SECTION 354.1071. Additional Claim Information Requirements

In addition to the general requirements in §354.1001 of this subchapter (relating to Claim Information Requirements), HHSC requires that the following information be submitted with hospital claims:

(1) Inpatient hospital care.

(A) Copy of the patient's itemized daily charges, including data elements and format as specified by HHSC.

(B) Date and hour of admission and discharge, including inclusive dates during which services were provided if claims are made for a period other than that beginning on the date of admission and ending with the date of discharge.

(C) Number of days of care.

(D) Charges for bed, meals, and nursing care.

(E) Admitting diagnoses or symptoms.

(F) Discharge diagnoses (or diagnoses at end of period for which a claim is made if discharge has not occurred).

(G) Surgical procedures, if any.

(H) Individual charges for ancillary services approved by HHSC.

(I) Dates on which the various types of services were provided. The posting date is satisfactory except when a portion of the period of care precedes or succeeds the certified period of eligibility. In such cases, record the actual date that each of the types of services listed in this paragraph was provided.

(J) Certification by the hospital that the hospital has on file a record that services provided were upon order of a physician or doctor, a record of admission, continued stay certification, extension recertification, and 60-day recertification.

(K) The hospital's medical record number.

(L) The name, address, and appropriate identification number of the attending physician and, if appropriate, consulting physician(s) or doctor(s).

(M) The certification portion of the Texas Admissions and Review Program (TARP) abstract must accompany claims from all certified hospitals. The entire abstract must accompany claims from noncertified hospitals.

(N) For medically necessary hysterectomies, a patient's acknowledgment statement that the person who secured authorization to perform the hysterectomy has informed the patient and her representative, if any, orally and in writing, that the hysterectomy renders the patient permanently sterile. The patient or her representative, if any, must sign the written acknowledgment of receipt of that information before the surgery. The provider must submit an acknowledgment statement with hospital claims for hysterectomies unless the patient is sterile at the time of the hysterectomy, or the patient requires a hysterectomy on an emergency basis because of a life-threatening situation and the physician determines that prior acknowledgment is not possible. If one of the exceptions applies, the physician performing the hysterectomy must certify in writing, to HHSC or its designee, that the specific circumstance existed at the time he or she operated.

(O) Present on admission indicators are required for all inpatient claims.

(2) Hospital outpatient services.

(A) Surgical procedure(s) related to each specific diagnosis, where possible.

(B) Medical treatment(s) related to each specific diagnosis, where possible.

(C) Diagnosis(es).

(D) Charges for each service.

(E) Date of each service.

(F) Name, address, and appropriate identification number of the attending physician and (if known) of ordering and consulting physician(s).

(3) An erroneous surgery, procedure, or treatment that is classified by HHSC as a preventable adverse event must be submitted with the appropriate modifier, as defined by HHSC or its designee, on all lines related to the erroneous surgery, procedure, or treatment.

Source Note: The provisions of this §354.1071 adopted to be effective May 30, 1977, 2 TexReg 1929; amended to be effective February 6, 1979, 4 TexReg 478; amended to be effective August 4, 1982, 7 TexReg 4162; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective September 1, 2010, 35 TexReg 6649; amended to be effective August 6, 2013, 38 TexReg 4886