified in the
         acknowledgment.




Texas Department of Insurance                                                        Information Management Services
Division of Workers’ Compensation                                                                      Page 39 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)   SECTION 4 – TEST TRANS. GUIDELINES




This page is meant to be blank.




Texas Department of Insurance                                          Information Management Services
Division of Workers’ Compensation                                                        Page 40 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)   SECTION 5 – MEDICAL EDI TERMINOLOGY




SECTION 5 – MEDICAL EDI TERMINOLOGY




Texas Department of Insurance                                            Information Management Services
Division of Workers’ Compensation                                                          Page 41 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)         SECTION 5 – MEDICAL EDI TERMINOLOGY



SECTION 5 – MEDICAL EDI TERMINOLOGY


USAGE NOTICE

These glossary terms are for your convenience when working with Texas EDI files or working in TXCOMP. Some
terms and some usages are specific to the Texas workers‟ compensation system and Texas EDI, and this glossary
attempts to identify such situations. In legal matters, refer to the Texas statutes or contact the Division of Workers‟
Compensation (DWC) (http://www.tdi.state.tx.us/wc/indexwc.html or
WorkersCompCustomerServices@tdi.state.tx.us). Additional information is available on the TDI Website
(http://www.tdi.state.tx.us/index.html, http://www.tdi.state.tx.us/consumer/glossary.html), on the DWC Website
(http://www.tdi.state.tx.us/wc/indexwc.html), in the Texas EDI Data Dictionaries, and in the IAIABC
Implementation Guides (http://www.iaiabc.org/i4a/pages/index.cfm?pageid=3339).

Other information on Texas EDI is located at http://www.tdi.state.tx.us/wc/edi/index.html. For assistance with
Texas EDI procedures or suggestions about this glossary, contact the EDI/TXCOMP Help Desk at 1-888-489-2667
(4TXCOMP); txcomp.help@www.tdi.state.tx.us.



148                                 See ANSI X12 148.
824                                 See ANSI X12 824.
835                                 See ANSI X12 835.
837                                 See ANSI X12 837, IAIABC 837.
997                                 See ANSI X12 997.
4010                                See Version.
5010                                See Version.
A49                                 See Subsequent Report of Injury.
Acknowledgment                      An electronic notification to the original sender of an electronic file that the file
                                    or the transactions within the file were received and were either accepted or
                                    rejected. For Medical EDI transactions sent by a Trading Partner, the two types
                                    of acknowledgment from TDI are the 997 and the 824 (ANSI formats). See also
                                    AK1, ANSI X12 824, ANSI X12 997.
Act, The                            The Texas Workers‟ Compensation Act, Title 5, Texas Labor Code, Chapters
                                    401 - 506. Provisions passed by the Texas Legislature governing the provision
                                    of workers‟ compensation in Texas. See also Division Rules.
ADA                                 American Dental Association, a national dentists‟ organization that provides
                                    various standards of conduct and practice in the field of dentistry. The ADA
                                    maintains the Current Dental Terminology (CDT) Codes used in Medical EDI
                                    transmissions.
ADA-J515                            American Dental Association (ADA) standard paper billing form. DWC
                                    FORM-70 (TX; http://www.tdi.state.tx.us/forms/dwc/dwc70.pdf) provides
                                    instructions for filling out this form for Texas workers‟ compensation claims.
ADL                                 DWC‟s Approved Doctor List: In the Texas workers‟ compensation system, if a
                                    doctor is not a participant in a workers‟ compensation health care network, the
                                    doctor must be on a DWC doctor list in order to receive reimbursement for
                                    providing health care, other than immediate post-injury care, to an Injured



Texas Department of Insurance                                                        Information Management Services
Division of Workers’ Compensation                                                                      Page 42 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)        SECTION 5 – MEDICAL EDI TERMINOLOGY


                                 Worker for a compensable injury. The ADL is scheduled to end by September
                                 1, 2007. See also Treating Doctor, Workers‟ Compensation Network.
Agreement                        An obligation between a Trading Partner and an Insurance Carrier to process
                                 and submit EDI data to DWC. The Insurance Carrier has ultimate responsibility
                                 for the data and for its transmission but can use multiple Trading Partners to
                                 submit its data. See also EDI-01.
AK1, AK2, AK5, AK9               Acknowledgment segments in a 997 Functional Acknowledgment. AK1 states
                                 which Functional Group is being reviewed; AK2 states which Transaction Set is
                                 being reviewed. AK5 and AK9 declare whether particular information in an
                                 inbound transmission was accepted or rejected. If an AK5 segment indicates
                                 that the batch was rejected, then the entire inbound transmission is rejected; it
                                 must be corrected and resubmitted. The AK9 segment is a synopsis for the
                                 entire transmission. See also Acknowledgment.
Alphanumeric                     Data formatting that includes the characters on a standard English-language
                                 keyboard: the letters A – Z and a - z, numeric digits 0 - 9, the space character,
                                 and selected special characters: , < . > / ? ; : ' " [ { ] } \ | ` ~ ! @ # $ % ^ & * ( ) -
                                 _ = + . The Texas EDI documentation defines certain special characters as
                                 delimiters (tilde, colon). Generally, any of the alphanumeric characters can be
                                 used in data elements with the alphanumeric data type. See also Non-
                                 Alphanumeric, Numeric.
AMA                              American Medical Association: A national physicians‟ group that provides
                                 various standards of conduct and practice for medical doctors. The AMA
                                 maintains various code lists used in Medical EDI transmissions, including the
                                 CPT Codes.
American Dental Association      (ADA) A national dentists‟ organization that provides various standards of
                                 conduct and practice in the field of dentistry. The ADA maintains the Current
                                 Dental Terminology (CDT) Codes used in Medical EDI transmissions.
American Medical Association     (AMA) A national physicians‟ group that provides various standards of conduct
                                 and practice for medical doctors. The AMA maintains various code lists used in
                                 Medical EDI transmissions, including the CPT Codes.
ANSI                             American National Standards Institute: A private, nonprofit organization that
                                 reviews, administers, and coordinates U.S. voluntary standardization efforts in
                                 many areas of business. ANSI-approved standards include both procedures and
                                 code sets, whether created by ANSI or accepted from outside organizations.
ANSI ASC X12                     ANSI Accredited Standards Committee X12: A national organization that
                                 develops and maintains standards for electronic transactions and the exchange of
                                 business data.
ANSI Envelope                    Same as ISA Envelope: The parts of an ANSI electronic file that contain
                                 information about the sender, the expected receiver, file creation date and time,
                                 ANSI version, transaction type (such as 148, 837, HIPAA), and amount of data
                                 included. The envelope includes both header and trailer control segments (ISA,
                                 GS, GE, IEA).
ANSI X12 148                     Report of Injury, Illness or Incident: A HIPAA-compliant national electronic
                                 file format for submitting a First Report of Injury (148, FROI) and Subsequent
                                 Report of Injury (A49; SROI). See also First Report of Injury, Subsequent
                                 Report of Injury.
ANSI X12 275                     An electronic file format for attachments and documentation associated with
                                 medical bills submitted electronically. The 275 format is being reviewed for
                                 possible adoption as a HIPAA standard format.



Texas Department of Insurance                                                       Information Management Services
Division of Workers’ Compensation                                                                     Page 43 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)      SECTION 5 – MEDICAL EDI TERMINOLOGY


ANSI X12 824                     Bill Payment Acknowledgment or Detail Acknowledgement: A HIPAA-
                                 compliant national electronic file format for responding to bills submitted
                                 electronically. For Texas Medical EDI processes, it is the final
                                 acknowledgement of data accepted and rejected for each transaction (bill)
                                 received. For Texas Medical EDI processes, an 824 represents successful
                                 completion of all workflow processes that translate the medical bill data, edit for
                                 quality and completeness, and load the data. If the 824 states that any
                                 transaction (bill) was rejected, TDI will perform no system updates based on
                                 that particular bill; the Trading Partner must correct the bill and resubmit it in a
                                 new Medical EDI transaction. In the Production environment, any bill that is
                                 accepted is deemed a proper filing with DWC and is stored in the database.
ANSI X12 835                     Health Care Claim Payment/Advice: A HIPAA-compliant national standard
                                 electronic file format for payer remittance and reimbursement for medical bills.
ANSI X12 837                     Medical EDI (Health Care Claim): A HIPAA-compliant national standard
                                 electronic file format for transmitting provider billing data for medical services:
                                 professional services (837P), institutional services (hospital/facility; 837I),
                                 dental services (837D), and pharmacy services (837RX, NCPDP
                                 Telecommunications Standard 5.1).
ANSI X12 997                     Functional Acknowledgment: A HIPAA-compliant national standard electronic
                                 file format that provides a confirmation from the receiver that a transmitted file
                                 was received and accepted, or was rejected. If the 997 indicates that the Medical
                                 EDI file was rejected (see the AK9 segment), TDI will perform no further
                                 processing on that particular file. The 997 Reject message details which specific
                                 Transaction Sets are accepted or rejected (see the AK5 segments); the Trading
                                 Partner must correct structural issues and resubmit the entire contents of the file.
Approved Doctor List             (ADL) In the Texas workers‟ compensation system, if a doctor is not a
                                 participant in a workers‟ compensation health care network, the doctor must be
                                 on a DWC doctor list in order to receive reimbursement for providing health
                                 care, other than immediate post-injury care, to an Injured Worker for a
                                 compensable injury. The ADL is scheduled to end by September 1, 2007. See
                                 also Treating Doctor, Workers‟ Compensation Network.
Authorization Process            The steps a Trading Partner must follow to become approved for transmitting
                                 EDI information to TDI for an Insurance Carrier. See also Trading Partner.
Batch                            An electronic transmission (file) or a specified part of the file, depending on the
                                 context.
                                 For Medical EDI, the term is not the entire file but is a specific component of
                                 the file, a Transaction Set, that contains a Transaction Set header and trailer
                                 control segment (ST/SE segments) plus information about a group of medical
                                 bills. A Medical EDI file can contain multiple batches; all must report
                                 information from the same Insurance Carrier.
                                 In other contexts, a batch is the entire file: a set of records containing one file
                                 header segment, one or more detail transactions, and one file trailer segment. A
                                 Claims EDI batch must contain either First Report or Subsequent Report data,
                                 but not both; the two transaction types must be submitted separately.
Batch Accept                     If all elements in a batch are correct, the Texas 824 Acknowledgment contains a
                                 single Batch Accept statement for the batch. In the Production environment for
                                 Medical EDI, any bill that is accepted is processed and is stored in the Texas
                                 workers‟ compensation database, so if the batch is accepted, all bills in the batch
                                 are accepted and stored.
Batch Reject                     For a Medical EDI transmission, if any element in a batch (Transaction Set) is
                                 not correct, the Texas 997 Functional Acknowledgment contains a single Batch

Texas Department of Insurance                                                    Information Management Services
Division of Workers’ Compensation                                                                  Page 44 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)       SECTION 5 – MEDICAL EDI TERMINOLOGY


                                 Reject statement (AK5 segment) for the batch, and the entire transmission must
                                 be corrected and resubmitted. In an 824 Detail Acknowledgment, the EDI
                                 system can accept a batch but does not reject a batch. If there is an error in a
                                 batch, the 824 details each transaction (bill) in the batch as being accepted or
                                 rejected. In the Production environment, any bill that is accepted is processed
                                 and is stored in the Texas workers‟ compensation database. If any bill is
                                 rejected, TDI will perform no system updates based on that particular bill; the
                                 Trading Partner must correct the bill and resubmit it in a new Medical EDI
                                 transaction. See also AK1.
Beneficiary                      In Texas workers‟ compensation, any of several classes of individual who may
                                 have a claim for death benefits because the individual is related to or dependent
                                 on a deceased Injured Worker. Examples: a spouse, a child, a dependent parent.
Benefits                         In Texas workers‟ compensation, payment to an Injured Worker or the worker‟s
                                 Beneficiaries based on a compensable injury: a medical benefit, an income
                                 benefit, a death benefit, or a burial benefit.
Bill                             A transaction representing all billing lines included on a single provider billing
                                 form for medical services provided to an Injured Worker. A bill must contain at
                                 least one line item.
Bill Payment Acknowledgment      Also called Detail Acknowledgment: The ANSI 824 electronic notification to
                                 the original sender of an electronic file stating that the transactions within a file
                                 were received and were either accepted or rejected. See also Batch Accept,
                                 Batch Reject.
Bill Type                        Professional, Institutional, Dental, or Pharmacy bills. Professional services are
                                 billed on a CMS-1500 form and reported in the SV1 segment of a Medical EDI
                                 transmission. Institutional (hospital, medical facility) services are billed on a
                                 CMS-1450 form (UB-04) and reported in the SV2 segment. Dental services are
                                 billed on an ADA-J515 form and reported in the SV3 segment. Pharmacy
                                 services are billed on a DWC-66 form for dates of service on or before
                                 December 31, 2007 and on the Universal Claim Form for services provided on
                                 and after January 1, 2008. Pharmacy services are reported in the SV4 segment.
Billing Line                     The individual line item within a bill transaction reported in a Medical EDI SV
                                 (service) segment (e.g., SV1, SV2, etc.). The lines within an EDI transaction
                                 represent each distinct line billed on a billing form.
Billing Provider                 The individual or organization that provides a service and receives a payment
                                 (or notice that a payment has been received). This is assumed to be the
                                 Rendering Provider for all services unless a specific rendering provider is
                                 identified at the bill or service line levels. See also Pay-To Provider, Rendering
                                 Provider.
BPI                              DWC‟s Business Process Improvement initiative is a group of coordinated
                                 projects designed to improve and streamline Texas workers‟ compensation
                                 business processes and software applications (http://www.tdi.state.tx.us/wc/bpi/
                                 ). The initiative resulted in the creation of the TXCOMP applications and in
                                 adoption of various national EDI standard procedures for tracking Texas
                                 workers‟ compensation data. TDI‟s Information Technology Systems work
                                 group handles all EDI processing for DWC. See also TXCOMP.
Cancellation                     The termination of an insurance contract, usually prior to the policy expiration
                                 date.
CARC                             Claim Adjustment Reason Codes: An ANSI code set used in remittance advice
                                 transactions to indicate the reasons for any differences between the original
                                 amount billed for a service and the current payment for the service; also used in
                                 some coordination of benefits transactions. In remittance advice transactions,

Texas Department of Insurance                                                     Information Management Services
Division of Workers’ Compensation                                                                   Page 45 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)     SECTION 5 – MEDICAL EDI TERMINOLOGY


                                 both Claim Adjustment Reason Codes and Remittance Advice Remark Codes
                                 must be used to report payment adjustments. See also Remittance Advice
                                 Remark Codes.
Carrier Austin Representative    (CAR) An individual or organization located in Austin, Texas, that is
                                 designated by an Insurance Carrier to act as the carrier‟s agent for receiving
                                 notices from DWC. DWC FORM-27 (TX;
                                 http://www.tdi.state.tx.us/forms/dwc/dwc027carsub.pdf is used to notify TDI of
                                 the designation.
Carrier Claim Number             See Claim Number.
CDT                              Current Dental Terminology: Codes for dental procedures and nomenclature
                                 published by the American Dental Association and used to bill dental services.
                                 Centers for Medicare and Medicaid Services (CMS; formerly HCFA) The
                                 federal agency that administers the Medicare and Medicaid programs under the
                                 Department of Health & Human Services.
Certified Self-Insurer           A private employer that has been granted a certificate of authority from DWC to
                                 self-insure for the payment of workers‟ compensation claims. A government
                                 agency also may self-insure. See also Self-Insured Government Entity.
Child                            A lower Hierarchical Level in a Transaction Set; groups of data are identified as
                                 belonging to an Insurance Carrier, an Employer, or a Claimant. The three terms
                                 convey information ranging from most general to most specific. See also
                                 Hierarchical Level, Parent.
Claim                            A demand under an insurance policy to recover for a loss. In Texas, when DWC
                                 receives notice that an employee has incurred a work-related injury, DWC
                                 creates a numbered claim record in TXCOMP to track the injury, the medical
                                 care the Injured Worker receives, and any benefits that are paid to the Injured
                                 Worker. An Insurance Carrier also creates a numbered claim record in its own
                                 claims processing system. See also Claim Number.
Claim Adjustment Reason Codes    (CARC) An ANSI code set used in remittance advice transactions to indicate
                                 the reasons for any differences between the original amount billed for a service
                                 and the current payment for the service; also used in some coordination of
                                 benefits transactions. In remittance advice transactions, both Claim Adjustment
                                 Reason Codes and Remittance Advice Remark Codes must be used to report
                                 payment adjustments. See also Remittance Advice Remark Codes.
Claim Administrator
Claim Number                     See Claim Number.
Claim Employer                   The Employer of an Injured Worker in the circumstances under which a work-
                                 related injury occurred.
Claim Form                       The form used to report a work-related injury or illness. For the report filed
                                 with DWC by an Injured Worker, Texas uses its own DWC FORM-41, Report
                                 of Injury (http://www.tdi.state.tx.us/forms/dwc/dwc041firstrpt.pdf) or its
                                 online equivalent Report of Injury in TXCOMP
                                 (https://txcomp.tdi.state.tx.us/TXCOMPWeb/notice/iec/SelectLanguage.jsp)
                                 . For the report filed by an Employer with an Insurance Carrier, Texas uses its
                                 own DWC FORM-1, Employer‟s First Report of Injury or Illness
                                 (http://www.tdi.state.tx.us/forms/dwc/dwc001rpt.pdf).
Claim Number                     When a new claim is recorded in a particular claims processing system, the
                                 claim is given a number in that system. Examples of claim numbers are DWC
                                 Claim Number (Texas), Claim Administrator Claim Number, or Carrier Claim
                                 Number. In EDI transmissions, each type of claim number should be reported in
                                 the appropriate Data Element. See also Claim.

Texas Department of Insurance                                                  Information Management Services
Division of Workers’ Compensation                                                                Page 46 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)     SECTION 5 – MEDICAL EDI TERMINOLOGY


Claim Participant                A person having an interest in and involvement with a claim. Examples: the
                                 Injured Worker, the Employer, a Representative for a Beneficiary, an employee
                                 of the Insurance Carrier, and any other person with an interest in a claim, such
                                 as doctors or hospitals that are seeking payment.
Claimant                         An individual, such as an Injured Worker or a Beneficiary, who asserts a right to
                                 benefits under a claim that results from a workers‟ compensation injury.
Claims EDI                       The electronic application for reporting workers‟ compensation claims. See
                                 ANSI X12 148, First Report of Injury, Subsequent Report of Injury.
Clean Claim                      (Same as Clean Bill, Complete Claim.) A claim that contains all required data
                                 for immediate payment, such as all data elements defined for a medical bill
                                 submitted under Medical EDI. State and federal laws require prompt payment
                                 of clean claims [e.g., Texas Insurance Code, Sec. 843.336; Texas Administrative
                                 Code, Sec. 133.501(b)(2)].
Clearinghouse                    An entity that either processes nonstandardized information from outside
                                 sources (nonstandard format or nonstandard data content) into a standard
                                 transaction; or that receives a standard transaction and processes that
                                 information into a nonstandard transaction. See also Switches.
CMS                              The Centers for Medicare and Medicaid Services (formerly HCFA); the federal
                                 agency that administers the Medicare and Medicaid programs under the
                                 Department of Health & Human Services.
CMS-1450                         The standard medical billing form used for hospital, facility, and some
                                 outpatient hospital charges; also called Universal Billing form (UB-92, UB-04),
                                 HCFA-1450. DWC previously used DWC 67 to provide instructions for filling
                                 out this form for Texas workers‟ compensation claims. DWC 67 was eliminated
                                 when the instructions were included in the EDI Guide.
CMS-1500                         The standard medical billing form used for professional charges; previously
                                 called HCFA-1500. DWC previously used DWC 68 to provide instructions for
                                 filling out this form for Texas workers‟ compensation claims. DWC 68 was
                                 eliminated when the instructions were included in the EDI Guide.
COB                              Coordination of Benefits: The transmission to a health plan of either health care
                                 claims information or health care payment information, for the purpose of
                                 determining the relative payment responsibilities of the health plan.
                                 Coordination of Benefits can be accomplished in two ways: either between
                                 health plans and other payers (for example, an auto insurance company), or from
                                 a health care provider to a health plan or other payer.
Code Sets                        Tables or lists of codes used for specific purposes. National standard formats
                                 may use code sets developed by a standards-setting organization (such as ANSI
                                 Provider Type qualifiers) or by other organizations (such as HCPCS codes).
COMPASS                          Texas Compensation Automated Support System: the DWC legacy mainframe
                                 application for tracking Texas workers‟ compensation claim data. The
                                 COMPASS application is being replaced by the expanded capabilities of the
                                 TXCOMP applications, including EDI components.
Compensable Injury               An injury that arises during the course of an Injured Worker‟s employment and
                                 for which compensation is payable under the Texas workers‟ compensation
                                 system. See Injury.
Compensation                     Payment of a benefit; in particular, a payment to an Injured Worker based on a
                                 compensable injury.
Complete Claim                   (Same as Clean Bill, Clean Claim.) A claim that contains all required data for
                                 immediate payment, such as all data elements defined for a medical bill


Texas Department of Insurance                                                  Information Management Services
Division of Workers’ Compensation                                                                Page 47 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)     SECTION 5 – MEDICAL EDI TERMINOLOGY


                                 submitted under Medical EDI. State and federal laws require prompt payment
                                 of clean claims [e.g., Texas Insurance Code, Sec. 843.336; Texas Administrative
                                 Code, Sec. 133.501(b)(2)].
Consulting Doctor                A doctor who examines an Injured Worker or the Injured Worker‟s medical
                                 record in response to a request from the Treating Doctor, the Designated Doctor,
                                 or DWC.
Control Segments                 See Envelope.
Coordination of Benefits         (COB) The transmission, from any entity to a health plan, of either health care
                                 claims information or health care payment information, for the purpose of
                                 determining the relative payment responsibilities of the health plan.
                                 Coordination of Benefits can be accomplished in two ways: either between
                                 health plans and other payers (for example, an auto insurance company), or from
                                 a health care provider to a health plan or other payer.
Coverage                         The holding of a policy of workers‟ compensation. An Employer may self-
                                 insure on approval by DWC; or may hold a policy issued by an Insurance
                                 Carrier and in effect on the date that an Employee was injured.
Covered Employer                 An Employer that has workers‟ compensation insurance coverage. The term
                                 includes a governmental entity that self-insures.
CPT (CPT-4)                      Current Procedural Terminology: Provider procedure codes published by the
                                 American Medical Association and used to identify and bill professional
                                 medical services. See also ICD-9.
CT                               Cumulative Trauma: Work-related injury sustained over a period of time, such
                                 as repeated exposure to airborne chemicals or loud noises, or damage from
                                 heavy lifting or repetitive motion; any progressive injury that is aggravated by
                                 job activities. This is a type of Occupational Disease and is included in the
                                 overall term “injury.”
Cumulative Trauma                (CT) Work-related injury sustained over a period of time, such as repeated
                                 exposure to airborne chemicals or loud noises, or damage from heavy lifting or
                                 repetitive motion; any progressive injury that is aggravated by job activities.
                                 This is a type of Occupational Disease and is included in the overall term
                                 “injury.”
Current Dental Terminology       (CDT) Codes for dental procedures and nomenclature published by the
                                 American Dental Association and used to identify and bill dental services.
Current Procedural Terminology   (CPT, CPT-4) Provider procedure codes published by the American Medical
                                 Association and used to identify and bill professional medical services. See also
                                 ICD-9.
Data Collection Agent            An entity that collects data from Insurance Carriers or Third Party
                                 Administrators for regulatory reporting purposes and submits that data
                                 electronically to TDI on behalf of the Insurance Carrier or Third Party
                                 Administrator.
Data Dictionary                  A file that lists tables of codes and definitions for the data used in EDI
                                 processes, including information specific to the jurisdiction (Texas). A Data
                                 Dictionary includes data element requirements for length and formatting, as well
                                 as whether elements are mandatory (required), conditional (situational), or
                                 optional. See also Jurisdictional, Situational.
Data Elements                    Individual defined types of data in an EDI transmission, expressed as DN 1,
                                 DN 2, . . . . IAIABC 837 is the standard that TDI uses for Texas Medical EDI
                                 data elements, modified as needed for Texas requirements (jurisdictional edits).
                                 The Texas EDI Data Dictionaries include data element requirements for length


Texas Department of Insurance                                                  Information Management Services
Division of Workers’ Compensation                                                                Page 48 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)      SECTION 5 – MEDICAL EDI TERMINOLOGY


                                 and formatting, as well as whether elements are mandatory (required),
                                 conditional (situational), or optional. See also Jurisdictional, Situational.
Date of Injury                   (DOI) The date on which an Injured Worker was injured or became ill. If the
                                 injury was caused by one event, the date that event happened is the date of
                                 injury. If the injury or illness was caused by repetitive motion or repeated
                                 exposures (occupational disease, including cumulative trauma), the date of
                                 injury is the date the Injured Worker knew or should have known that the injury
                                 was caused by work activities or environment.
Date of Service                  (DOS) The date on which medical or pharmacy services were provided, or a
                                 data range representing the first and last dates that medical or pharmacy services
                                 were provided. Hospital services report DOS at the bill level. All other bill
                                 types report DOS at the line level.
DDL                              DWC‟s Designated Doctor List; a certification for a doctor who undergoes
                                 training in order to participate in the Texas workers‟ compensation system in
                                 resolving disputes on the medical condition of an Injured Worker.
DEA                              Drug Enforcement Agency, a U.S. federal agency that monitors pharmacy
                                 operations as a part of its responsibility for enforcing controlled substances
                                 regulations.
DEA Number                       A prescriber identifier used for pharmacy billing; being replaced by a National
                                 Provider Identifier (NPI).
Default Values                   Data values that are provided automatically if no other value is supplied;
                                 especially, Texas values applicable during the transitional period for acceptance
                                 of historic data: If data becomes mandatory that previously was not required,
                                 some data elements are specified so that historic data can be supplied under
                                 current reporting requirements. A Texas example, for medical bills that
                                 preceded the establishment of Texas workers‟ compensation health care
                                 networks, is DN 507, Default Value = N, No Agreement (no provider network).
Deny                             An Insurance Carrier‟s (Payer‟s) decision not to pay a medical bill.
                                 Circumstances that might cause a denial include: the Provider did not obtain
                                 required preauthorization; the injury treated was not part of the Claimant‟s
                                 workers‟ compensation injury. See also Reject.
Department                       The Texas Department of Insurance (TDI). This state agency regulates the
                                 insurance industry and protects the people and businesses that are served by
                                 insurance. TDI is the parent agency of the Division of Workers‟ Compensation
                                 (DWC).
Designated Doctor                In Texas, a doctor on the DWC Designated Doctor List (DDL) who is appointed
                                 by DWC to recommend a resolution of a dispute on the medical condition or the
                                 medical treatment of an Injured Worker.
Detail Acknowledgment            The 824 Bill Payment Acknowledgment: An electronic notification to the
                                 original sender of an electronic file (such as Medical EDI) stating that the file
                                 was received and accepted and that transactions within the file were either
                                 accepted or rejected.
Disability                       An Injured Worker‟s inability, because of a work-related injury, to obtain and
                                 retain employment at wages equivalent to the preinjury wage. A disability is
                                 indicated as a percentage of whole body impairment.
Disability Management            A process to prevent disability from occurring or to intervene early, following
                                 an injury or the start of a disability, to monitor and recommend medical care in
                                 order to return an Injured Worker to health quickly.



Texas Department of Insurance                                                    Information Management Services
Division of Workers’ Compensation                                                                  Page 49 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)    SECTION 5 – MEDICAL EDI TERMINOLOGY


Dispute                          A disagreement about a right to workers‟ compensation payments, services, or
                                 other benefits.
Division of Workers‟
Compensation                     (DWC; the Division) A division within the Texas Department of Insurance
                                 (TDI), a state agency. DWC regulates the provision of workers‟ compensation
                                 services in Texas: it administers workers‟ compensation laws, resolves disputes
                                 over workers‟ compensation benefits, and provides information and assistance to
                                 Injured Workers and others about the Texas workers‟ compensation system.
                                 Before September 2005 this entity was called the Texas Workers‟ Compensation
                                 Commission (TWCC).
Division Rules                   (Rules) Requirements and guidelines passed by the Commissioner of Workers‟
                                 Compensation (DWC Commissioner) to supplement the provisions of laws that
                                 govern the Texas workers‟ compensation system. The Rules are incorporated in
                                 Title 28, Texas Administrative Code, Part 2
                                 (http://www.tdi.state.tx.us/wc/rules/index.html). See also Act, The.
DN 1, DN 2, …                    Data Element Names: Individual defined types of data in an EDI transmission,
                                 expressed as DN 1, DN 2, . . . . Each type of EDI process specifies the data
                                 elements that it uses. For example, IAIABC 837 is the standard that TDI uses
                                 for Texas Medical EDI data elements, modified as needed for Texas
                                 requirements (jurisdictional edits). The Texas EDI Data Dictionaries include
                                 data element requirements for length and formatting, as well as whether
                                 elements are mandatory (required), conditional (situational), or optional. See
                                 also Jurisdictional, Situational.
Doctor                           A doctor of medicine, osteopathic medicine, optometry, dentistry, podiatry, or
                                 chiropractic who is licensed and authorized to practice. See also Approved
                                 Doctor List.
DOI                              Date of Injury: The date on which an Injured Worker was injured or became ill.
                                 If the injury was caused by one event, the date that the event happened is the
                                 date of injury. If the injury or illness was caused by repetitive motion or
                                 repeated exposures (occupational disease, including cumulative trauma), the
                                 date of injury is the date the Injured Worker came to know or should have
                                 known that the injury was caused by work activities or environment.
DOS                              Date of Service: The date on which medical or pharmacy services were
                                 provided, or a data range representing the first and last dates that medical or
                                 pharmacy services were provided. Hospital services report DOS at the bill level.
                                 All other bill types report DOS at the line level.
Drug Enforcement Agency          (DEA) A U.S. federal agency that monitors pharmacy operations as a part of its
                                 responsibility for enforcing controlled substances regulations.
DWC                              The Texas Department of Insurance, Division of Workers‟ Compensation.
                                 DWC regulates the provision of workers‟ compensation services in Texas: it
                                 administers workers‟ compensation laws, resolves disputes over workers‟
                                 compensation benefits, and provides information and assistance to Injured
                                 Workers and others about the Texas workers‟ compensation system. Before
                                 September 2005 this entity was called the Texas Workers‟ Compensation
                                 Commission (TWCC).
DWC Claim Number                 See Claim Number.
DWC Forms                        To view the list of paper forms used by the Division of Workers‟ Compensation,
                                 see http://www.tdi.state.tx.us/forms/form20.html.




Texas Department of Insurance                                                  Information Management Services
Division of Workers’ Compensation                                                                Page 50 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)      SECTION 5 – MEDICAL EDI TERMINOLOGY


DWC FORM-1                       http://www.tdi.state.tx.us/forms/dwc/dwc001rpt.pdf DWC‟s Employer‟s
                                 First Report of Illness or Injury; sent from the Employer to the Insurance Carrier
                                 and the Injured Worker.
DWC FORM-62                       http://www.tdi.state.tx.us/forms/dwc/dwc062eob.pdf DWC‟s proprietary
                                 Explanation of Benefits (EOB) form is sent by the Insurance Carrier to the
                                 health care provider to explain payment or denial of a medical bill. The EOB
                                 also can be used to request a return of an overpayment or to acknowledge receipt
                                 of a refund.
DWC FORM-66                      http://www.tdi.state.tx.us/forms/dwc/dwcc066pharm.pdf DWC‟s proprietary
                                 Statement of Pharmacy Services form for pharmacy charges billing, including
                                 instructions specific to Texas workers‟ compensation. See also NCPDP
                                 Telecommunication 5.1.
DWC FORM-70                      http://www.tdi.state.tx.us/forms/dwc/dwc70.pdf Instructions specific to
                                 Texas workers‟ compensation for completing the ADA-J515 dental charges
                                 billing form.
eBill                            An electronic medical bill; also, DWC‟s BPI Electronic Medical Billing and
                                 Reimbursement Project. The eBill project is designed to support the electronic
                                 exchange of medical records and reports, including eventual direct medical
                                 billing and reimbursement, under ANSI X12 835.
ECS                              Electronic Claim Submission: The proprietary electronic format that Texas
                                 used, before the implementation of TXCOMP and the current ANSI-based EDI
                                 procedures, for receiving electronic medical bill payment data from Insurance
                                 Carriers.
EDI                              Electronic Data Interchange: The transfer of data between different entities
                                 using computer networks; in particular, the capacity for an Insurance Carrier to
                                 exchange information electronically with TDI, either directly or through a
                                 Trading Partner. Current Texas EDI procedures are based primarily on ANSI
                                 standards.
EDI-01                           EDI-01 (TX; http://www.tdi.state.tx.us/forms/dwc/edi01.doc) is the paper
                                 form and agreement a Trading Partner sends to TDI in preparation for
                                 submitting EDI transactions to TDI that conveys information about the
                                 responsibilities of the participants.
EFT                              Electronic Funds Transfer: The submission of bills electronically and the
                                 payment of approved bills by electronic transmission of funds directly to the
                                 provider of goods or services or a designee.
Electronic Claim Submission      (ECS) The proprietary electronic format that Texas used, before the
                                 implementation of TXCOMP and the current ANSI-based EDI procedures, for
                                 receiving electronic medical bill payment data from Insurance Carriers.
Electronic Data Interchange      (EDI) The transfer of data between different entities using computer networks;
                                 in particular, the capacity for an Insurance Carrier to exchange information
                                 electronically with TDI, either directly or through a Trading Partner. Current
                                 Texas EDI procedures are based primarily on ANSI standards.
Electronic File                  A collection of data stored in a defined electronic format. An electronic file
                                 may be a single electronic record or a set or series of transactions.
Electronic Format                The specifications that define the layout of data in an electronic file. ANSI is an
                                 organization that defines electronic formats for a wide variety of business uses.
Electronic Funds Transfer        (EFT) The submission of bills electronically and the payment of approved bills
                                 by electronic transmission of funds directly to the provider of goods or services
                                 or a designee.


Texas Department of Insurance                                                   Information Management Services
Division of Workers’ Compensation                                                                 Page 51 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)      SECTION 5 – MEDICAL EDI TERMINOLOGY


Electronic Record                A group of related data elements. In a Medical EDI file, a record might
                                 represent a line item, a provider, or an employer. One or more records forms a
                                 transaction.
Electronic Transaction           A grouping of information or data stored electronically in a defined format that
                                 has a distinct meaning as a set. An electronic transaction is made up of one or
                                 more electronic records.
Electronic Transmission          A single electronic file sent from a sender to a receiver. Broadly, the sending of
                                 information by facsimile, electronic mail, electronic data interchange, or any
                                 other similar method, not including telephone communication. In this glossary,
                                 an inbound transmission is an EDI file sent by means of SFTP from the sender
                                 to the receiver, and an outbound transmission is sent from the original receiver
                                 to the original sender. For Medical EDI, the sender of an inbound transmission
                                 is a Trading Partner and the receiver is TDI.
Employee                         An individual whose work activities are in the service of another individual or
                                 entity (the Employer) under a contract of hire, whether expressed or implied, or
                                 oral or written; in particular, an Injured Worker. The term includes
                                 undocumented workers and minors.
Employer                         An individual or entity who makes a contract of hire and employs one or more
                                 employees; in particular, an Employer that has workers‟ compensation insurance
                                 coverage. The term includes a governmental entity that self-insures.
Endorsement                      A modification to an insurance policy subsequent to the policy‟s original
                                 issuance. Most often, an endorsement adds or removes coverage for the insured
                                 after the policy is issued.
Envelope                         ANSI Envelope or ISA Envelope: The parts (control segments) of an ANSI
                                 electronic file that contain information about the sender, the expected receiver,
                                 file creation date and time, ANSI version, transaction type (such as 148, 837,
                                 HIPAA), and amount of data included. The envelope includes both header and
                                 trailer control segments (ISA, GS, GE, IEA).
Environment                      The computer context, either Test or Production, into which data is sent. For
                                 Medical EDI, Trading Partners initially send data files to the Test environment
                                 to assure that the files are formatted appropriately for processing. Data sent to
                                 the Test environment does not update Production, so the data can be re-sent or
                                 deleted as necessary. Data sent to the Production environment updates actual
                                 DWC claim files and is tracked in various update logs. Data sent to the
                                 Production environment is tracked for submission success rates for Trading
                                 Partner status approvals.
EOB                              Explanation of Benefits: The DWC FORM-62 (TX;
                                 http://www.tdi.state.tx.us/forms/dwc/dwc062eob.pdf) paper form that is sent
                                 by an Insurance Carrier to a health care provider to explain payment or denial of
                                 a medical bill. The EOB also can be used to request a return of an overpayment
                                 or to acknowledge receipt of a refund.
Error Reports                    Text files generated by the EDI system when an inbound file is not processed
                                 successfully. Most of the error reports are generated to report structural errors in
                                 the EDI submissions from Trading Partners. The structural errors are
                                 communicated to Trading Partners through traffic reports, and the error reports
                                 are placed on the secure SFTP Trading Partner directory to facilitate
                                 troubleshooting. See also Traffic Reports.
Explanation of Benefits          (EOB) The DWC FORM-62 (TX;
                                 http://www.tdi.state.tx.us/forms/dwc/dwc062eob.pdf) paper form sent by an
                                 Insurance Carrier to a health care provider to explain payment or denial of a


Texas Department of Insurance                                                    Information Management Services
Division of Workers’ Compensation                                                                  Page 52 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)     SECTION 5 – MEDICAL EDI TERMINOLOGY


                                 medical bill. The EOB also can be used to request a return of an overpayment
                                 or to acknowledge receipt of a refund.
Family and Medical Leave Act     (FMLA) A federal law that provides up to 12 weeks of unpaid, job-protected
                                 leave per year for employees who have serious health problems or who need to
                                 care for a child or other family member. The FMLA also requires that group
                                 health benefits be maintained during the leave.
Federal Employer ID Number       (FEIN) Also called Federal Taxpayer ID. The business equivalent of an
                                 individual‟s Social Security Number as a unique nine-digit ID. A FEIN is
                                 issued to anyone, including individuals, who must pay withholding taxes on
                                 employees. In Texas EDI transmissions, the FEIN is used as the Sender ID or
                                 Receiver ID. See also SSN, Tax ID.
FEIN                             Federal Employer ID Number (Federal Taxpayer ID): the business equivalent
                                 of an individual‟s Social Security Number as a unique nine-digit ID. A FEIN is
                                 issued to anyone, including individuals, who must pay withholding taxes on
                                 employees. In Texas EDI transmissions, the FEIN is used as the Sender ID or
                                 Receiver ID. See also SSN, Tax ID.
FG                               Functional Group: The second part of an ANSI file, where the sender specifies
                                 the type of EDI transmission included in the file. The Texas implementation
                                 allows only a single Functional Group in a Medical EDI file. The Functional
                                 Group includes both a header control segment (GS) and a trailer control segment
                                 (GE) and the Transaction Sets between those segments.
Field Office                     One of the DWC offices throughout Texas, other than the DWC Central Office
                                 in Austin, that assists Texas workers‟ compensation system participants.
File                             A single EDI transmission. A Medical EDI file sent to TDI must contain: one
                                 ISA statement including its header/trailer control segments; one Functional
                                 Group including its header/trailer control segments; and at least one Transaction
                                 Set (batch) including detail records.
Filter                           In a computer application such as TXCOMP, to provide search criteria that
                                 restrict the information found in a prior search. Examples: Provide a Start Date
                                 and End Date; Provide a Texas County.
First Report of Injury           (FROI/148) An electronic report filed with DWC by a Trading Partner for an
                                 Employer; it contains information conveyed from an Employer to an Insurance
                                 Carrier about an initial report of a Texas workers‟ compensation injury, and it
                                 results in the creation at DWC of a claim record in TXCOMP. The report from
                                 the Employer to the Insurance Carrier and the Injured Worker is the DWC
                                 FORM-1 (TX; http://www.tdi.state.tx.us/forms/dwc/dwc001rpt.pdf). See
                                 also Claims EDI, Subsequent Report of Injury (SROI/A49), TXCOMP.
Fiscal Intermediary              In the Medicare system, a private company that has been contracted to process
                                 and pay medical bills. This is a type of Third Party Administrator or Claim
                                 Administrator.
FMLA                             Family and Medical Leave Act: A federal law that provides up to 12 weeks of
                                 unpaid, job-protected leave per year for employees who have serious health
                                 problems or who need to care for a child or other family member. The FMLA
                                 also requires that group health benefits be maintained during the leave.
Fraud                            Any knowingly false or fraudulent statement made for the purpose of obtaining
                                 or denying workers‟ compensation benefits. In Texas, the penalties for
                                 committing fraud are fines up to $150,000, imprisonment for up to five years, or
                                 both.
FROI/148                         First Report of Injury: An electronic report filed with DWC by a Trading
                                 Partner for an Employer; it contains information conveyed from an Employer to

Texas Department of Insurance                                                  Information Management Services
Division of Workers’ Compensation                                                                Page 53 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)       SECTION 5 – MEDICAL EDI TERMINOLOGY


                                 an Insurance Carrier about an initial report of a Texas workers‟ compensation
                                 injury, and it results in the creation at DWC of a claim record in TXCOMP. The
                                 report from the Employer to the Insurance Carrier and the Injured Worker is the
                                 DWC FORM-1 (TX; http://www.tdi.state.tx.us/forms/dwc/dwc001rpt.pdf).
                                 See also Claims EDI, Subsequent Report of Injury (SROI/A49), TXCOMP.
Functional Acknowledgment        An electronic notification to the original sender of an electronic file that the file
                                 was received and accepted, or was rejected and will not undergo further
                                 processing. Texas uses the ANSI 997 file format for this transmission.
Functional Group                 (FG) The second part of an ANSI file, in which the sender specifies the type of
                                 EDI transmission included in the file. The Texas implementation allows only a
                                 single Functional Group in a Medical EDI file. The Functional Group includes
                                 both a header control segment (GS) and a trailer control segment (GE) and the
                                 Transaction Sets between those segments.
Governmental Entity              A political subdivision or any public sector entity, such as a city, county, state
                                 agency, school board, water district, or other taxing entity. In Texas,
                                 governmental entities are required by law to insure for workers‟ compensation,
                                 either through a commercial carrier or by self-insuring.
GS/GE                            See Functional Group.
HCFA                             Health Care Finance Administration. In 1977 the agency was established to
                                 administer the Medicare and Medicaid programs. This agency has been
                                 replaced by CMS, the Centers for Medicare and Medicaid Services, under the
                                 Department of Health & Human Services.
HCFA-1450                        The standard medical billing form, now called CMS-1450, used for hospital,
                                 facility, and some outpatient hospital charges. Also called Universal Billing
                                 form (UB-92, UB-04). DWC previously used DWC 67 to provide instructions
                                 specific to Texas workers‟ compensation for completing the HCFA-1450. DWC
                                 67 was eliminated when the instructions were included in the EDI Guide.
HCFA-1500                        The standard medical billing form, now called CMS-1500, used for professional
                                 charges. DWC previously used DWC 68 to provide instructions specific to
                                 Texas workers‟ compensation for completing the CMS-1500. DWC 68 was
                                 eliminated when the instructions were included in the EDI Guide.
HCP                              Health Care Provider: An all-inclusive term for the individual or organization
                                 that delivers health care services: a health care facility (institution), health care
                                 practitioner, or pharmacy.
HCPCS                            Healthcare Common Procedure Coding System: HIPAA categories of medical
                                 procedure codes. Level II codes, commonly referred to as HCPCS codes,
                                 include ambulance, durable medical equipment, prosthetics, orthotics, and
                                 supply codes (DMEPOS). Level I HCPCS codes are the CPT (CPT-4)
                                 professional services codes.
Header                           Part of an EDI file; a header must have a corresponding trailer. Headers and
                                 trailers define a file‟s ISA information, Functional Group, and Transaction Sets.
Health Care                      All reasonable and necessary medical aid, examinations, treatments, diagnoses,
                                 evaluations, and services provided in treating an injury; the term does not
                                 include vocational rehabilitation.
Health Care Facility             A hospital, emergency clinic, outpatient clinic, or other institution or facility that
                                 provides health care.
Health Care Practitioner         A licensed individual who provides health care; or a nonlicensed individual who
                                 provides health care under the direction or supervision of a Doctor. The term



Texas Department of Insurance                                                     Information Management Services
Division of Workers’ Compensation                                                                   Page 54 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)        SECTION 5 – MEDICAL EDI TERMINOLOGY


                                  Doctor includes a doctor of medicine, osteopathic medicine, optometry,
                                  dentistry, podiatry, or chiropractic who is licensed and authorized to practice.
Health Care Provider              (HCP) An all-inclusive term for the individual or organization that delivers
                                  health care services: a health care facility (institution), health care practitioner,
                                  or pharmacy.
                                  Health Insurance Portability and Accountability Act (HIPAA) Federal
                                  legislation passed in 1996 that requires covered entities (including health plans,
                                  health care clearinghouses, and most health care providers) to comply with three
                                  primary sets of federal rules: privacy; transactions and code sets (EDI
                                  provisions); and security. HIPAA includes provisions that mandate electronic
                                  billing in the Medicare system and establishes national standard electronic file
                                  formats and code sets. See also ANSI.
Health Maintenance Organization (HMO) A managed care plan that provides health care services to its members
                                through a network of contracted doctors, hospitals, and health care providers.
Hierarchical Level                (HL) A statement in the Transaction Set of a Medical EDI file that identifies
                                  groups of data as belonging to an Insurance Carrier, an Employer, or a Claimant.
                                  The HL statements are numbered consecutively, and each new Hierarchical
                                  Level identifies a new participant, always beginning with an Insurance Carrier
                                  and always ending with a Claimant. Each Claimant record also contains billing
                                  information for medical services. See also Child, Parent.
HIPAA                             1996 Health Insurance Portability and Accountability Act: Federal legislation
                                  passed in 1996 that requires covered entities (including health plans, health care
                                  clearinghouses, and most health care providers) to comply with three primary
                                  sets of federal rules: privacy; transactions and code sets (EDI provisions); and
                                  security. HIPAA includes provisions that mandate electronic billing in the
                                  Medicare system and establishes national standard electronic file formats and
                                  code sets. See also ANSI.
Historic Data                     Data reported to TDI for medical billing reports based on information that
                                  precedes 2007 and the current reporting requirements; in particular, data that
                                  was not processed under ECS (Texas proprietary EDI system) before ECS was
                                  discontinued in February 2005. Historic data may not contain all current
                                  required data elements, so default data element values and relaxed edits may
                                  have been applied to historic data. Many of the edits that were relaxed for
                                  historic data were reinstituted for data transmitted to TDI beginning in 2007.
                                  See also Implementation Date.
HITSP                             Health Information Technology Standards Panel: A federal initiative under the
                                  Office of the National Coordinator for Health Information Technology to
                                  improve electronic communication about health data.
HL                                Hierarchical Level: A statement in the Transaction Set of a Medical EDI file
                                  that identifies groups of data as belonging to an Insurance Carrier, an Employer,
                                  or a Claimant. The HL statements are numbered consecutively, and each new
                                  Hierarchical Level identifies a new participant, always beginning with an
                                  Insurance Carrier and always ending with a Claimant. Each Claimant record
                                  also contains billing information for medical services. See also Child, Parent.
HMO                               Health Maintenance Organization: A managed care plan that provides health
                                  care services to its members through a network of contracted doctors, hospitals,
                                  and health care providers.
IAIABC                            International Association of Industrial Accident Boards and Commissions: An
                                  association of government agencies that administer and regulate their
                                  jurisdictions‟ workers‟ compensation acts, as well as private organizations
                                  involved in the delivery of workers‟ compensation coverage and benefits.

Texas Department of Insurance                                                      Information Management Services
Division of Workers’ Compensation                                                                    Page 55 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)          SECTION 5 – MEDICAL EDI TERMINOLOGY


IAIABC 837                            A version of ANSI X12 837 guidelines that specifically address workers‟
                                      compensation data reporting and billing. Texas has adopted the IAIABC 837
                                      electronic file format as its primary standard; exceptions are documented in the
                                      Texas Medical EDI Companion Guide to the IAIABC 837 (TX;
                                      http://www.tdi.state.tx.us/wc/edi/mededitoc.html).
ICD-9                                 International Classification of Diseases Codes, Clinical Modification (ICD-9-
                                      CM): The code set administered by the World Health Organization and used by
                                      hospitals to describe diagnoses and procedures in a hospital setting. Similar to
                                      CPT-4 codes used to describe provider procedures.
IEA                                   See ISA Envelope.
Impairment                            For an Injured Worker, any anatomic or functional abnormality or loss existing
                                      after maximum medical improvement (MMI) that (1) results from a
                                      compensable injury or occupational disease, and (2) is reasonably presumed to
                                      be permanent.
Impairment Rating                     (IR) For an Injured Worker, an assessment of the percentage of permanent
                                      impairment of the whole body that has resulted from a compensable injury; this
                                      is used to calculate an Injured Worker‟s permanent disability rating. Impairment
                                      ratings are determined based on guidelines published by the American Medical
                                      Association (AMA). See also Permanent Disability.
Implementation Date                   The date for TDI‟s full Production use of IAIABC 837 submissions, currently
                                      set as March 1, 2007. Some default values or relaxed edits were effect in both
                                      the Test and Production environments until the Implementation Date. See also
                                      Historic Data.
Inbound                               EDI files, such as Medical EDI transmissions, that are sent from a Trading
                                      Partner to TDI, or EDI files sent by the owner of data to a Trading Partner or
                                      Clearinghouse or Data Collection Agent.
Independent Review Organization (IRO) An entity that conducts independent external medical reviews of disputed
                                health care treatment decisions, such as appropriateness of health care, medical
                                necessity, or length of hospital stay. TDI has an authorization process for
                                certifying IROs that operate in Texas.
Individual                            A single human being as contrasted with an organizational entity. See also
                                      Person.
Injured Worker                        (Same as Injured Employee) In Texas, an individual who has a work-related
                                      injury or occupational disease and has notified DWC of the injury.
Injury                                Damage or harm to the physical structure of an individual‟s body. Injury is an
                                      overall term that includes accident, disease, infection, and occupational disease
                                      or cumulative trauma.
Injury Incident                       The circumstances under which a compensable injury arose, whether as a
                                      specific event or as the result of an occupational disease (including cumulative
                                      trauma). The injury becomes the basis for a workers‟ compensation claim.
Inpatient                             Medical care that is administered to a patient who has been admitted to an
                                      institutional facility for an overnight stay.
Institution; Institutional Facility   A Health Care Facility: a hospital, emergency clinic, outpatient clinic, or other
                                      facility that provides health care.
Insurance Carrier                     An Insurer: an insurance company, a certified self-insurer for workers‟
                                      compensation insurance, or a governmental entity that self-insures. The
                                      Insurance Carrier has the responsibility of paying for claims that meet the
                                      criteria of loss under an insurance policy. See also Insured, Insurer.


Texas Department of Insurance                                                        Information Management Services
Division of Workers’ Compensation                                                                      Page 56 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)      SECTION 5 – MEDICAL EDI TERMINOLOGY


Insurance Group                  A group of insurance companies under common ownership and, often, common
                                 management.
Insured                          The holder of an insurance policy that provides workers‟ compensation
                                 coverage; the Covered Employer. One policy may cover a number of
                                 Employers associated with the policyholder.
Insurer                          The Insurance Carrier that assumes an Employer‟s financial responsibility for
                                 workers‟ compensation claims. In Texas, an Employer may self-insure (act as
                                 its own Insurance Carrier) if approved by DWC.
Interchange Control Structures   (Control segments) The headers and trailers that define components of an
                                 electronic file.
IR                               Impairment Rating: For an Injured Worker, an assessment of the percentage of
                                 permanent impairment of the whole body that has resulted from a compensable
                                 injury; this is used to calculate an Injured Worker‟s permanent disability rating.
                                 Impairment ratings are determined based on guidelines published by the
                                 American Medical Association (AMA). See also Permanent Disability.
IRO                              Independent Review Organization: An entity that conducts independent
                                 external medical reviews of disputed health care treatment decisions, such as
                                 appropriateness of health care, medical necessity, or length of hospital stay.
                                 TDI has an authorization process for certifying IROs that operate in Texas.
ISA Envelope                     Same as ANSI Envelope: The parts of an ANSI electronic file that contain
                                 information about the sender, the expected receiver, file creation date and time,
                                 ANSI version, transaction type (such as 148, 837, HIPAA), and amount of data
                                 included. The envelope includes two header control segments (ISA, GS) at the
                                 beginning of the file and two trailer control segments (GE, IEA) at the end of the
                                 file.
ISA Header                       The Interchange Control Header segment that begins and identifies the EDI file.
                                 See also Interchange Control Structures.
Joint Insurance Fund             An organization created by two or more governmental entities to self-insure
                                 collectively by entering into an agreement with other political subdivisions
                                 providing for self-insurance; also called Risk Pool. See also Self-Insured
                                 Governmental Entity.
Jurisdictional                   Information, code sets, or requirements that are specific to a jurisdiction such as
                                 Texas; exceptions to general EDI usage.
Loop                             A defined, named series of data segments and data elements; a Loop ID is a
                                 quick way to refer to a related cluster of information. Examples are Loop ID
                                 1000A, Sender Information; or Loop ID 2310D, Facility Information. See also
                                 Segment.
Maximum Medical Improvement      (MMI) In Texas, a certification (1) that an Injured Worker‟s injury or illness
                                 has improved as much as it is going to improve; or (2) that 104 weeks have
                                 elapsed since the worker became eligible to receive income benefits. After
                                 certification of MMI, an MMI/IR Doctor can assess how much permanent
                                 disability may have resulted from the injury or illness. See also MMI/IR,
                                 Permanent Disability.
Medical Care                     For workers‟ compensation, treatment reasonably required to cure or relieve the
                                 effects of a work-related injury or illness.
Medical EDI                      An IAIABC interpretation of the ANSI 4010 standard for transmitting medical
                                 billing data. Texas has adopted the IAIABC 837 standard.
MMI                              Maximum Medical Improvement: A certification (1) that an Injured Worker‟s
                                 injury or illness has improved as much as it is going to improve; or (2) that 104

Texas Department of Insurance                                                    Information Management Services
Division of Workers’ Compensation                                                                  Page 57 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)     SECTION 5 – MEDICAL EDI TERMINOLOGY


                                 weeks have elapsed since the worker became eligible to receive income benefits.
                                 In Texas, after certification of MMI, an MMI/IR Doctor can assess how much
                                 permanent disability may have resulted from the injury or illness. See also
                                 MMI/IR, Permanent Disability.
MMI/IR                           In Texas, a Doctor‟s authorization by DWC to certify maximum medical
                                 improvement (MMI) and to assign impairment ratings (IR). See also
                                 Impairment Rating, Maximum Medical Improvement, Permanent Disability.
NABP                             National Association of Boards of Pharmacy: an organization that assists in
                                 developing, implementing, and enforcing uniform standards of pharmacist
                                 education, licensure, and practice.
NABP Number                      A unique identifier for a pharmacy location, now called the NCPDP number.
                                 This will be replaced by an NPI for the pharmacy.
National Association of Boards
of Pharmacy                      (NABP) An organization that assists in developing, implementing, and
                                 enforcing uniform standards of pharmacist education, licensure, and practice.
National Provider Identifier     (NPI) A single standardized national ID number for individual and corporate
                                 health care providers; mandated by HIPAA for use in most electronic
                                 transactions by May 23, 2007. Texas can accept NPI data but does not require
                                 its use.
NCPDP                            National Council for Prescription Drug Programs: An ANSI-accredited
                                 standards development organization for the transfer of data to and from the
                                 pharmacy services sector of the health care industry.
NCPDP Number                     A unique identifier for a pharmacy location. This has replaced the NABP
                                 Number and will be replaced by an NPI for the pharmacy.
NCPDP Telecommunication 5.1      A HIPAA-compliant national standard billing format for pharmacy services.
NDC                              National Drug Code: A code set that identifies the manufacturer, type, and
                                 strength of medication dispensed by a pharmacy.
Network                          See Workers‟ Compensation Network.
Non-Alphanumeric                 Data formatting that includes non-standard ASCII characters (characters not
                                 included on a standard English-language keyboard), such as non-English letters,
                                 or symbols other than punctuation (   ™ ñ é ü). See also Alphanumeric,
                                 Numeric.
Non-Covered Employer             A business that does not carry workers‟ compensation insurance for its
                                 employees. In Texas, such a business (1) must notify DWC that the business is
                                 not covered, and (2) must post DWC‟s required notices for the business‟s
                                 employees. See DWC Forms.
Nonrenewal                       A decision by an Insurance Carrier not to renew a workers‟ compensation
                                 policy.
NPI                              National Provider Identifier: A single standardized national ID number for
                                 individual and corporate health care providers; mandated by HIPAA for use in
                                 most electronic transactions by May 23, 2007. Texas EDI procedures for eBills
                                 and Medical EDI can accept NPI data but do not require its use.
Numeric                          Data formatting that includes only numeric digits 0 – 9. Generally, data
                                 elements with the numeric data type do not include separators such as slash or
                                 hyphen; for instance, a date is formatted as CCYYMMDD rather than as
                                 2007/02/01 or 2/1/2007, and a Social Security Number or FEIN is formatted as
                                 nine continuous digits. See also Alphanumeric, Non-Alphanumeric.



Texas Department of Insurance                                                  Information Management Services
Division of Workers’ Compensation                                                                Page 58 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)       SECTION 5 – MEDICAL EDI TERMINOLOGY


Occupational Disease               Disease arising out of and in the course of employment that causes damage or
                                   harm to the physical structure of the body, including a repetitive trauma
                                   (cumulative trauma) injury.
Office of Injured
Employee Counsel                   (OIEC) Texas state agency that assists Injured Workers with their claims at the
                                   Texas Department of Insurance, Division of Workers‟ Compensation.
Office of the National Coordinator for
Health Information Technology        (ONC) A federal office that coordinates the establishment of standards for the
                                    development, application, and use of health information.
OIEC                               Office of Injured Employee Counsel: Texas state agency that assists Injured
                                   Workers with their claims at the Texas Department of Insurance, Division of
                                   Workers‟ Compensation.
Ombudsman                          A staff member of the Texas Office of Injured Employee Counsel whose
                                   function is to assist Injured Workers with their claims at DWC so the Injured
                                   Workers do not have to hire attorneys for representation.
ONC                                Office of the National Coordinator for Health Information Technology: A
                                   federal office that coordinates the establishment of standards for the
                                   development, application, and use of health information.
Original Transaction ID            (OTI) An identifier segment in an 824 Acknowledgment that refers to a batch
                                   number in the Medical EDI transmission to which the 824 is the response.
OTI                                Original Transaction ID: An identifier segment in an 824 Acknowledgment that
                                   refers to a batch number in the Medical EDI transmission to which the 824 is the
                                   response.
Outbound                           Electronic files transmitted from TDI to an EDI Trading Partner, or any
                                   response from a receiver to the original sender of electronic data.
Outpatient                         Medical care that is administered to a patient who has not been admitted to an
                                   institutional facility for an overnight stay.
Parent                             A higher Hierarchical Level in a Transaction Set; groups of data are identified as
                                   belonging to an Insurance Carrier, an Employer, or a Claimant. The three terms
                                   convey information ranging from most general to most specific. See also Child,
                                   Hierarchical Level.
Participant                        Any of the parties concerned with reporting, treating, and tracking an injury; any
                                   individual or organization that plays a significant role in the Texas workers‟
                                   compensation system and has rights to non-public information stored in
                                   TXCOMP.
Pay-To Provider                    The provider or organization that will receive a payment. This data element is
                                   used when the entity receiving payment is different than the Billing Provider.
                                   See also Billing Provider.
Payer                              (Payor) The Insurance Carrier or Third Party Administrator that is processing
                                   and paying medical bills; the entity that reimburses for services delivered under
                                   a workers‟ compensation claim. See also Fiscal Intermediary.
PBM                                Pharmacy Benefits Manager (or Management): a company that provides
                                   support services to a pharmacy, such as drug information reviews, billing,
                                   education, risk management, and benefit plan administration.
PDF                                Portable Document Format: A means of displaying computerized information in
                                   a form that can be utilized by many software applications.




Texas Department of Insurance                                                     Information Management Services
Division of Workers’ Compensation                                                                   Page 59 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)       SECTION 5 – MEDICAL EDI TERMINOLOGY


Peer Reviewer                     A health care provider who, at an Insurance Carrier‟s request, performs an
                                  administrative review of the health care provided under a workers‟
                                  compensation claim.
Permanent Disability              Any lasting disability that results in a reduced earning capacity for the Injured
                                  Worker after maximum medical improvement (MMI) is reached. A Permanent
                                  Disability Rating (Impairment Rating; IR) is assessed as a percentage of whole
                                  body impairment.
Person                            An overall legal term including singular and plural, individuals, corporations,
                                  companies, associations, agents, business entities, partnerships, ... In some
                                  contexts, the appropriate term might be Individual.
Personal Doctor                   A Doctor who has provided medical care or services to an Injured Worker in
                                  circumstances other than a work-related injury and has the Injured Worker‟s
                                  ongoing medical records. See also Treating Doctor.
Pharmacist                        A person licensed to provide drugs, especially drugs prescribed by a Doctor and
                                  dispensed by the pharmacist when working at a pharmacy.
Pharmacy                          A licensed facility that provides drugs, especially drugs prescribed by a Doctor
                                  and dispensed by a licensed pharmacist.
Pharmacy Benefits Manager
(or Management)                   (PBM) A company that provides support services to a pharmacy, such as drug
                                  information reviews, billing, education, risk management, and benefit plan
                                  administration.
Place of Service                  (POS) The location where a healthcare service was provided.
POC                               Proof of Coverage: Verification that an insurance policy is in effect. In 2002,
                                  DWC implemented electronic reporting of proof of coverage by commercial
                                  insurance carriers. DWC‟s online TXCOMP application provides a search
                                  capability to verify whether a Texas Employer carries workers‟ compensation
                                  insurance and provides contact information for Insurance Carriers. See also
                                  TXCOMP.
Policy                            A contract between an insured and an Insurance Carrier to secure the insured‟s
                                  liability and obligations and to pay compensation; in particular, a workers‟
                                  compensation policy.
POS                               Place of Service: The location where a healthcare service was provided. Also,
                                  Point of Sale for medical equipment.
PPO                               Preferred Provider Organization: An organization of health care providers who
                                  provide health care to an insurer‟s or administrator‟s clients, generally at rates
                                  lower than the providers‟ usual rates.
Preauthorization                  Prospective approval obtained from the Insurance Carrier by the provider or the
                                  Injured Worker prior to the delivery of health care treatment or services.
Preferred Provider Organization   (PPO) An organization of health care providers who provide health care to an
                                  insurer‟s or administrator‟s clients, generally at rates lower than the providers‟
                                  usual rates.
Production                        The computer context into which data is sent; the options are Test and
                                  Production. See also Environment.
Proof of Coverage                 (POC) Verification that an insurance policy is in effect. In 2002, DWC
                                  implemented electronic reporting of proof of coverage by commercial insurance
                                  carriers. DWC‟s online TXCOMP application provides a search capability to
                                  verify whether a Texas Employer carries workers‟ compensation insurance and
                                  provides contact information for Insurance Carriers. See also TXCOMP.


Texas Department of Insurance                                                     Information Management Services
Division of Workers’ Compensation                                                                   Page 60 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)       SECTION 5 – MEDICAL EDI TERMINOLOGY


Provider                         (Health Care Provider, HCP) An all-inclusive term for the individual or
                                 organization that delivers health care services: a health care facility (institution),
                                 health care practitioner, or pharmacy. See also TXCOMP.
RARC                             Remittance Advice Remark Codes: A national code set maintained by the
                                 Centers for Medicare & Medicaid Services (CMS), and used by all payers to
                                 indicate the reasons for any differences between the original amount billed for a
                                 service and the current payment for the service. Both Claim Adjustment Reason
                                 Codes and Remittance Advice Remark Codes must be used to report payment
                                 adjustments in remittance advice transactions. See also Claim Adjustment
                                 Reason Codes.
Reason Codes                     See Claim Adjustment Reason Codes.
Receiver                         The entity receiving an electronic transmission. In response to an original
                                 inbound transaction such as a Medical EDI transmission, the receiver (such as
                                 TDI (DWC)) submits an electronic notification (acknowledgment such as 997)
                                 to the original sender that the file or the transactions in the file were received
                                 and accepted, or were rejected.
Receiver ID                      An identifier that designates the entity intended to receive an electronic
                                 transmission. Texas EDI transmissions use an entity‟s FEIN as its Sender ID or
                                 Receiver ID.
Referral Doctor                  A Doctor who examines and treats an Injured Worker in response to a request
                                 from the Treating Doctor.
Reinstatement                    The process by which an Insurance Carrier puts back in force a policy that had
                                 lapsed, such as for nonpayment of premiums.
Reject                           An Insurance Carrier‟s (Payer‟s) refusal to pay a medical bill based on
                                 inadequate or incorrect documentation. In a Medical EDI file, a Trading Partner
                                 must correct and resubmit a rejected bill. See also Deny.
Relaxed Edits                    Edits applied to data, generally during a transitional period, that permit
                                 acceptance of data that otherwise might not be satisfactory. Examples: using
                                 codes that are no longer active; not providing mandatory values; not applying
                                 matching logic to address fields. As the Texas EDI process becomes better
                                 established, Texas edits will be tightened. See also Historic Data.
Remark Codes                     See Remittance Advice Remark Codes.
Remittance                       In the electronic environment, the term refers to reimbursement or denial of
                                 medical bills.
Remittance Advice Remark
Codes                            (RARC) A national code set maintained by the Centers for Medicare &
                                 Medicaid Services (CMS), and used by all payers to indicate the reasons for any
                                 differences between the original amount billed for a service and the current
                                 payment for the service. Both Claim Adjustment Reason Codes and Remittance
                                 Advice Remark Codes must be used to report payment adjustments in
                                 remittance advice transactions. See also Claim Adjustment Reason Codes.
Rendering Provider               The health care provider that delivered medical care or services. Rendering
                                 Provider information is captured only when it is different than the Billing
                                 Provider. See also Billing Provider, Pay-To Provider.
Renewal                          A reissued insurance policy that is a continuation of an expiring policy from the
                                 same company or group; not new business.
Repetitive Trauma                Also called cumulative trauma. Damage to the physical structure of the body
                                 occurring as the result of repetitious, physically traumatic activities that occur


Texas Department of Insurance                                                     Information Management Services
Division of Workers’ Compensation                                                                   Page 61 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)        SECTION 5 – MEDICAL EDI TERMINOLOGY


                                    over time as the result of a person‟s employment. This is a type of Occupational
                                    Disease and is included in the overall term “injury.”
Representative                      A person, including an attorney, authorized to assist or represent an Injured
                                    Worker, a person claiming a death benefit, or an Insurance Carrier in a claim.
Required Medical Examination        (RME) An Insurance Carrier may request that DWC require an Injured Worker
                                    to undergo a medical examination by an RME Doctor to confirm the Injured
                                    Worker‟s condition or to review the Injured Worker‟s health care.
Return to Work                      (RTW) Programs set up by an Employer so Injured Workers can return to
                                    employment more quickly and safely while they heal. The employment may
                                    involve changes to an employee‟s regular job or a temporary, alternate work
                                    assignment.
Revenue Code                        A hospital code used to describe the procedure or procedure category of medical
                                    care provided.
Risk Pool                           An organization created by two or more governmental entities to self-insure
                                    collectively by entering into an agreement with other political subdivisions
                                    providing for self-insurance. Same as Joint Insurance Fund. See also Self-
                                    Insured Governmental Entity.
RME                                 Required Medical Examination: An Insurance Carrier may request that DWC
                                    require an Injured Worker to undergo a medical examination by an RME Doctor
                                    to confirm the Injured Worker‟s condition or to review the Injured Worker‟s
                                    health care.
RTW                                 Return to Work: Programs set up by an Employer so Injured Workers can return
                                    to employment more quickly and safely while they heal. The employment may
                                    involve changes to an employee‟s regular job or a temporary, alternate work
                                    assignment.
Rules                               Division Rules: In Texas, requirements and guidelines passed by the
                                    Commissioner of Workers‟ Compensation to supplement the provisions of laws
                                    that govern the Texas workers‟ compensation system. The Rules are
                                    incorporated in Title 28, Texas Administrative Code, Part 2
                                    (http://www.tdi.state.tx.us/wc/rules/index.html). See also Act, The.
SARF                                System Access Request Form: A barcoded DWC form that is processed in order
                                    to give a Texas workers‟ compensation system participant appropriate online
                                    access to non-public TXCOMP data. The request for access is initiated when
                                    the participant fills out an online form in TXCOMP. See also TXCOMP.
Secure File Transfer Protocol       (SFTP) An interactive file transfer program that encrypts both commands and
                                    data, preventing passwords and sensitive information from being transmitted in
                                    the clear. All TDI-approved Medical EDI Trading Partners must be able to
                                    transmit data using SFTP.
Segment                             A defined sequence of data elements that identifies a specific part of an EDI file,
                                    such as a header. At the end of a segment is a segment terminator character, a
                                    tilde (~). Examples: an ISA Header segment contains 16 data elements; an N4
                                    segment contains City, State, and Postal Code data elements for a particular
                                    defined address. See also Loop.
Self-Insurance Group                A group of Employers that is established for the purpose of providing workers‟
                                    compensation insurance to the members of the group.
Self-Insured Governmental Entity (SIGE) A governmental entity is a political subdivision or any public sector
                                 entity, such as a city, county, state agency, school board, water district, or other
                                 taxing entity. In Texas, governmental entities are required by law to insure for
                                 workers‟ compensation, either through a commercial carrier or by self-insuring.


Texas Department of Insurance                                                      Information Management Services
Division of Workers’ Compensation                                                                    Page 62 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)      SECTION 5 – MEDICAL EDI TERMINOLOGY


Self-Insurer                     A private employer that is granted a certificate of authority from DWC to
                                 self-insure for the payment of workers‟ compensation claims (Certified Self-
                                 Insurer). A government agency also may self-insure (Self-Insured
                                 Governmental Entity).
Sender                           The entity that has submitted an electronic transmission to the receiver. For a
                                 Medical EDI transmission, the sender is the external Trading Partner and the
                                 Receiver is TDI (DWC). For an acknowledgment to that transmission (for a 997
                                 or 824), the sender is TDI and the receiver is the original sender.
Sender ID                        An identifier that designates the entity that initiates an electronic transmission.
                                 Texas EDI transmissions use an entity‟s FEIN as its Sender ID or Receiver ID.
Separator                        A character placed between items to separate them. In Medical EDI
                                 transmissions, an asterisk (*) is the separator between data elements in a
                                 segment, and a colon (:) is the separator between sub-elements in a segment.
SFTP                             Secure File Transfer Protocol: An interactive file transfer program that encrypts
                                 both commands and data, preventing passwords and sensitive information from
                                 being transmitted in the clear. All TDI-approved Medical Bill Payment Trading
                                 Partners must be able to transmit data using SFTP.
SIGE                             Self-Insured Governmental Entity: A governmental entity is a political
                                 subdivision or any public sector entity, such as a city, county, state agency,
                                 school board, water district, or other taxing entity. In Texas, governmental
                                 entities are required by law to insure for workers‟ compensation, either through
                                 a commercial carrier or by self-insuring.
Situational                      A data edit condition under which a Data Element may become required in some
                                 circumstances, based on the data provided in a different Data Element.
                                 Example: If a Last Name is provided, a First Name then becomes required. See
                                 also Data Elements, Jurisdictional.
Specific Injury                  Damage to an individual‟s body caused by a single incident at work. Examples:
                                 being injured in a fall or traffic accident, being burned in a fire or by contact
                                 with a chemical, inhaling damaging vapors in a single incident. See also
                                 Cumulative Trauma.
SROI/A49                         Subsequent Report of Injury: An electronic report filed by a Trading Partner
                                 that contains information supplemental to a First Report of Injury (FROI/148).
SSN                              Social Security Number: a unique nine-digit ID that is assigned to an individual
                                 at a U.S. federal level. A SSN frequently is used as a tracking number or
                                 identifier for an individual. See also FEIN, Tax ID.
Subsequent Report of Injury      (SROI/A49) An electronic report filed by a Trading Partner that contains
                                 information supplemental to a First Report of Injury (FROI/148).
SV1, SV2, SV3, SV4               Services segments for reporting different types of bill information. Professional
                                 services are billed on a CMS-1500 form and reported in the SV1 segment.
                                 Institutional (hospital, medical facility) services are billed on a CMS-1450 form
                                 (UB-92, UB-04) and reported in the SV2 segment. Dental services are billed on
                                 an ADA-J515 form and reported in the SV3 segment. In Texas, pharmacy
                                 services are billed on a DWC-66 form (TX;
                                 http://www.tdi.state.tx.us/forms/dwc/dwcc066pharm.pdf) and reported in the
                                 SV4 segment.
Switches                         Clearinghouses that transmit information between entities that do not convert
                                 data. Switches may serve as a connection between entities that do not have a
                                 direct interface. See Clearinghouse.



Texas Department of Insurance                                                    Information Management Services
Division of Workers’ Compensation                                                                  Page 63 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)    SECTION 5 – MEDICAL EDI TERMINOLOGY


System Access Request Form       (SARF) A barcoded DWC form that is processed in order to give a Texas
                                 workers‟ compensation system participant appropriate online access to non-
                                 public TXCOMP data. The request for access is initiated when the participant
                                 fills out an online form in TXCOMP. See also TXCOMP.
TAC                              Texas Administrative Code; the location in which Division Rules are provided
                                 (http://www.tdi.state.tx.us/wc/rules/index.html). Rules have the effect of law
                                 but are passed by the Commissioner of Workers‟ Compensation (DWC
                                 Commissioner) rather than by the Texas Legislature or by Congress. Rules
                                 generally provide the administrative details needed when DWC prepares to
                                 implement a requirement of a new law. See also Rules.
Tax ID                           Either a Social Security Number (SSN) or a Federal Employer Identification
                                 Number (FEIN). All these terms refer to a unique nine-digit ID that is assigned
                                 at a U.S. federal level.
TDI                              The Texas Department of Insurance, a Texas state agency; the Division of
                                 Workers‟ Compensation (DWC) became part of TDI in September 2005. TDI
                                 oversees the provision of insurance services in Texas: it regulates insurance
                                 carriers, agents, and adjusters; sets rates; reviews disputes; and provides
                                 educational and safety services. It also compiles data about the insurance
                                 industry in Texas and manages the computer networks that store information
                                 about Texas workers‟ compensation claims.
Test                             The computer context into which data is sent; the options are Test and
                                 Production. See also Environment.
Texas Administrative Code        (TAC) The location in which Division Rules are provided
                                 (http://www.tdi.state.tx.us/wc/rules/index.html). Rules have the effect of law
                                 but are passed by the Commissioner of Workers‟ Compensation (DWC
                                 Commissioner) rather than by the Texas Legislature or by Congress. Rules
                                 generally provide the administrative details needed when DWC prepares to
                                 implement a requirement of a new law. See also Rules.
Texas Department of Insurance    (TDI) A Texas state agency; the Division of Workers‟ Compensation (DWC)
                                 became part of TDI in September 2005. TDI oversees the provision of
                                 insurance services in Texas: it regulates insurance carriers, agents, and
                                 adjusters; sets rates; reviews disputes; and provides educational and safety
                                 services. It also compiles data about the insurance industry in Texas and
                                 manages the computer networks that store information about Texas workers‟
                                 compensation claims.


Texas Impairment Rating
Skills Assessment Test           (TIRSAT) In Texas, a test that a doctor must pass in order to be on the DWC
                                 doctor lists MMI/IR or DDL.
Texas Workers‟ Compensation
Commission                       (TWCC, now DWC) The former name of the Texas Department of Insurance,
                                 Division of Workers‟ Compensation: the Texas state agency that regulates the
                                 provision of workers‟ compensation services. See also Texas Department of
                                 Insurance.
Third Party Administrator        (TPA) Any of several types of business entity that handle claims for an
                                 Insurance Carrier. For processing Medical EDI transactions, this business entity
                                 may act as the Insurance Carrier‟s Trading Partner with TDI.
TIRSAT                           Texas Impairment Rating Skills Assessment Test: In Texas, a test that a doctor
                                 must pass in order to be on the DWC doctor lists MMI/IR or DDL.



Texas Department of Insurance                                                  Information Management Services
Division of Workers’ Compensation                                                                Page 64 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)      SECTION 5 – MEDICAL EDI TERMINOLOGY


TPA                              Third Party Administrator: Any of several types of business entity that handle
                                 claims for an Insurance Carrier. For processing Medical EDI transactions, this
                                 business entity may act as the Insurance Carrier‟s Trading Partner with TDI.
Trading Partner                  A business entity that has entered into an agreement with TDI to exchange
                                 information electronically. An Insurance Carrier is the owner of most EDI
                                 information. The Trading Partner that transmits the information to TDI can be
                                 the Insurance Carrier, or a Certified Self-Insured, a Governmental Entity, a
                                 Third Party Administrator (TPA), a servicing agent, or a vendor representing
                                 one or more Insurance Carriers. See also EDI-01.
Traffic Reports                  Electronic summaries that provide information about the overall processing of
                                 Medical EDI files that were submitted by Trading Partners to TDI. The reports
                                 track every file from the moment it enters TDI‟s EDI system for processing to
                                 the point where 997 and 824 acknowledgment files are delivered to the SFTP
                                 server utilities for delivery to the various Trading Partners. The traffic reports
                                 provide summary details on file processing time; structural validation results;
                                 acknowledgments generated; and processing results. See also Error Reports.
Trailer                          Part of an EDI file; a header must have a corresponding trailer. Headers and
                                 trailers define a file‟s ISA information, Functional Group, and Transaction Sets.
Transaction                      The information for one medical bill, including provider information and
                                 services information. See also Transaction Set.
Transaction Set                  (ST/SE) The data segments from the ST Transaction Set Header segment
                                 through the SE Transaction Set Trailer segment. In a Medical EDI file, a
                                 Transaction Set contains all the information for numerous medical bills,
                                 including Claimant (Injured Worker) information, provider information, and
                                 services information. As an example:  In the 997 Functional Acknowledgment
                                 to a Medical EDI file, each incoming Transaction Set is acknowledged as being
                                 accepted or rejected, and the entire file is rejected if any Transaction Set is
                                 rejected.  In the 824 Detail Acknowledgment to a Medical EDI file, an entire
                                 Transaction Set can be accepted (Batch Accept). If there is any error in a
                                 Transaction Set, each individual line item of a medical bill is acknowledged as
                                 being accepted or rejected, and any transaction (bill) that is rejected must be
                                 corrected and then resubmitted in a subsequent Medical EDI transmission.
Transaction Type                 Information that identifies the data within the EDI transaction, such as
                                 identifying the transaction as containing 837 medical billing data or First Report
                                 of Injury data or being a 997 acknowledgment.
Translator                       Conversion software, such as software that converts a flat file (table structure) to
                                 an EDI-compatible text file.
Transmission                     A single electronic file that is sent from a sender to a receiver. A Medical EDI
                                 transmission that is sent from a Trading Partner and received satisfactorily by
                                 TDI will trigger a 997 acknowledgment from TDI.
Treating Doctor                  The Doctor selected by an Injured Worker to have primary responsibility for the
                                 worker‟s health care for a work-related injury. In Texas, such a doctor must be
                                 on DWC‟s Approved Doctor List or be associated with a Texas workers‟
                                 compensation network. See also Approved Doctor List, Personal Doctor,
                                 Workers‟ Compensation Network.
TRICARE                          A health care plan using military health care as the main delivery system,
                                 augmented by a civilian network of providers and facilities. Based on 42 United
                                 States Code 1395cc(a)(1)(j), all providers participating in Medicare must also
                                 participate in TRICARE for inpatient hospital services.



Texas Department of Insurance                                                    Information Management Services
Division of Workers’ Compensation                                                                  Page 65 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)       SECTION 5 – MEDICAL EDI TERMINOLOGY


TWCC                              (now DWC) Texas Workers‟ Compensation Commission. The former name of
                                  the Texas Department of Insurance, Division of Workers‟ Compensation: the
                                  Texas state agency that regulates the provision of workers‟ compensation
                                  services. See also Texas Department of Insurance.
TXCOMP                            The Web-based tracking of Texas workers‟ compensation claims and data.
                                  Components of TXCOMP include the TXCOMP Health Care Provider
                                  Management Online System that provides information about doctors and health
                                  care facilities; the TXCOMP Coverage application that provides coverage
                                  searches by Employer or by Insurance Carrier; the TXCOMP Claims application
                                  that tracks DWC claims for workers‟ compensation injuries and medical care,
                                  and the EDI applications that process 148/A49 and medical billing data.
UB-04                             Universal Billing Form used for hospital (institutional) billing, also referred to
                                  as a CMS-1450 billing form. It is scheduled to replace the UB-92 completely by
                                  May 23, 2007.
UB-92                             Universal Billing Form used for hospital (institutional) billing, also referred to
                                  as a CMS-1450 billing form; UB-92 is being replaced by UB-04.
UCF                               Universal Claim Form: an NCPDP proprietary pharmacy billing form. For
                                  Texas, see also DWC FORM-66 (TX;
                                  http://www.tdi.state.tx.us/forms/dwc/dwcc066pharm.pdf), Statement of
                                  Pharmacy Services.
Units                             The quantity of a drug dispensed, such as a number of pills or a volume of a
                                  solid or liquid (## cc, mg, ml). Also, the number of hours or days during which
                                  a service was provided.
Utilization Review                The process used by Insurance Carriers in deciding whether to authorize and pay
                                  for treatment recommended by an Injured Worker‟s Treating Doctor or other
                                  health care professional.
Version                           The release number for an electronic format. Later releases contain changes
                                  from earlier versions, so an EDI file indicates which version‟s requirements
                                  should apply. Version naming conventions are administered by the organization
                                  that defined the format; for example, ANSI has released format versions 3050,
                                  4010, and 4050, and Texas Medical EDI uses ANSI Version 4010. In Division
                                  Rules (Texas Administrative Code, Sec. 133.500(a)), DWC has defined the
                                  versions of certain EDI standards that Texas will follow.
Wages                             All forms of remuneration payable for a given period to an employee for the
                                  employee‟s services, including the market value of any benefit that can be
                                  estimated in money that the employee receives from the employer as part of the
                                  employee‟s remuneration.
Waiver                            An exception to electronic billing and reimbursement requirements for health
                                  care providers and Insurance Carriers. TDI is no longer approving waivers to
                                  Medical EDI submission requirements.
WCIO                              Workers‟ Compensation Insurance Organizations: A voluntary association of
                                  organizations that collect workers compensation insurance information in one or
                                  more states. It publishes specifications and guidelines for the exchange of
                                  information about workers compensation insurance.
WEDI                              Workgroup for Electronic Data Interchange: An association whose aim is to
                                  “improve the quality of healthcare through effective and efficient information
                                  exchange and management.” Members include providers, health plans, vendors,
                                  standards organizations, and government organizations.
Workers‟ Compensation Network An association of physicians, hospitals, and other providers who work
                              cooperatively to provide patient care. Insurance Carriers may establish or

Texas Department of Insurance                                                     Information Management Services
Division of Workers’ Compensation                                                                   Page 66 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)    SECTION 5 – MEDICAL EDI TERMINOLOGY


                                 contract with workers‟ compensation health care networks certified by TDI to
                                 provide health care for Injured Workers.
Workgroup for Electronic
Data Interchange                 (WEDI) An association whose aim is to “improve the quality of healthcare
                                 through effective and efficient information exchange and management.”
                                 Members include providers, health plans, vendors, standards organizations, and
                                 government organizations.
X12                              ANSI Accredited Standards Committee X12: A national organization that
                                 develops and maintains standards for electronic transactions and the exchange of
                                 business data, including medical data. See also ANSI.




Texas Department of Insurance                                                 Information Management Services
Division of Workers’ Compensation                                                               Page 67 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)   SECTION 5 – MEDICAL EDI TERMINOLOGY




This page is meant to be blank.




Texas Department of Insurance                                            Information Management Services
Division of Workers’ Compensation                                                          Page 68 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)   SECTION 6 – TEXAS REPORTING CRITERIA




SECTION 6 – TEXAS REPORTING CRITERIA
MEDICAL BILLING/PAYMENT ACTIONS OR EVENTS




Texas Department of Insurance                                            Information Management Services
Division of Workers’ Compensation                                                          Page 69 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)   SECTION 6 – TEXAS REPORTING CRITERIA




This page is meant to be blank.




Texas Department of Insurance                                            Information Management Services
Division of Workers’ Compensation                                                          Page 70 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)         SECTION 6 – TEXAS REPORTING CRITERIA




SECTION 6 – TEXAS REPORTING CRITERIA
The Texas Department of Insurance, Division of Workers‟ Compensation Rules 134.802 defines specific criteria
Trading Partners are required to electronically file with the Division. The following tables include the actions and
events that can trigger the requirement to submit information electronically and the timeframe in which the data
should be submitted for medical billing and payment actions:

MEDICAL BILLING/PAYMENT ACTIONS OR EVENTS

MTC*                       ACTION or EVENT                                       EDI SUBMISSION DUE
00 (Original)              Original transactions must be submitted when the      No later than the 30th day
                           carrier issues payment, denies payment, or issues
                           a reduced payment. The Original transaction is
                           also used in identifying appeals and requests for
                           reconsideration and the carrier must use the
                           W3/W4 claim adjustment reason codes.
01 (Cancel)                Cancellations are submitted when the insurance        No later than the seventh (7th) day
                           carrier had previously issued an incorrect file. A
                           common situation is when the carrier submits a
                           bill paid to a Texas provider, but the claim is
                           actually handled under another jurisdiction‟s
                           coverage. Cancellations are notifications that the
                           bill should never have been reported to the Texas
                           Department of Insurance.
05 (Replace)               Replacements are corrections to previous original     No later than the 30th day
                           submission. A common situation is when the
                           carrier discovers that incorrect values were
                           submitted in the original submission.

** If an insurance carrier denies a medical bill due to compensability or extent of injury, the carrier is also
required to provide the Division with a written copy of the denial notice provided to the claimant, PLN-01 (Notice of
Compensability/Liability and Refusal to Pay), per Rule 124.2(d).




Texas Department of Insurance                                                      Information Management Services
Division of Workers’ Compensation                                                                    Page 71 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)   SECTION 7 – REFERENCE TABLES



SECTION 7 – REFERENCE TABLES


Functional Tables
        ISA – Interchange Control Header
        GS – Functional Group
        997 – Functional Acknowledgment
        824 – Detail Acknowledgment
        824 Error Codes
        837 – Medical Services

Element Tables
        Required Element Table (see Section 6)

Edits Matrix Tables
        Edits Matrix - All Data Elements




Texas Department of Insurance                                     Information Management Services
Division of Workers’ Compensation                                                   Page 72 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)   SECTION 7 – REFERENCE TABLES




This page is meant to be blank.




Texas Department of Insurance                                     Information Management Services
Division of Workers’ Compensation                                                   Page 73 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)   SECTION 8 – ACKS/TRAFFIC REPORTS




SECTION 8 – ACKNOWLEDGMENTS/TRAFFIC REPORTS


Acknowledgements (AK1/824)

Traffic Report

       OVERVIEW

       REPORT DETAILS

                File Transmission Summary

                Processing and Acknowledgement Summary

                Tracking Ids – Reference Only




Texas Department of Insurance                                        Information Management Services
Division of Workers’ Compensation                                                      Page 74 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)   SECTION 8 ACKS/ TRAFFIC REPORTS




This page is meant to be blank




Texas Department of Insurance                                        Information Management Services
Division of Workers’ Compensation                                                      Page 75 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)                   SECTION 8 ACKS/ TRAFFIC REPORTS




SECTION 8 – ACKNOWLEDGMENTS/TRAFFIC REPORTS
997 Functional Acknowledgements
The IAIABC 837 electronic file format supports reporting multiple transaction sets or “batches” in a single 837 file.
A transaction set is defined as the segments beginning with, and including, the ST Transaction Set Header Segment
and ending with, and including, the SE Transaction Set Trailer Segment.

The 997 Functional Acknowledgement file is intended to communicate the file status of the inbound 837 file. The
997 file is generated by the receiver of the inbound 837 file and transmitted to the sender of the inbound 837 file.
The Texas implementation allows for 997 Functional Acknowledgements to be generated at the highest level of the
837 file, the interchange level. Each batch will be acknowledged in the AK5 segment of the 997 Functional
Acknowledgement, with the AK9 segment providing the status of the entire file. When one or more files are
rejected in a multiple batch file, the AK9 segment will indicate the entire file was rejected.

Trading partners are responsible for monitoring the status of their files and the errors or status indicators included in
the Functional and Detail Acknowledgements. Trading partners do not respond to these acknowledgements, except
to correct the errors and submit corrections as appropriate.

**Please refer to the reference tables for specifications.

824 Detail Acknowledgements
When TDI accepts an EDI 837 file and sends a response, 997-Accept, TDI will process the incoming file and send
an 824 Detail Acknowledgment that provides information about the internal edits applied to the data. The
acknowledgment messages are

       BA      Batch Accepted -- all items in a Transaction Set (batch) were accepted, that means that every line item
               of every Transaction (bill) was accepted.
       BR      Batch Rejected -- within a Transaction Set (batch), TDI identified at least one problem. If any batch is
               rejected TDI rejects the entire file, but the 824 will detail the results of the edits in the batch in detail.
       TA      Transaction Accepted -- the associated individual files within a Transaction Set (batch) were accepted
               by TDI and will be loaded in the reporting database.
       TR      Transaction Rejected – the associated individual files within a Transaction Set (batch) were rejected
               and the 824 Detail Acknowledgement provides information on the rejection reason.

If every Transaction Set (batch) is accepted, that means that every line item of every bill was accepted. The entire
inbound EDI 837 file is processed and the Trading Partner needs to perform no further action on the data.

If any Transaction Set (batch) is rejected, the TDI EDI 837 application will indicate whether individual Transactions
(medical bills) were accepted or rejected, and will detail the results of the edits applied to every line item of every
bill. If any batch fails, TDI rejects the entire file. The Trading Partner must decide the appropriate business
approach to submit the corrected files. While it is preferred that the trading partner corrects and resend the entire
file, the Division understands that there may be situations where the trading partner resends the correct records,
correct the remaining, and submit another batch for the previously rejected files. In any event, it is the responsibility
of the trading partner and insurance carrier to ensure all records are successfully transmitted and accepted.

**Please refer to the reference tables for specifications.




Texas Department of Insurance                                                          Information Management Services
Division of Workers’ Compensation                                                                        Page 76 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)               SECTION 8 ACKS/ TRAFFIC REPORTS



Traffic Report
OVERVIEW
Beginning February 2007, Division of Workers‟ Compensation began track data movements through the claims EDI
processing system and back to the Trading Partner. The traffic report provides information about the overall
processing of EDI First Reports of Injury files submitted by Trading Partners. The Subsequent Reports of Injury are
not included in the traffic report, at this time.
The traffic report is a tool that provides information about the overall processing of accepted EDI 837 files submitted
by Trading Partners to the Texas Department of Insurance. The tool tracks a file from the moment it enters the
system for processing to the point where the file is delivered to the SFTP server utilities to be appropriately sorted
into the various trading partners file structures. The traffic report indicates when acknowledgement files are created,
however the tool may not reflect any delivery problems encountered on the SFTP server.

The traffic report provides summary details on:
        File processing time
        Structural validation results
        Acknowledgements generated for each file
        Processing results
Accepted EDI files meet size limit requirements and have proper naming conventions as defined in the SFTP
Trading Partner Instructions Web Page (http://www.tdi.state.tx.us/wc/edi/sftp.html). Allowed deviations on the
naming conventions through the use of other unique identification numbers will be reviewed on a case-by-case basis.

REPORT DETAILS
File Transmission Metadata
Processed Date / Time:              Provides the date and time when an accepted file begins the medical EDI
                                    processing workflow. A delay between the date a file is submitted to the SFTP
                                    box for processing and the date processing begins, may reflect a processing
                                    backlog.
Trading Partner:                    The name on file of the trading partner who owns the file based on the extracted
                                    FEIN and the listing of Trading Partners who submitted EDI-01 forms
                                    requesting active partner status.
Extracted FEIN:                     The Trading Partner FEIN number extracted from the file name based on the file
                                    naming conventions.
Input File:                         The name of the inbound file as submitted by the Trading Partner without file
                                    extensions.
File Size:                          The size in bites of the inbound 837 file after it is extracted from the zip format
                                    required during SFTP file submissions.
Structural Evaluation Results
File Data Status:                   For reports post August 14th, 2006, this represents the highest level of validation
                                    at the ANSI X12 ISA envelope. During this validation, the system attempts to
                                    recognize the file type, the sender, and intended receiver. Messages in this
                                    column are primarily for internal DWC staff to determine, at a high level, the
                                    status of the file. See structural check codes below for possible values.
Structure:                          The result of the file structure validation against the ANSI 837 (version 4010)
                                    guidelines. The result of this validation can be:
                                    Fail – The file contains invalid ANSI/837 structures per the 837 Medical
                                         Implementation Guide. The file is rejected through a 997
                                         acknowledgement. No 824 acknowledgements should be expected.

Texas Department of Insurance                                                       Information Management Services
Division of Workers’ Compensation                                                                     Page 77 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)             SECTION 8 ACKS/ TRAFFIC REPORTS


                                 Pass – The file meets ANSI /837 structure and will continue processing through
                                     data edits and validations. A 997 and an 824 acknowledgement should be
                                     expected.
                                 Unknown – The system couldn‟t validate structure because the ANSI envelope is
                                     invalid due to invalid structural envelope, unrecognized sender;
                                     unrecognized receiver information, invalid counters, and/or invalid data in
                                     other envelope fields. A 997 acknowledgement WILL NOT be created.
Structural Check:                High-level results of structural validation. Detail information regarding the error
                                 message may be available in the error logs generated to determine the exact
                                 location of the structural problem. The error logs are available upon request
                                 based on the TXCOMP Help Desk service level agreements guidelines.
                                 The following is a list of potential values for this column. In addition, these
                                 status codes are used in the error report logs available for files that fail envelop
                                 or structure validations.


                                 STATUS
                                                                 DESCRIPTION                                LEVEL
                                 _CODE
                                 D01        Mandatory element missing                                     CRITICAL
                                 D02        Data element has incorrect size                               CRITICAL
                                 D03        Invalid code for identifier                                   CRITICAL
                                 D04        Invalid date format                                           CRITICAL
                                 D05        Invalid time format                                           CRITICAL
                                 E00        Unknown data element                                          CRITICAL
                                 E01        Code list error                                               CRITICAL
                                 E02        Data element has incorrect format                             CRITICAL
                                 E03        Data element has incorrect size                               CRITICAL
                                 E04        Missing segment                                               CRITICAL
                                 E05        Missing segment terminator                                    CRITICAL
                                 E06        Mandatory element missing                                     CRITICAL
                                 E07        Error in data                                                 CRITICAL
                                 E08        Unknown element found                                         CRITICAL
                                 E09        Failed business rule                                          CRITICAL
                                 E10        Missing element                                               CRITICAL
                                 E11        ISA/IEA format or content error                               CRITICAL
                                 E12        GS/GE format or content error                                 CRITICAL
                                 E13        Invalid because of errors elsewhere                           CRITICAL
                                 E14        Missing tradelink                                             CRITICAL
                                 E15        Unknown transaction/VersionRelease                            CRITICAL
                                 E16        Failed to route to PUT post office                            CRITICAL
                                 E17        Valid but not delivered because of errors elsewhere           CRITICAL
                                 E18        Functional group does not contain any transaction             CRITICAL
                                 E19        Contains transaction(s) that do not belong in this            CRITICAL
                                            functional group
                                 E20        Duplicate transaction                                         CRITICAL
                                 E21        Duplicate functional group                                    CRITICAL
                                 F01        FA in error                                                   CRITICAL
                                 F02        Rejected via TA1                                              INFO
Texas Department of Insurance                                                     Information Management Services
Division of Workers’ Compensation                                                                   Page 78 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)             SECTION 8 ACKS/ TRAFFIC REPORTS


                                 STATUS
                                                                 DESCRIPTION                               LEVEL
                                 _CODE
                                 S01       Segment out of sequence or unknown                            CRITICAL
                                 S02       Missing mandatory segment/loop                                CRITICAL
                                 S03       Loop exceeded limit                                           CRITICAL
                                 S04       Segment exceeded limit                                        CRITICAL
                                 S05       Segment has element error                                     CRITICAL
                                 V00       Data valid                                                    INFO
                                 V01       Error data found                                              WARNING
                                 V02       Contains functional group with unknown tradelink              WARNING
                                 V03       Duplicate interchange                                         CRITICAL
                                 V04       Failed to deliver some or all functional groups (inbound)     WARNING
                                 V05       In process                                                    INFO
                                 V06       Failed to deliver some or all interchanges (outbound)         WARNING
                                 V07       Accepted with errors via TA1                                  WARNING
                                 V08       Failed Interchange Authorization Check                        CRITICAL
                                 V09       Failed Interchange Security Check                             CRITICAL

                                 The LEVEL column provides a measure of criticality for the issue found as
                                 follows:
                                 CRITICAL – Issue is significant for processing. The file structure is invalid and
                                    no additional processing is expected.
                                 WARNING – An issue was found that may or may not affect file structure. The
                                    file is allowed to continue to the next structural check for final validation.
                                 INFO – status information on the processing of the file within the structural
                                    checks.

ANSI Acknowledgments Generated


997 Date and Time:               The date and time the 997 acknowledgment was generated. Note that there
                                 maybe a few milliseconds or seconds delay in the final timestamp of the 997 file
                                 due to renaming of the output file based on EDI Guide conventions. The final
                                 file timestamp is added to the outbound file name.


824 Acknowledgement:              Column contains the name of the 824 file generated after the successful
                                 processing of the 837 file. This file is available to Trading Partners.


824 Ack Date:                    The date and time the 824 acknowledgment was created. A blank value does not
                                 automatically indicate a problem. There are various valid reasons why the 824 is
                                 not generated. The file is available to the Trading Partner within minutes of the
                                 824 ack date unless there are specific SFTP pick up and drop off windows.
Processing Results Summary
Processing Status:               Describes the final processing status for each file at the time the traffic report
                                 was generated. The following are possible values:
                                 In Process – The file is still processing within the system. If the file has been in
                                     process for a couple of days, the issue should be reported to the TXCOMP
                                     Help Desk.

Texas Department of Insurance                                                    Information Management Services
Division of Workers’ Compensation                                                                  Page 79 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)             SECTION 8 ACKS/ TRAFFIC REPORTS


                                 Complete –The file is considered fully processed and acknowledged based on
                                     the defined rules in the Implementation Guide and the results of the
                                     structural validation.
                                 Investigating – A potential obstacle was encountered during the processing of
                                     this file. The TXCOMP Help Desk team will investigate and identify a final
                                     resolution for processing. The solutions may include reprocessing the file,
                                     and/or file errors that need to be communicated to the Trading Partner,
                                     etc…A help desk ticket will be associated with a collection of files under
                                     investigation.
                                 Envelope Failed. Inform TP -No additional processing is possible on this file
                                     due to an unknown file structure. The system was not able to generate and
                                     send a 997, indicating an error in the ISA segments of the envelope. The
                                     sender is encouraged to validate the envelope information in particular to
                                     check for proper FEIN and ZIP codes. Submitting invalid FEIN for the
                                     receiver, the Division of Worker‟s Compensation is a common error for
                                     those having envelope problems. The next common error are structurally
                                     invalid ANSI envelop of counters. End users are encouraged to use the
                                     TEST environment to troubleshoot envelope issues. TXCOMP Help desk
                                     maybe contacted to provide generated error logs.
Last Processing Step:            The last processing step initiated for the 837 files within the 837 workflow. This
                                 field is a reference to the internal staff to facilitate troubleshooting.
                                 The following steps are currently defined for the processing of an 837 file:
                                 1-gtwy:    Files with valid structure are registered for further processing
                                 2-dcid:    Copy of source file is kept based on Texas Department of Insurance
                                            data retention schedule.
                                 3-xlat:    ANSI file is translated into another file format for edit checks
                                 4-edit:    Data edits are applied based on 837 Medical Implementation Guide
                                 5-load:    Data is loaded into the database. This is a parallel process to creating
                                            and delivering the 824 acknowledgements.
                                 6-aak1:    Application acknowledgement is formatted into the ANSI 824 format
                                            and a user-friendly file name is provided based on EDI naming
                                            guidelines.
                                 7-mail     (Reports prior to August 14th, 2006) – The system was streamlined
                                            and this additional step removed. Acknowledgement files are
                                            provided immediately after step 6-aak1.
Error File:                      (Available in TEST and in Production Reports prior to August 14th, 2006) The
                                 name of the file generated by the system describing the errors within the 837
                                 files or processing obstacles. This field was dropped and transmissionid was
                                 added to find all error files and logs available for the 837 files.


Tracking Ids – Reference Only
TRANSMISSIONID:                  Internal id used to facilitate research, troubleshooting, and locating error logs for
                                 the 837 files.


INBOUND_TRACKING_ID:             Secondary tracking id for acknowledgements




Texas Department of Insurance                                                    Information Management Services
Division of Workers’ Compensation                                                                  Page 80 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)   SECTION 8 ACKS/ TRAFFIC REPORTS




This page is meant to be blank.




Texas Department of Insurance                                        Information Management Services
Division of Workers’ Compensation                                                      Page 81 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)              SECTION 9 – FAQS



SECTION 9 – FAQS
SETUP / MODES / FORMATS / TESTING ISSUES

TRANSACTION QUESTONS




Texas Department of Insurance                                   Information Management Services
Division of Workers’ Compensation                                                 Page 82 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)              SECTION 9 – FAQS




This page is meant to be blank




Texas Department of Insurance                                   Information Management Services
Division of Workers’ Compensation                                                 Page 83 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)                                      SECTION 9 – FAQS




FAQS
SETUP / MODES / FORMATS / TESTING ISSUES
Once a Trading Partner has moved into the production environment, where should questions be directed?
If a Trading Partner has questions after being moved into production, the EDI Help Desk to that Trading Partner
should be contacted at (888)489-2667.
How many bills should be submitted for testing?
The trading partner should submit 10% of their expected volume per bill type, not to exceed 100 bills for each type.
For example, if a trading partner will be submitting high volumes of all claim types, they should submit 100
professional, 100 institutional, and 100 pharmacy, and 10% of the expected dental (dental is typically low volume).
A trading partner that will only submit pharmacy bills would be required to submit 100 pharmacy bills.
Are you expecting one file per TPA or one file per insurance carrier? We report on behalf of the TPA and not
the insurance carrier.
Each trading partner will send one file per insurance carrier. The insurance carrier is responsible for all aspects of a
claim, even if they have outsourced certain aspects to a TPA. The insurance carrier is responsible to ensure that all
of their entities or associated companies submit the data to the Division as required by the rules. It is possible that
more than one trading partner will submit data for an individual insurance carrier, not only for TPA relationships but
also for bill types (some insurance carriers have pharmacy benefit management companies transmitting their
pharmacy data).
Does a trading partner have to zip an EDI transmission file when sending data over to the SFTP server?
Yes. The medical EDI transmission file must be zipped when sending to the SFTP server. The text file within the
transmission file does not have to be zipped.



TRANSACTION QUESTONS
How does a carrier report pharmacy compound medication billing?
Under Rule 134.502, pharmacies are required to bill compound medications by listing each drug used in the
compound and billing separately for each drug. The EDI837 reporting follows the same approach – the carrier
reports each line item of each drug based upon the valid NDC code.
How does a carrier report shipping charges for pharmacy services?
Shipping charges are not considered medical expenses and are not reported in the EDI837 transaction.
If only replacing one line, is the trading partner required to send all lines as replacements?
Yes. The “05” replacement is a complete replacement of the bill and the carrier is required to submit all the
information related to the replacement.

If a data element is required on the medical billing form, but is listed as optional for state reporting; can the
trading partner omit that data from the EDI837 transaction?
Yes. However, if the data is included in the transmission, it must meet all associated edits. The Division encourages
the insurance carriers to report data that is used to determine reimbursement to ensure the accuracy of analysis
during fee guideline development or other research activities which use the EDI837 data.

Will the Division accept a dental transaction (SV3) which contains HCPCS Level 1 codes (professional
medical services)?
No. Under Rule 133.10, professional medical services (HCPCS Level 1 services) must be billed using the CMS-
1500 form. Dental code values (ADA Codes) are the only codes that may be submitted on the ADA J515 form
based on the instructions published by the American Dental Association and the Division. The data mapping
processes for the different transaction types (SV2, SV3, etc…) are based on these billing and reimbursement
policies. If a dentist provides professional medical services in addition to dental services, the dentist is required to
submit the CMS1500 for the professional services and the ADA J515 for the dental services. This will result in two
transactions being submitted by the insurance carrier (one SV2 transaction and one SV3 transaction).

Texas Department of Insurance                                                        Information Management Services
Division of Workers’ Compensation                                                                      Page 84 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)              SECTION 9 – FAQS




This page is meant to be blank.

.




Texas Department of Insurance                                   Information Management Services
Division of Workers’ Compensation                                                 Page 85 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)     SECTION 10 – APPENDICES



APPENDICES
Appendix A – SFTP Naming Convention

Appendix B – Scenarios
        Link to current scenarios




Texas Department of Insurance                                   Information Management Services
Division of Workers’ Compensation                                                 Page 86 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)     SECTION 10 – APPENDICES




This page is meant to be blank




Texas Department of Insurance                                   Information Management Services
Division of Workers’ Compensation                                                 Page 87 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)        APPENDIX A – STFP NAMING CONVENTION



Appendix A – SFTP Naming Convention
The file name convention for inbound and outbound EDI files consists of a composite of multiple values that are
expected to facilitate the proper transfers of files placed on or picked up from the SFTP server by Trading Partners.


INBOUND FILES
         <TX><TP FEIN+4><TP Zip><IC FEIN><Rcd Type><T or P><CCYYMMDD><HHMMSS>.<txt>
tx123456789123451234123456789148p20050315162252.txt
OUTBOUND FILES
    <TX><TP FEIN+4><TP Zip><IC FEIN><Rcd Type>TransType<T or P><CCYYMMDD><HHMMSS>.<txt>
tx123456789123451234123456789148824p20050315162252.txt

TX - State Indicator – 2 alphanumeric (Static value indicating the outbound file was produced from Texas. Valid
value is „TX‟.)
Trading Partner FEIN – 9 numeric digits (FEIN of the Trading Partner defined on the EDI-01 Form)
Trading Partner Zip – 9 numeric digits (Zip Code of the Trading Partner defined on the EDI-01 Form)
Insurance Carrier FEIN 9 numeric digits (FEIN of the Insurance Carrier defined on the EDI-01 Form)
Record Type        3 alphanumeric (Type of data contained in the file. Values are 148, a49, and 837)
Transaction Type –          3 alphanumeric (Value indicating the transactional context of the data in the outbound
file. Valid values are 997, 824 and ak1.)
Test/Production Indicator –          1 alphanumeric (Values accepted are „t‟ for Test files or „p‟ for Production)
CCYYMMDD - 8 numeric digits (Date Sender provided the file. This value is used to distinguish files but not used
in processing the inbound data. The Sender has flexibility to establish a date meaningful in communicating with the
Division.)
HHMMSS -           6 numeric digits (Time Sender provided the file. This value is used to distinguish files but not used
in processing the inbound data. The Sender has flexibility to establish a time meaningful in communicating with
Division.
Extension Delimiter                  1 special character (Format: Period ‘.’ Standard extension delimiter)
File Extension                      3 alphanumeric (Standard file extension. Valid values are ‘zip’ and ‘txt’.)




Texas Department of Insurance                                                       Information Management Services
Division of Workers’ Compensation                                                                     Page 88 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)   APPENDIX A – STFP NAMING CONVENTION




This page is meant to be blank




Texas Department of Insurance                                             Information Management Services
Division of Workers’ Compensation                                                           Page 89 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)       APPENDIX B – SCENARIOS


Appendix B – Scenarios




This page is meant to be blank




Texas Department of Insurance                                   Information Management Services
Division of Workers’ Compensation                                                 Page 90 of 91
Texas Medical State Reporting EDI Implementation Guide (v1.0)                           APPENDIX B – SCENARIOS



Appendix B – Scenarios
How to Use the Document:
Each scenario will contain at least one event/trigger. The more complex scenarios will contain numerous
events/triggers. Each scenario will contain three parts: Trading partners should use both the scenarios contained in
the Texas guides as well as those from the IAIABC guides, modified for Texas use where needed.
Insurance carriers and trading partners may view the current scenarios online at
http://www.tdi.state.tx.us/wc/edi/medappend.html#b.




Texas Department of Insurance                                                      Information Management Services
Division of Workers’ Compensation                                                                    Page 91 of 91

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:225
posted:4/21/2011
language:English
pages:91
Description: Flowchart of Medical Billing document sample