Section 21.4507 - Data Required(a) Applicable health benefit plans must include the following information as a cover page to each report:(2) company or plan name;(3) NAIC number, issued to the company by the National Association of Insurance Commissioners;(5) contact information for the person designated to discuss the report with TDI staff, including name, telephone number, and email address;(6) an indication of whether the report is for insurance business or HMO business, consistent with subsection (d) of this section, or "NA" for reports limited to self-insured business;(7) an indication of whether the report includes data on self-insured business, including data for certain governmental plans required to report under Insurance Code Chapter 38, Subchapter H; and(8) a certification that the information provided is a full and true statement of the data required under this subchapter.(b) Applicable health benefit plans must submit the following data, for in-network and out-of-network claims, for each geographic region, as defined by § 21.4503 of this title, for each service identified in subsection (c) of this section, with data columns reported in the following order: (1) network status of the claims data, using "IN" to indicate in-network claims and "OON" to indicate out-of-network claims;(2) geographic region of the claims data, using the three-digit ZIP code to indicate the applicable region;(3) total number of unique claim identifiers for all claim types;(4) for inpatient procedure facility claims, the total number of discharges;(6) total amount allowed;(9) median amount billed;(10) median amount allowed;(11) maximum amount billed;(12) maximum amount allowed;(13) minimum amount billed;(14) minimum amount allowed;(15) lower quartile amount billed, representing the 25th percentile of all amounts billed;(16) lower quartile amount allowed, representing the 25th percentile of all amounts allowed;(17) upper quartile amount billed, representing the 75th percentile of all amounts billed; and(18) upper quartile amount allowed, representing the 75 percentile of all amounts allowed.(c) Data elements identified in subsection (b) of this section must be reported in the specified manner for each category of services in this subsection. (1) Inpatient procedures. Data on inpatient procedure claims must be reported separately for facility claims and professional claims.(A) Facility claims data must be grouped by discharge and only include claims that occurred in an inpatient hospital.(B) Professional claims data must be reported separately for surgical claims, radiology claims, pathology claims, and anesthesia claims, as applicable, and only include claims for which the place-of-service code indicates inpatient hospital.(C) Inpatient procedure claims data must be reported for the full cost of any claim, or the full cost of any discharge for facility claims, for the following services, using the medical billing codes specified by TDI consistent with § 21.4505(b) of this title: (i) cesarean section delivery;(vi) coronary artery bypass grafting;(vii) back surgery - laminectomy;(viii) inguinal hernia repair, unilateral;(ix) inguinal hernia repair, bilateral;(x) laparoscopic cholecystectomy; and(2) Outpatient procedures. Data on outpatient facility procedure claims must be reported separately for facility claims and professional claims. (A) Facility claims data must be reported separately for outpatient procedures that occurred in an outpatient hospital and those that occurred in an ambulatory surgical center or freestanding clinic.(B) Professional claims data must only include claims for which the place-of-service code indicates outpatient hospital or ambulatory surgical center, and be reported separately for surgical claims, radiology claims, pathology claims, and anesthesia claims, as applicable.(C) Data on outpatient procedure facility claims must be reported for the full cost of any claim for the following services, using the medical billing codes specified by TDI, consistent with § 21.4505(b) of this title:(i) back surgery - laminectomy(ii) inguinal hernia repair, unilateral;(iii) inguinal hernia repair, bilateral;(iv) laparoscopic cholecystectomy;(viii) tonsillectomy and adenoidectomy;(xii) upper and lower GI endoscopy;(xv) rotator cuff repair;(xvi) cardiac catheterization, left;(xvii) cardiac catheterization, right;(xviii) cardiac catheterization, left and right; and(xix) percutaneous transluminal coronary angioplasty.(3) Emergency services. Data on emergency room visits must be reported only for professional claims for which the place of service is an emergency room or outpatient hospital. An emergency room includes both a hospital emergency room and a freestanding emergency medical care facility. Data must be reported at the claim-line level for the following types of emergency room visits, using the medical billing codes specified by TDI, consistent with § 21.4505(b) of this title: (A) emergency department visit, self-limited or minor problem;(B) emergency department visit, low to moderately severe problem;(C) emergency department visit, moderately severe problem;(D) emergency department visit, problem of high severity; and(E) emergency department visit, problem with significant threat to life or function.(4) Imaging services. Data on imaging services must be reported separately for facility claims and professional claims.(A) Facility claims must include only claims that occurred in an outpatient hospital, and for which units of service equal one.(B) Professional claims must be reported only for claims for which units of service equal one. Data must be reported separately for claims billed with CPT code modifiers for the professional component (26), technical component (TC), and a missing or null modifier. Data must be reported separately by place-of-service code: (iii) all other place-of-service codes, excluding office, inpatient hospital, outpatient hospital, and emergency room.(C) Data must be reported at the claim-line level for the following imaging services, using the medical billing codes specified by TDI, consistent with § 21.4505(b) of this title:(i) CT abdomen and pelvis;(v) CT scan mouth, jaw, and neck;(vi) CT scan soft tissue neck;(viii) CT scan lumbar lower spine;(ix) CT scan lower extremity;(xi) MRI head, orbit/face/neck;(xii) MRI angiography head;(xvii) MRI upper limb, other than joint;(xviii) MRI lower limb with joint;(xix) MRI upper limb with joint;(xxiv) mammogram, analog;(xxv) mammogram with CAD; and(xxvi) mammogram, digital.(5) Pathology services. Data on pathology services must be reported only for professional claims for which the place of service is an independent lab. (A) Data must be reported at the claim-line level and averaged to reflect the cost per unit of service.(B) Data must be reported for the following pathology services, using the medical billing codes consistent with § 21.4505(b) of this title:(i) organ or disease panels;(ii) evocative suppression testing;(v) hematology-coagulation;(viii) anatomic pathology;(ix) screening cytopathology; and(x) complete blood count.(6) Office visits. Data on office visits must be reported only for professional claims for which the place of service is an office or rural health clinic. (A) For data elements listed in subparagraph (B) of this paragraph, data must be reported at the claim-line level and averaged to reflect the cost per unit of service.(B) Data must be reported for the following types of office visits, using the medical billing codes consistent with § 21.4505(b) of this title: (i) office or other outpatient visit with a new patient, by time or complexity;(ii) office or other outpatient visit with an established patient, by time or complexity;(iii) office consultation, by time or complexity;(iv) preventive medicine evaluation and management, new patient, by age group;(v) preventive medicine evaluation and management, established patient, by age group;(vi) annual gynecological exam, new patient;(vii) annual gynecological exam, established patient;(viii) screening pelvic and breast exam;(ix) screening pap smear; and(x) cytopathology for pap smear.(C) Data must be reported for well-woman exams so that all costs associated with a claim are reported with respect to the medical billing consistent with § 21.4505(b) of this title.(d) In reporting data required under this section, issuers must: (1) report data elements according to medical billing codes specified by § 21.4505(b) of this title;(2) separately report data for insurance and HMO and exclude any HMO claims paid through a capitation agreement;(3) separately report data for in-network and out-of-network claims; and(4) filter claims data to include only: (A) claims incurred during the 12-month reporting period. For the 2015 reporting period, limit data for inpatient procedure claims and outpatient procedure claims to claims incurred before October 1, 2015, or the date on which the issuer transitioned billing systems to use ICD-10 procedure codes;(B) claims for which adjudication is final; exclude pending or denied claims;(C) claims for which the issuer is the primary plan responsible for payment; exclude claims for which issuer is the secondary plan; and(D) claims with an allowed amount greater than zero.28 Tex. Admin. Code § 21.4507
The provisions of this §21.4507 adopted to be effective January 9, 2011, 35 TexReg 11868; Amended by Texas Register, Volume 41, Number 23, June 3, 2016, TexReg 4027, eff. 6/6/2016