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At a Glance:

§ 42.145


(a) General. All bills submitted to carriers shall:

(1) contain the identifying information required by § 42.30(d) of this title (relating to Written Communications), if available;

(2) itemize services and goods provided; and

(3) after January 1, 1989, identify services and goods provided by appropriate procedural and diagnostic codes, with descriptions, as established in the fee guidelines.

(b) Billing by report.

(1) A provider shall bill by report when no procedural definition and/or dollar value is established for a procedure, or when a provider seeks payment in excess of that established in the fee guidelines.

(2) The report shall:

(A) describe the procedure in sufficient detail to permit evaluation;

(B) contain substantiating documentation to establish the fairness and reasonableness of the charge(s); and

(C) include correct diagnostic codes and descriptions, when appropriate.

(3) The report shall be attached to the bill.

(c) Billing requirements. Failure to comply with billing requirements shall suspend the carrier's obligation to review the bill. The carrier shall return a noncompliant bill to the provider within three working days of receipt.

(d) Billing forms. The board may prescribe forms for billing purposes.

The provisions of this § 42.145 adopted to be effective October 20, 1988, 13 TexReg 4994.

End of Document