Definitions

(1) “Business day” means Monday through Friday, excluding days on which a holiday is observed by this jurisdiction. (2) “CAQH CORE” Council for Affordable Quality Healthcare Committee on Operating Rules for Information Exchange is a national standards organization that develops operating rules for the business aspects of the United States Department of Health and Human Services (HHS) mandates for electronic healthcare transactions. (3) “Clearinghouse” means a public or private entity, including a billing service, repricing company, community health management information system or community health information system, and “value-added” networks and switches, that is an agent of either the payer or the provider and that may perform the following functions: (a) Processes or facilitates the processing of medical billing information received from a client in a nonstandard format or containing nonstandard data content into standard data elements or a standard transaction for further processing of a bill related transaction; or (b) Receives a standard transaction from another entity and processes or facilitates the processing of medical billing information into nonstandard format or nonstandard data content for a client entity. (4) “CMS” means the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services (HHS), the federal agency that administers these programs. ELECTRONIC MEDICAL BILLING FOR WORKERS’ CHAPTER 0800-02-26 COMPENSATION (5) “Companion Guide” means the Tennessee Bureau of Workers’ Compensation Electronic Billing and Payment Companion Guide, based on IAIABC National Companion Guide, and is a separate document which gives detailed information for Electronic Data Interchange (EDI) medical billing and payment for the workers’ compensation industry using national standards and Tennessee jurisdictional procedures. (6) “Complete electronic medical bill” means a medical bill that meets all of the criteria enumerated in 0800-02-26-.05(3). (7) “Electronic” refers to communication between computerized data exchange systems that complies with the standards enumerated in this rule. (8) “Health care provider” means a person or entity, appropriately certified or licensed, as required, who provides medical services or products to an injured worker in accordance with 0800-02-06. Health Care Providers are responsible for the acts or omissions of their agents related to the performance of electronic medical billing services. (9) “Health care provider agent” means a person or entity that contracts with a health care provider establishing an agency relationship to process bills for services provided by the health care provider under the terms and conditions of a contract between the agent and health care provider. Such contracts may permit the agent to submit bills, request reconsideration, receive reimbursement, and seek medical dispute resolution for the health care provider services billed in accordance with Tennessee Workers’ Compensation Act and bureau rules. (10) “Health Plan Identifier” or “HPID” means an identifier for health plans (as defined in 45 CFR § 160.103) that need to be identified in standard transactions. (11) “National Provider Identification Number” or “NPI” means the unique identifier assigned to a health care provider or health care facility by the Secretary of the United States Department of Health and Human Services. (12) “Other Entity Identifier” or “OEID” means an identifier for entities that are not health plans, health care providers, or “individuals” (as defined in 45 CFR § 160.103), but that need to be identified in standard transactions (including, for example, workers’ compensation payers, third party administrators, transaction vendors, clearinghouses, and other payers). (13) “Operating Rules” means the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications. (14) “Payer” means the employer, its insurer or authorized self-insured employer or an entity authorized to make payments on behalf of the insurer or authorized self-insured employer legally responsible for paying the workers’ compensation medical bills. Payers are responsible for the acts or omissions of their agents related to the performance of electronic medical billing services. (15) “Payer agent” here is broadly construed to mean any person or entity that performs medical bill related processes for the payer responsible for the bill. These processes include, but are not limited to, reporting to government agencies, electronic transmission, forwarding, or receipt of documents, review of reports, adjudication of bills, and their final payment. ELECTRONIC MEDICAL BILLING FOR WORKERS’ CHAPTER 0800-02-26 COMPENSATION (16) “Supporting documentation” means those documents necessary for the payer to process a bill. These include, but are not limited to, any written authorization received from the third party administrator or any other records as required by 0800-02-26-.05. (17) “Technical Report Type 3” (TR3 Implementation Guide) is an ASC X12 published document for national electronic standard formats that specifies data requirements and data transaction sets, as referenced in 0800-02-26-.03 of this rule.