TDI Issues Reminder: Chapter 134.800 Rules Take Effect September 1, 2015

The Texas Department of Insurance, Division of Workers’ Compensation has published a memo reminding system participants that the adopted amendments to 28 TAC §§134.802 – 134.805, 134.807, and 134.808 (medical state reporting rules) regarding medical services, charges, and payments are effective September 1, 2015. System stakeholders are expected to be compliant with the new rules by the effective date.

Many system payers have been challenged by the language in amended  Rule 134.802 that requires carriers to report medical bill processing data using the original claim administrator claim number. This requirement, that payors report a claim number that may have been generated and formatted by a different carrier or third party administrator, has caused a great deal of angst among claims administrators and carriers. The Division has not clarified whether the requirement obligates reporting entities to re-report old data that may have been submitted using a more recently assigned claim number. Moreover, some carriers and TPAs complain that their systems are not yet capable of reporting claim numbers in a different format. Finally, a number of payors complain that they are not able to identify the original claims administrator claim number in order to report it.

During informal discussions with system stakeholders, senior regulators at the Division have emphasized their belief that this requirement is not new; that it has been the obligation of payors since Texas adopted IAIABC Release 1. They also emphasize that while the requirement is an important one to the Division, the agency does not intend to audit for this data element in 2015 or 2016. Division staff have encouraged carriers, TPAs and medical bill processing vendors who report EDI data to develop the capacity to report the data correctly as soon as possible, if they are not able to do so by the September 1, 2015 deadline. Of course, carriers who are able to comply with the requirement on September 1, 2015 should do so.

We have been advised to expect further clarification regarding the Division’s position on resubmissions in the near future.

The adoption of amended 28 TAC §§134.802 – 134.805, 134.807, and 134.808 regarding reporting of medical services, charges, and payments was published in the Texas Register (40 TexReg 595) on February 6, 2015 and is available at www.sos.state.tx.us/texreg/pdf/backview/0206/0206adop.pdf. A courtesy copy of the adoption is currently available at www.tdi.texas.gov/wc/rules/adopted/index.html.

Among the other important Rules changes that the Division has emphasized in its memo:

• Rule134.804(a) highlights the existing requirement that all subsequent actions, not just payment actions, must be reported by insurance carriers to the division. Amended §134.804(b) and (c) specify that an “00” original medical EDI record must be submitted before an “01” cancel or “05” replacement medical EDI record to ensure the division maintains the most current medical EDI records submitted by insurance carriers. Amended §134.804(d) emphasizes that insurance carriers must submit accurate medical EDI records to the division.

If you have not completed and filed an EDI-03, we recommend that you do so at this time. If you are unsure whether your EDI Compliance Coordinator information on file with the Division is accurate, we can review that information with you and help you confirm the name and contact information that the agency has on file for your company.

Please contact James Sheffield, Steve Tipton or Bobby Stokes with any inquiries regarding the implementation of these rules.