Tenn. Comp. R. & Regs. 0800-02-26-.05

Current through October 22, 2024

Section 0800-02-26-.05 - ELECTRONIC MEDICAL BILLING, REIMBURSEMENT, AND DOCUMENTATION

(1) Applicability

(a) This section outlines the exclusive process for the initial exchange of electronic medical bill and related payment processing data for professional, institutional/hospital, pharmacy, and dental services.

(b) Unless exempted from this process in accordance with subsection (2) of this section, payers or their agents shall:

1. Accept electronic medical bills submitted in accordance with the adopted standards;

2. Transmit acknowledgments and remittance advice in compliance with the adopted standards in response to electronically submitted medical bills; and

3. Support methods to receive electronic documentation required for the adjudication of a bill, as described in 0800-02-26-.08 below.

(c) A health care provider shall:

1. Implement a software system capable of exchanging medical bill data in accordance with the adopted standards, or contract with a clearinghouse to exchange its medical bill data;

2. Submit medical bills as defined by 0800-02-26-.03(1)(a) to any payers that have established connectivity to the health care provider's system or clearinghouse;

3. Submit required documentation in accordance with subsection (5) below; and

4. Receive and process any acceptance or rejection acknowledgment from the payer.

(d) Payers shall be able to exchange electronic data by January 1, 2018, unless exempted from the process in accordance with subsection (2) of this section.

(e) Health care providers or their agents shall be able to exchange electronic data by June 1, 2018, unless exempted from the process in accordance with subsection (2) of this section.

(2) Exceptions to Mandatory Participation

(a) A health care provider is waived from the requirement to submit medical bills electronically to a payer if:

1. The health care provider employs 10 or fewer full-time employees (used by Medicare), or

2. The health care provider submitted fewer than one hundred twenty (120) bills for workers' compensation treatment in the previous calendar year.

3. The Bureau of Workers' Compensation may grant an exception on a case-by-case basis if the health care provider establishes that electronic billing will result in an unreasonable financial burden.

(b) A payer is waived from the requirement to receive medical bills electronically from health care providers if:

1. The payer processed fewer than two hundred fifty (250) medical bills for workers' compensation treatment or services in the previous calendar year.

2. The Bureau of Workers' Compensation may grant an exception on a case-by-case basis if the payer establishes that electronic billing will result in an unreasonable financial burden.

(3) Complete Electronic Medical Bill. To be considered a complete electronic medical bill, the bill or supporting transmissions shall:

(a) Be submitted in the correct billing format;

(b) Be transmitted in compliance with the format requirements described in 0800-02-26-.03 of this rule;

(c) Include in legible text all supporting documentation for the bill, including, but not limited to, medical reports and records, evaluation reports, narrative reports, assessment reports, progress reports/notes, clinical notes, hospital records and diagnostic test results that are expressly required by Rule 0800-02-17-.03;

(d) Identify the:

1. Injured employee;

2. Employer;

3. Insurance carrier, third party administrator, managed care organization or its agent; Health care provider;

4. Medical service product; and

5. Any other requirements as presented in the Tennessee electronic billing companion guide; and

(e) Use current and valid codes and values as defined in the applicable formats referenced in the jurisdictional regulatory requirements.

(4) Acknowledgement

(a) An Interchange Acknowledgment (TA1) notifies the sender of the receipt of, and certain structural defects associated with, an incoming transaction.

(b) An Implementation Acknowledgment (ASC X12 999) transaction is an electronic notification to the sender of the file that it has been received and has been:

1. Accepted as a complete and structurally correct file, or

2. Rejected with a valid rejection error code.

(c) A Health Care Claim Acknowledgment (ASC X12 277CA) is an electronic acknowledgment to the sender of an electronic transaction that the transaction has been received and has been:

1. Accepted as a complete, correct submission, or

2. Rejected with a valid rejection error code.

(d) A payer shall acknowledge receipt of an electronic medical bill by returning an Implementation Acknowledgment (ASC X12 999) within one (1) business day of receipt of the electronic submission.

1. Notification of a rejected bill is transmitted using the appropriate acknowledgment when an electronic medical bill does not meet the definition of a complete electronic medical bill as described in 0800-02-26-.05(5) or does not meet the edits defined in the applicable implementation guide or guides.

2. A health care provider or its agent shall not submit a duplicate electronic medical bill earlier than 60 calendar days from the date originally submitted if a payer has acknowledged acceptance of the original complete electronic medical bill. A health care provider or its agent may submit a corrected medical bill electronically to the payer after receiving notification of a rejection. The corrected medical bill is submitted as a new, timely original bill if resubmitted within 60 days of the notice of rejection.

(e) A payer shall acknowledge receipt of an electronic medical bill by returning a Health Care Claim Acknowledgment (ASC X12 277CA) transaction (detail acknowledgment) within two (2) business days of receipt of the electronic submission.

1. Notification of a rejected bill is transmitted in an ASC X12N 277CA response or acknowledgment when an electronic medical bill does not meet the definition of a complete electronic medical bill or does not meet the edits defined in the applicable implementation guide or guides.

(f) Acceptance of a complete medical bill is not an admission of liability by the payer. A payer may subsequently reject an accepted electronic medical bill if the employer or other responsible party named on the medical bill is not legally liable for its payment.

1. The rejection is transmitted by means of an 835 transaction.

2. The subsequent rejection of a previously accepted electronic medical bill shall occur no later than fifteen (15) business days from the date of receipt of the complete electronic medical bill.

3. The transaction to reject the previously accepted complete medical bill shall clearly indicate that the reason for rejection is that the payer is not legally liable for its payment.

(g) Acceptance of an incomplete medical bill does not satisfy the written notice of injury requirement from an employee or payer as required in T.C.A. § 50-6-201.

(h) Acceptance of a complete or incomplete medical bill by a payer does not begin the time period by which a payer shall accept or deny liability for any alleged claim related to such medical treatment.

(i) Transmission of an Implementation Acknowledgment under 0800-02-26-.05(4)(b), and acceptance of a complete, structurally correct file serves as proof of the received date for an electronic medical bill in 0800-02-26-.05(3).

(5) Electronic Documentation

(a) Electronic documentation, including but not limited to medical reports and records submitted electronically that support an electronic medical bill, may be required by the payer before payment may be remitted to the health care provider, in accordance with regulations established by the Bureau of Workers' Compensation here and in 0800-0217. Further information is available in the Tennessee Bureau of Workers' Compensation Electronic Billing and Payment Companion Guide, a copy of which is available on the Bureau website and is adopted herein by reference.

(b) Complete electronic documentation shall be submitted by secure fax, secure encrypted electronic mail, or in a secure electronic format as defined in 0800-02-26-.03.

(c) The electronic transmittal, either by secure fax or by secure encrypted electronic mail or any other secure electronic format, shall prominently contain the following details on its cover sheet or first page of the transmittal:

1. The name of the injured employee,

2. Identification of the worker's employer, the employer's insurance carrier, or the third party administrator or its agent handling the workers' compensation claim;

3. Identification of the health care provider billing for services to the injured worker, and where applicable, its agent;

4. Date(s) of service;

5. The workers' compensation claim number assigned by the payer, if established by the payer; and

6. The unique attachment indicator number.

(d) When requested by the payer, a health care provider or its agent shall submit electronic documentation within seven (7) business days of the payer's request.

1. Electronic documentation may be submitted simultaneously with the electronic medical bill.

2. Electronic documentation may be submitted separately from the electronic medical bill within seven (7) business days of successful submission of the electronic medical bill.

(6) Electronic Remittance Advice (ERA) and Electronic Funds Transfer (EFT)

(a) An Electronic Remittance Advice (ERA) is an Explanation of Benefits (EOB) or Explanation of Review (EOR), submitted electronically, regarding payment or denial of a medical bill, recoupment request, or receipt of a refund.

(b) All payments for service are required to be paid via electronic funds transfer (EFT) unless an alternate electronic method is agreed upon by the payer and provider. The operating rules must comply with the Committee on Operating Rules for Information Exchange of the Council for Affordable Quality Health Care to comply with applicable Federal standards.

(c) The ERA shall contain the appropriate Group Claim Adjustment Reason Codes, Claim Adjustment Reason Codes (CARC) and associated Remittance Advice Remark Codes (RARC) as specified in the Code Value Usage in Health Care Claim Payments and Subsequent Claims Technical Report Type 2 (TR2) Workers' Compensation Code Usage Section and for pharmacy charges, the National Council for Prescription Drugs Program (NCPDP) Reject Codes, denoting the reason for payment, adjustment, or denial.

(d) The ERA shall be sent within five (5) business days of:

1. The expected date of receipt by the medical provider of payment from the payer, or

2. The date of the bill's rejection by the payer.

(7) Requirements for Health Care Providers Exempted from Electronic Billing

(a) Health care providers exempted from electronic medical billing pursuant to 0800-02-26.05(2) shall submit paper medical bills for payment in the following formats as applicable:

1. On the current standard forms used by the Centers for Medicare and Medicaid Services (CMS);

2. On the current National Council for Prescription Drug Programs (NCPDP) Workers' Compensation/Property and Casualty Universal Claim Form (WC/PC UCF);

3. On the current American Dental Association (ADA) Claim Form.

(8) Resubmissions

(a) A health care provider or its agent shall not submit a duplicate medical bill earlier than 30 calendar days from the date originally submitted unless the payer has rejected the medical bill as incomplete in accordance with 0800-02-26-.06 (Employer, Insurance Carrier, Managed Care Organization, or Agents' Receipt of Medical Bills from Health Care Providers). A health care provider or its agent may submit a corrected medical bill to the payer after receiving notification of the rejection of an incomplete medical bill. The corrected medical bill is submitted as a new, timely original bill if resubmitted within 60 calendar days of the notice of rejection.

(9) Connectivity

(a) Unless the payer or its agent is exempted from the electronic medical billing process in accordance with 0800-02-26-.05 (Electronic Medical Billing, Reimbursement, and Documentation), it should attempt to establish connectivity through a trading partner agreement with any clearinghouse that requests the exchange of data in accordance with 0800-02-26-.03 (Formats for Electronic Medical Bill Processing).

(10) Fees

(a) No party to the electronic transactions shall charge excessive fees of any other party in the transaction. A payer or clearinghouse that requests another payer or clearinghouse to receive, process, or transmit a standard transaction shall not charge fees or costs in excess of the fees or costs for normal telecommunications that the requesting entity incurs when it directly transmits, or receives, a standard transaction.

(11) A health care provider agent may charge reasonable fees related to data translation, data mapping, and similar data functions when the health care provider is not capable of submitting a standard transaction. In addition, a health care provider agent may charge a reasonable fee related to:

(a) Transaction management of standard transactions, such as editing, validation, transaction tracking, management reports, portal services and connectivity; and,

(b) Other value added services, such as electronic file transfers related to medical documentation.

(12) A payer or its agent shall not reject a standard electronic transaction on the basis that it contains data elements not needed or used by the payer or its agent or that the electronic transaction includes data elements that exceed those required for a complete bill as enumerated in 0800-02-26-.05(3).

(13) A health care provider that has not implemented a software system capable of sending standard transactions is required to use a secure Internet-based direct data entry system offered by a payer if the payer does not charge a transaction fee. A health care provider using an Internet-based direct data entry system offered by a payer or other entity shall use the appropriate data content and data condition requirements of the standard transactions.

(14) The payer's failure to comply with any requirements of this rule will result in an administrative violation under 0800-02-17-.13, 0800-02-18-.15, 0800-02-19-.06, 0800-02-01-.10 or T.C.A. § 50-6-125 as applicable.

Tenn. Comp. R. & Regs. 0800-02-26-.05

Original rules filed December 13, 2017; effective March 13, 2018. Amendments filed June 24, 2021; effective 9/22/2021.

Authority: T.C.A. § 50-6-202.