Texas Register, Volume 38, Number 46, Pages 8023-8312, November 15, 2013 Page: 8,116
This periodical is part of the collection entitled: Texas Register and was provided to The Portal to Texas History by the UNT Libraries Government Documents Department.
Extracted Text
The following text was automatically extracted from the image on this page using optical character recognition software:
or the provider has made a good faith but unsuccessful attempt to
obtain from the enrollee or the insured any of the information needed
to complete this data element;
(J) other insured's or enrollee's date of birth (CMS-1500
(08/05), field 9b) is required if the patient is covered by more than one
health benefit plan, generally in situations described in subsection (d)
of this section. If the required data element specified in subparagraph
(Q) of this paragraph [( t(Q) of this subsection], "disclosure of any
other health benefit plans," is answered "yes," this element is required
unless the physician or the provider submits with the claim documented
proof that the physician or the provider has made a good faith but un-
successful attempt to obtain from the enrollee or the insured any of the
information needed to complete this data element;
(K) other insured's or enrollee's plan name (employer,
school, etc.), (CMS-1500 (08/05), field 9c) is required if the patient is
covered by more than one health benefit plan, generally in situations
described in subsection (d) of this section. If the required data element
specified in subparagraph (Q) of this paragraph [( (Q} of this subse -
tion], "disclosure of any other health benefit plans," is answered "yes,"
this element is required unless the physician or the provider submits
with the claim documented proof that the physician or the provider has
made a good faith but unsuccessful attempt to obtain from the enrollee
or the insured any of the information needed to complete this data ele-
ment. If the field is required and the physician or the provider is a fa-
cility-based radiologist, pathologist, or anesthesiologist with no direct
patient contact, the physician or the provider must either enter the in-
formation or enter "NA" (not available) if the information is unknown;
(L) other insured's or enrollee's HMO or insurer name
(CMS-1500 (08/05), field 9d) is required if the patient is covered by
more than one health benefit plan, generally in situations described in
subsection (d) of this section. If the required data element specified in
subparagraph (Q) of this paragraph [(1(Q} off this subsection], "disclo-
sure of any other health benefit plans," is answered "yes," this element
is required unless the physician or the provider submits with the claim
documented proof that the physician or the provider has made a good
faith but unsuccessful attempt to obtain from the enrollee or the insured
any of the information needed to complete this data element;
(M) whether the patient's condition is related to em-
ployment, auto accident, or other accident (CMS-1500 (08/05), field
10) is required, but facility-based radiologists, pathologists, or anes-
thesiologists must [shall] enter "N" if the answer is "No" or if the in-
formation is not available;
(N) if the claim is a duplicate claim, a "D" is required;
if the claim is a corrected claim, a "C" is required (CMS-1500 (08/05),
field 10d);
(0) subscriber's policy number (CMS-1500 (08/05),
field 11) is required;
(P) HMO or insurance company name (CMS-1500
(08/05), field 11c) is required;
(Q) disclosure of any other health benefit plans (CMS-
1500 (08/05), field 11id) is required;
(i) if answered "yes," then:
(I) data elements specified in subparagraphs (H)
- (L) of this paragraph [(lt( - (L) of this subsection] are required un-
less the physician or the provider submits with the claim documented
proof that the physician or the provider has made a good faith but un-
successful attempt to obtain from the enrollee or the insured any of the
information needed to complete the data elements in subparagraphs (H)
- (L) of this paragraph [(5(t) - (L) of this subsection];(II) the data element specified in subparagraph
(KK) of this paragraph [(9(TII of this subsection] is required when sub-
mitting claims to secondary payor MCCs [HMOs or efeed provider
carriers];
(ii) if answered "no," the data elements specified in
subparagraphs (H) - (L) of this paragraph [( - ( b - (L) of this subsee-
tion] are not required if the physician or the provider has on file a doc-
ument signed within the past 12 months by the patient or authorized
person stating that there is no other health care coverage; although the
submission of the signed document is not a required data element, the
physician or the provider must [shall] submit a copy of the signed doc-
ument to the MCC [HMO or preferred provider carrier] upon request;
(R) patient's or authorized person's signature or a no-
tation that the signature is on file with the physician or the provider
(CMS-1500 (08/05), field 12) is required;
(S) subscriber's or authorized person's signature or a no-
tation that the signature is on file with the physician or the provider
(CMS-1500 (08/05), field 13) is required;
(T) date of injury (CMS-1500 (08/05), field 14) is re-
quired if due to an accident;
(U) when applicable, the physician or the provider must
[shall] enter the name of the referring primary care physician, specialty
physician, hospital, or other source (CMS-1500 (08/05), field 17); how-
ever, if there is no referral, the physician or the provider must [shall]
enter "Self-referral" or "None";
(V) if there is a referring physician noted in CMS-1500
(08/05), field 17, the physician or the provider must [shall] enter the ID
Number of the referring primary care physician, specialty physician, or
hospital (CMS-1500 (08/05), field 17a);
(W) [for claims filed or re-filed on or after May 23
2008,] if there is a referring physician noted in CMS-1500 (08/05), field
17, the physician or the provider must [shall] enter the NPI number of
the referring primary care physician, specialty physician, or hospital
(CMS-1500 (08/05), field 17b) if the referring physician is eligible for
an NPI number;
(X) narrative description of procedure (CMS-1500
(08/05), field 19) is required when a physician or a provider uses an
unlisted or unclassified [not classified] procedure code or an NDC
code for drugs;
(Y) for diagnosis codes or nature of illness or injury
(CMS-1500 (08/05), field 21), up to four diagnosis codes may be en-
tered, but at least one is required, but the [(]primary diagnosis must be
entered first[)];
(Z) verification number (CMS-1500 (08/05), field 23)
is required if services have been verified under [pursuant to] 19.1719
[ !9 4724] of this title (relating to Verification for Health Maintenance
Organizations and Preferred Provider Benefit Plans). If no verification
has been provided, a prior authorization number (CMS-1500 (08/05),
field 23) is required when prior authorization is required and granted;
(AA) date(s) of service (CMS-1500 (08/05), field 24A)
is required;
(BB) place of service code(s) (CMS-1500 (08/05), field
24B) is required;
(CC) procedure/modifier code (CMS-1500 (08/05),
field 24D) is required;38 TexReg 8116 November 15, 2013 Texas Register
Upcoming Pages
Here’s what’s next.
Search Inside
This issue can be searched. Note: Results may vary based on the legibility of text within the document.
Tools / Downloads
Get a copy of this page or view the extracted text.
Citing and Sharing
Basic information for referencing this web page. We also provide extended guidance on usage rights, references, copying or embedding.
Reference the current page of this Periodical.
Texas. Secretary of State. Texas Register, Volume 38, Number 46, Pages 8023-8312, November 15, 2013, periodical, November 15, 2013; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth379973/m1/94/?rotate=90: accessed July 18, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu.; crediting UNT Libraries Government Documents Department.