(a) Health care providers, including those providing services for a certified workers' compensation health care network as defined in Insurance Code Chapter 1305 or to political subdivisions with contractual relationships under Labor Code §504.053(b)(2), must submit medical bills for payment in an electronic format in accordance with §133.500 and §133.501 of this title (relating to Electronic Formats for Electronic Medical Bill Processing and Electronic Medical Bill Processing), unless the health care provider or the billed insurance carrier is exempt from the electronic billing process in accordance with §133.501 of this title.
(b) Except as provided in subsection (a) of this section, health care providers, including those providing services for a certified workers' compensation health care network as defined in Insurance Code Chapter 1305 or to political subdivisions with contractual relationships under Labor Code §504.053(b)(2), must submit paper medical bills for payment on:
  (1) the 1500 Health Insurance Claim Form Version 02/12 (CMS-1500);
  (2) the Uniform Bill 04 (UB-04); or
  (3) applicable forms prescribed for pharmacists, dentists, and surgical implant providers specified in subsections (c), (d), and (e) of this section.
(c) Pharmacists and pharmacy processing agents must submit bills using the division form DWC-066. A pharmacist or pharmacy processing agent may submit bills using an alternate billing form if:
  (1) the insurance carrier has approved the alternate billing form prior to submission by the pharmacist or pharmacy processing agent; and
  (2) the alternate billing form provides all information required on the division form DWC-066.
(d) Dentists must submit bills for dental services using the 2006 American Dental Association (ADA) Dental Claim form.
(e) Surgical implant providers requesting separate reimbursement for implantable devices must submit bills using:
  (1) the form prescribed in subsection (b)(1) of this section when the implantable device reimbursement is sought under §134.402 of this title (relating to Ambulatory Surgical Center Fee Guideline); or
  (2) the form prescribed in subsection (b)(2) of this section when the implantable device reimbursement is sought under §134.403 or §134.404 of this title (relating to Hospital Facility Fee Guideline--Outpatient and Hospital Facility Fee Guideline--Inpatient).
(f) All information submitted on required paper billing forms must be legible and completed in accordance with this section. The parenthetical information following each term in this section refers to the applicable paper medical billing form and the field number corresponding to the medical billing form.
  (1) The following data content or data elements are required for a complete professional or noninstitutional medical bill related to Texas workers' compensation health care:
    (A) patient's Social Security number (CMS-1500/field 1a) is required;
    (B) patient's name (CMS-1500/field 2) is required;
    (C) patient's date of birth and gender (CMS-1500/field 3) is required;
    (D) employer's name (CMS-1500/field 4) is required;
    (E) patient's address (CMS-1500/field 5) is required;
    (F) patient's relationship to subscriber (CMS-1500, field 6) is required;
    (G) employer's address (CMS-1500, field 7) is required;
    (H) workers' compensation claim number assigned by the insurance carrier (CMS-1500/field 11) is required when known; the billing provider must leave the field blank if the workers' compensation claim number is not known by the billing provider;
    (I) date of injury and "431" qualifier (CMS-1500, field 14) are required;
    (J) name of referring provider or other source is required when another health care provider referred the patient for the services; no qualifier indicating the role of the provider is required (CMS-1500, field 17);
    (K) referring provider's state license number (CMS-1500/field 17a) is required when there is a referring doctor listed in CMS-1500/field 17; the billing provider must enter the '0B' qualifier and the license type, license number, and jurisdiction code (for example, 'MDF1234TX');
    (L) referring provider's National Provider Identifier (NPI) number (CMS-1500/field 17b) is required when CMS-1500/field 17 contains the name of a health care provider eligible to receive an NPI number;
    (M) diagnosis or nature of injury (CMS-1500/field 21) is required; at least one diagnosis code and the applicable ICD indicator must be present;
    (N) prior authorization number (CMS-1500/field 23) is required in the following situations:
      (i) Preauthorization, concurrent review, or voluntary certification was approved, and the insurance carrier provided an approval number to the requesting health care provider. Include the approval number in the prior authorization field (CMS-1500/field 23).
      (ii) The division ordered a designated doctor examination and provided an assignment number. Include the assignment number in the prior authorization field (CMS-1500/field 23).
      (iii) The designated doctor referred the injured employee for additional testing or evaluation, and the division provided an assignment number. Include the assignment number in the prior authorization field (CMS-1500/field 23).
    (O) date or dates of service (CMS-1500, field 24A) is required;
      (i) If the designated doctor referred the injured employee for additional testing or evaluation, the "From" date is the date of the designated doctor examination, and the "To" date is the date of service of the additional testing or evaluation.
      (ii) If the designated doctor did not refer the injured employee for additional testing or evaluation, the "From" and "To" dates are the date of the designated doctor examination.
    (P) place of service code or codes (CMS-1500, field 24B) is required;
    (Q) procedure/modifier code (CMS-1500, field 24D) is required;
    (R) diagnosis pointer (CMS-1500, field 24E) is required;
    (S) charges for each listed service (CMS-1500, field 24F) is required;
    (T) number of days or units (CMS-1500, field 24G) is required;
    (U) rendering provider's state license number (CMS-1500/field 24j, shaded portion) is required when the rendering provider is not the billing provider listed in CMS-1500/field 33; the billing provider must enter the '0B' qualifier and the license type, license number, and jurisdiction code (for example, 'MDF1234TX');
    (V) rendering provider's NPI number (CMS-1500/field 24j, unshaded portion) is required when the rendering provider is not the billing provider listed in CMS-1500/field 33 and the rendering provider is eligible for an NPI number;
    (W) supplemental information (shaded portion of CMS-1500/fields 24d - 24h) is required when the provider is requesting separate reimbursement for surgically implanted devices or when additional information is necessary to adjudicate payment for the related service line;
    (X) billing provider's federal tax ID number (CMS-1500/field 25) is required;
    (Y) total charge (CMS-1500/field 28) is required;
    (Z) signature of physician or supplier, the degrees or credentials, and the date (CMS-1500/field 31) is required, but the signature may be represented with a notation that the signature is on file and the typed name of the physician or supplier;
    (AA) service facility location information (CMS-1500/field 32) is required;
    (BB) service facility NPI number (CMS-1500/field 32a) is required when the facility is eligible for an NPI number;
    (CC) billing provider name, address, and telephone number (CMS-1500/field 33) is required;
    (DD) billing provider's NPI number (CMS-1500/Field 33a) is required when the billing provider is eligible for an NPI number; and
    (EE) billing provider's state license number (CMS-1500/field 33b) is required when the billing provider has a state license number; the billing provider must enter the '0B' qualifier and the license type, license number, and jurisdiction code (for example, 'MDF1234TX').
  (2) The following data content or data elements are required for a complete institutional medical bill related to Texas workers' compensation health care:
    (A) billing provider's name, address, and telephone number (UB-04/field 01) is required;
    (B) patient control number (UB-04/field 03a) is required;
    (C) type of bill (UB-04/field 04) is required;
    (D) billing provider's federal tax ID number (UB-04/field 05) is required;
    (E) statement covers period (UB-04/field 06) is required;
Cont'd...