December 15, 2017

Texas Work Comp Commissioner Adopts EDI Reporting Changes

On June 20, 2011 the Commissioner of Workers’ Compensation, Rod Bordelon, adopted amended 28 Texas Administrative Code (TAC) §134.802 and new §§134.800, 134.801, and 134.803 – 134.808 regarding insurance carrier medical electronic data interchange (EDI) reporting. The adoption was filed with the Office of the Secretary of State on June 20, 2011 for publication and will be published in the
July 1, 2011 issue of the Texas Register. The adoption may be accessed at that time at
http://www.sos.state.tx.us/texreg/index.shtml.

As of the date of the notice, a courtesy copy of the adoption may be viewed on the Texas Department of Insurance (TDI) website at
http://www.tdi.state.tx.us/wc/rules/adopted/index.html.

The purpose of these adopted rules is to implement the requirements of Texas Labor Code §413.007 and §413.008 and improve insurance carriers’ understanding of the requirements associated with reporting medical charges and payment data pursuant to these statutes. Texas Labor Code §413.007 requires the Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) to maintain a statewide data base of medical charges, actual payments, and treatment protocols to be used to adopt medical policies and fee guidelines and administer the medical policies, fee guidelines, or rules. These adopted rules require insurance carriers to submit information to the TDI-DWC to populate the data base. The adopted rules codify the existing TDI-DWC medical EDI reporting requirements with minimal changes to the current technical infrastructure associated with medical EDI reporting.

These rules adopt by reference the IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 1.0, dated July 4, 2002 which is published by the International Association of Industrial Accident Boards and Commissions.

These adopted rules also adopt by reference the Texas EDI Medical Difference Table, Texas EDI Medical Data Element Edit Table, and Texas EDI Medical Data Element Requirement Table. These tables are published by the TDI-DWC and are available along with the adoption on the TDI website.

The DWC EDI-02 (Insurance Carrier or Trading Partner Medical EDI Profile) and EDI-03 (Medical EDI Compliance Coordinator and Trading Partner Notification) forms are new forms related to these adopted rules. An insurance carrier or trading partner sending the medical EDI transmission must send to the TDI-DWC a completed DWC EDI-02 at least five working days prior to sending its first test transaction
under these adopted rules. An insurance carrier must send to the TDI-DWC a completed DWC EDI-03 at least five working days prior to sending its first transaction under these adopted rules. Both forms are available on the agency website at http://www.tdi.state.tx.us/forms/form20.html and should be sent to TDI-DWC at the address indicated at the top of each form. The TDI-DWC notes that trading partners or insurance carriers that already have a valid DWC EDI-01 (EDI Trading Partner Profile) on file with the TDI-DWC do not have to file the new DWC EDI-02 form unless there are changes to their information. All insurance carriers, however, must file an EDI-03 (Medical EDI Compliance Coordinator and Trading Partner Notification) form.

The adopted rules are effective September 1, 2011.

Source: TDI-DWC

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