See bold text below:
The following words and terms when used in this subchapter have the following meanings unless the context clearly indicates otherwise:
(1) Audit–A procedure authorized by and described in § 21.2809 of this title (relating to Audit Procedures) under which a managed care carrier (MCC) may investigate a claim beyond the statutory claims payment period without incurring penalties under § 21.2815 of this title (relating to Failure to Meet the Statutory Claims Payment Period).
(2) Batch submission–A group of electronic claims submitted for processing at the same time within a HIPAA standard ASC X12N 837 Transaction Set and identified by a batch control number.
(3) Billed charges–The charges for medical care or health care services included on a claim submitted by a physician or a provider. For purposes of this subchapter, billed charges must comply with all other applicable requirements of law, including Health and Safety Code § 311.0025, Occupations Code § 105.002, and Insurance Code Chapter 552.
(4) CMS–The Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services.
(5) Catastrophic event–An event, including an act of God, civil or military authority, or public enemy; war, accident, fire, explosion, earthquake, windstorm, flood, or organized labor stoppage, that cannot reasonably be controlled or avoided and that causes an interruption in the claims submission or processing activities of an entity for more than two consecutive business days.
(6) Clean claim–
(A) For nonelectronic claims, a claim submitted by a physician or a provider for medical care or health care services rendered to an enrollee under a health care plan or to an insured under a health insurance policy that includes: (i) the required data elements set out in § 21.2803(b) or (c) of this title (relating to Elements of a Clean Claim); and (ii) if applicable, the amount paid by the primary plan or other valid coverage under § 21.2803(d) of this title;
(B) For electronic claims, a claim submitted by a physician or a provider for medical care or health care services rendered to an enrollee under a health care plan or to an insured under a health insurance policy using the ASC X12N 837 format and in compliance with all applicable federal laws related to electronic health care claims, including applicable implementation guides, companion guides, and trading partner agreements.
(7) Condition code–The code utilized by CMS to identify conditions that may affect processing of the claim.
(8) Contracted rate–Fee or reimbursement amount for a preferred provider’s services, treatments, or supplies as established by agreement between the preferred provider and the MCC.
(9) Corrected claim–A claim containing clarifying or additional information necessary to correct a previously submitted claim.
(10) Deficient claim–A submitted claim that does not comply with the requirements of § 21.2803(b), (c), or (e) of this title.
(11) Diagnosis code–Numeric or alphanumeric codes from the International Classification of Diseases (ICD-9-CM), Diagnostic and Statistical Manual (DSM-IV), or their successors, valid at the time of service.
(12) Duplicate claim–Any claim submitted by a physician or a provider for the same health care service provided to a particular individual on a particular date of service that was included in a previously submitted claim. The term does not include:
(A) corrected claims; or
(B) claims submitted by a physician or a provider at the request of the MCC.
(13) Exclusive provider carrier–An insurer that issues an exclusive provider benefit plan as provided by Insurance Code Chapter 1301.
(14) HMO–A health maintenance organization as defined by Insurance Code § 843.002(14).
(15) HMO delivery network–As defined by Insurance Code § 843.002(15).
(16) Institutional provider–An institution providing health care services, including, but not limited to, hospitals, other licensed inpatient centers, ambulatory surgical centers, skilled nursing centers, and residential treatment centers.
(17) MCC or managed care carrier–An HMO, a preferred provider carrier, or an exclusive provider carrier.
(18) NPI number–The National Provider Identifier standard unique health identifier number for health care providers assigned under 45 Code of Federal Regulations Part 162 Subpart D or a successor rule.
(19) Occurrence span code–The code used by the Centers for Medicare and Medicaid Services (CMS) to define a specific event relating to the billing period.
(20) Patient control number–A unique alphanumeric identifier assigned by the institutional provider to facilitate retrieval of individual financial records and posting of payment.
(21) Patient financial responsibility–Any portion of the contracted rate for which the patient is responsible under the terms of the patient’s health benefit plan.
(22) Patient discharge status code –The code used by CMS to indicate the patient’s status at the time of discharge or billing.
(23) Physician–Anyone licensed to practice medicine in this state.
(24) Place of service code–The code used by CMS that identifies the place where the service was rendered.
(25) Point of Origin for Admission or Visit code–The code used by CMS to indicate the source of an inpatient admission.
(26) Preferred provider–
(A) with regard to a preferred provider carrier or an exclusive provider carrier, a preferred provider as defined by Insurance Code § 1301.001; and
(B) with regard to an HMO: (i) a physician, as defined by Insurance Code § 843.002, who is a member of that HMO’s delivery network; or (ii) a provider, as defined by Insurance Code § 843.002, who is a member of that HMO’s delivery network.
(27) Preferred provider carrier–An insurer that issues a preferred provider benefit plan as provided by Insurance Code Chapter 1301.
(28) Primary plan–As defined in § 3.3506 of this title (relating to Use of the Terms “Plan,” “Primary Plan,” “Secondary Plan,” and “This Plan” in Policies, Certificates, and Contracts), or in a successor rule adopted by the commissioner.
(29) Procedure code–Any alphanumeric code representing a service or treatment that is part of a medical code set that is adopted by CMS as required by federal statute and valid at the time of service. In the absence of an existing federal code, and for nonelectronic claims only, this definition may also include local codes developed specifically by Medicaid, Medicare, or an MCC to describe a specific service or procedure.
(30) Provider–Any practitioner, institutional provider, or other person or organization that furnishes health care services and that is licensed or otherwise authorized to practice in this state, other than a physician.
(31) Revenue code–The code assigned by CMS to each cost center for which a separate charge is billed.
(32) Secondary plan–As defined in § 3.3506 of this title, or in a successor rule adopted by the commissioner.
(33) Statutory claims payment period–
(A) the 45 calendar days during which an MCC must pay or deny a claim, in whole or in part, after receipt of a nonelectronic clean claim under Insurance Code Chapters 843 and 1301, and any extended period permitted under § 21.2804 of this title (relating to Requests for Additional Information from Treating Provider) or § 21.2819 of this title (relating to Catastrophic Event);
(B) the 30 calendar days during which an MCC must pay or deny a claim, in whole or in part, after receipt of an electronically submitted clean claim under Insurance Code Chapters 843 and 1301, and any extended period permitted under § 21.2804 or § 21.2819 of this title;
(C) the 21 calendar days during which an MCC must pay a claim after affirmative adjudication of a claim for a prescription benefit that is not electronically submitted under Insurance Code Chapters 843 and 1301 and § 21.2814 of this title (relating to Adjudication of Prescription Benefits), and any extended period permitted under § 21.2804 or § 21.2819; or
(D) the 18 calendar days during which an MCC must make a claim payment after affirmative adjudication of an electronically submitted claim for a prescription benefit under Insurance Code Chapters 843 and 1301 and § 21.2814 of this title, and any extended period permitted under § 21.2804 or § 21.2819 of this title.
(34) Subscriber–If individual coverage, the individual who is the contract holder and is responsible for payment of premiums to the MCC; or if group coverage, the individual who is the certificate holder and whose employment or other membership status, except for family dependency, is the basis for eligibility for enrollment in a group health benefit plan issued by the MCC.
(35) Type of bill code–The three-digit alphanumeric code used by CMS to identify the type of facility, the type of care, and the sequence of the bill in a particular episode of care.