(a) Facilities shall submit event files electronically in the file format for emergency visit bills defined by ANSI, commonly known as the ANSI ASC X12N form 837 Health Care Claims transaction for institutional claims. ANSI updates these formats from time to time by issuing new versions and the United States Department of Health and Human Services adopts regulations regarding HIPAA that update the version allowed for claim submissions.
(b) DSHS will make detailed specifications for these data elements available to submitters and to the public.
(c) In addition to the data elements contained in the ANSI 837 Institutional Guide, DSHS has specified the location where additional data elements shall be reported in the ANSI 837 Institutional Guide format. These are specified in §421.67(c) of this title (relating to Event Files--Records, Data Fields and Codes.)
(d) Facilities shall submit the required minimum data set in the following modified ANSI 837 Institutional Guide format for all patients that are uninsured or considered self-pay or covered by third party payers in which the payer requires the claim be submitted in an ANSI 837 Institutional Guide format for which an event claim is required by this subchapter. The required minimum data set for the modified (as specified in subsection (c) of this section) ANSI 837 Institutional Guide format includes the following data elements as listed in this subsection:
  (1) Patient Name:
    (A) Patient Last Name;
    (B) Patient First Name; and
    (C) Patient Middle Initial.
  (2) Patient Address:
    (A) Patient Address Line 1;
    (B) Patient Address Line 2 (if applicable);
    (C) Patient City;
    (D) Patient State;
    (E) Patient ZIP; and
    (F) Patient Country (if address is not in United States of America, or one of its territories).
  (3) Patient Birth Date;
  (4) Patient Sex;
  (5) Patient Race;
  (6) Patient Ethnicity;
  (7) Patient Social Security Number;
  (8) Patient Account Number;
  (9) Patient Medical Record Number;
  (10) Claim Filing Indicator Code (primary and secondary);
  (11) Payer Name - Primary and secondary (if applicable, for both);
  (12) National Plan Identifier - for primary and secondary (if applicable) payers (National Health Plan Identification number, if applicable and when assigned by the Federal Government);
  (13) Type of Bill (Facility Type Code plus Claim Frequency Code);
  (14) Statement Dates;
  (15) Principal Diagnosis;
  (16) Patient's Reason for Visit;
  (17) External Cause of Injury (E-Code) up to 10 occurrences (if applicable);
  (18) Other Diagnosis Codes - up to 24 occurrences (all applicable);
  (19) Occurrence Code - up to 24 occurrences (if applicable);
  (20) Occurrence Code Associated Date - up to 24 occurrences (if applicable);
  (21) Value Code - up to 24 occurrences (if applicable);
  (22) Value Code Associated Amount - up to 24 occurrences (if applicable);
  (23) Condition Code - up to 24 occurrences (if applicable);
  (24) Related Cause Code - up to 3 occurrences (if applicable);
  (25) Attending Physician or Attending Practitioner Name (if applicable):
    (A) Attending Practitioner Last Name;
    (B) Attending Practitioner First Name; and
    (C) Attending Practitioner Middle Initial.
  (26) Attending Practitioner Primary Identifier (National Provider Identifier) (if applicable);
  (27) Attending Practitioner Secondary Identifier (Texas state license number) (if applicable);
  (28) Operating Physician or Other Health Professional Name (if applicable):
    (A) Operating Physician or Other Health Professional Last Name;
    (B) Operating Physician or Other Health Professional First Name; and
    (C) Operating Physician or Other Health Professional Middle Initial.
  (29) Operating Physician or Other Health Professional Primary Identifier (National Provider Identifier) (if applicable);
  (30) Operating Physician or Other Health Professional Secondary Identifier (Texas state license number) (if applicable);
  (31) Total Claim Charges;
  (32) Revenue Service Line Details (up to 999 service lines) (all applicable);
    (A) Revenue Code;
    (B) Procedure Code;
    (C) HCPCS Procedure Modifier 1 (applicable to each submitted Procedure code);
    (D) HCPCS Procedure Modifier 2 (applicable to each submitted Procedure code);
    (E) HCPCS Procedure Modifier 3 (applicable to each submitted Procedure code);
    (F) HCPCS Procedure Modifier 4 (applicable to each submitted Procedure code);
    (G) Charge Amount;
    (H) Unit Code;
    (I) Unit Quantity;
    (J) Unit Rate; and
    (K) Non-covered Charge Amount.
  (33) Service Line Date;
  (34) Service Provider Name;
  (35) Service Provider Primary Identifier - Provider Federal Tax ID (EIN) or National Provider Identifier;
  (36) Service Provider Address:
    (A) Service Provider Address Line 1;
    (B) Service Provider Address Line 2 (if applicable);
    (C) Service Provider City;
    (D) Service Provider State; and
    (E) Service Provider ZIP; and
  (37) Service Provider Secondary Identifier - THCIC 6-digit facility ID assigned to each facility;
  (38) Point of Origin (Source of Admission); and
  (39) Patient Status.
(e) Facilities shall submit the required minimum data set to DSHS for each patient who has one or more of the following revenue codes in this subsection. Facilities operating in the State of Texas shall submit the required data elements as specified in subsection (d) of this section relating to the revenue codes in this subsection.
  (1) 0450 Emergency Room--General Classification;
  (2) 0451 Emergency Room--EMTALA Emergency Medical Screening;
  (3) 0452 Emergency Room--Emergency Room beyond EMTALA;
  (4) 0456 Emergency Room--Urgent Care; and
  (5) 0459 Emergency Room--Other Emergency Room;
(f) This section is effective 90 calendar days after being published in the Texas Register.

Source Note: The provisions of this §421.77 adopted to be effective December 18, 2014, 39 TexReg 7582; amended to be effective June 17, 2020, 45 TexReg 4041