Tenn. Comp. R. & Regs. 1200-07-04-.04

Current through December 26, 2024

Section 1200-07-04-.04 - REQUIRED DATA ELEMENTS

(1) CMS-1500 Claims Forms

(a) Each ASTC and ODC must report to the Department all the following data elements for each and every claim based on the CMS-1500 form:

1. Patient's Birth Date

2. Patient's Sex

3. Patient's Address (State)

4. Patient's Address (Zip Code)

5. Dates of Service (Through Date)

6. Diagnosis or Nature of Illness or Injury

7. Total Charge

8. Patient's Social Security Number

9. Patient's Race/Ethnicity

(b) Each ASTC and ODC must report to the Department all CMS-1500 data elements listed in the relevant ASTC or ODC Procedural Manual whenever the data element is collected by the ASTC or ODC and/or used for billing.

(2) UB-04 Claims Forms

(a) Each ASTC and ODC must report to the Department all the following data elements for each and every claim based on the UB-04 form:

1. Statement Covers Period

2. Patient's Address (State)

3. Patient's Address (Zip Code)

4. Patient's Date of Birth

5. Patient's Sex

6. Revenue Codes

7. Total Charges (By Revenue Code Category)

8. Principal Diagnosis Code

9. Patient's Social Security Number

10. Patient's Race/Ethnicity

(b) Each ASTC and ODC must report to the Department all UB-04 data elements listed in the relevant ASTC or ODC Procedural Manual whenever the data element is collected by the ASTC or ODC and/or used for billing.

(3) Each ASTC and ODC shall report to the Department all data elements that it collected from patients and which it reported by making an entry in any or all of the data element spaces contained on any form other than the CMS-1500 or UB-04 on which it submits a claim. However, the data elements identified in paragraphs (1)(a) and (2)(a) above that must be collected, entered and reported to the Department by the ASTC or ODC for the identified claim form shall also be reported to the Department when any other claim form is used.

(4) Data elements collected by the ASTC or ODC that are not specifically identified in either paragraphs (1) through (3) of this rule or in the procedural manual shall not be reported to the vendor or the Department.

Tenn. Comp. R. & Regs. 1200-07-04-.04

Original rule filed January 27, 2005; effective April 12, 2005. Repeal and new rule filed January 29, 2013; effective June 30, 2013.

Authority: T.C.A. §§ 68-1-103 and 68-1-119.