All TX providers must file their bills for injured worker treatment electronically (e-billing).
Claims administrators are required to accept providers’ e-bills and respond with electronic Explanation of Benefits (EOB).
This rule applies to both network and non-network claims.
Electronic Billing Mandate
The Texas Department of Insurance, Division of Workers’ Compensation (DWC) requires providers to bill electronically, with some exceptions.
For more information, see Texas Administrative Code Rule §133.500 on Electronic Formats for Electronic Medical Bill Processing and Rule §133.501 on Electronic Medical Bill Processing.
Health care providers in the state should e-bill unless they meet the exception criteria below.
Exemptions to Mandatory e-Billing
e-Billing is required for all providers. However, a provider may be exempt from e-billing if one of the following applies:
- The provider has fewer than 10 full-time employees
- The provider has treated 32 or fewer injured workers in the previous calendar year, or
- The provider can demonstrate that setting up e-billing would cause an unreasonable financial burden and can submit financial statements and other documentation as proof of implementation costs.
If a provider claims one of these exemptions, the DWC may ask for proof. The provider must submit all supporting documentation within 15 days of the DWC’s request.
Texas |
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Statute |
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Subsection Text |
(a) The commissioner, by rule and in cooperation with the commissioner of insurance, shall adopt rules regarding the electronic submission and processing of medical bills by health care providers to insurance carriers. (b) Insurance carriers shall accept medical bills submitted electronically by health care providers in accordance with commissioner rule. (c) The commissioner shall by rule establish criteria for granting exceptions to insurance carriers and health care providers who are unable to submit or accept medical bills electronically. (d) On or after January 1, 2008, the commissioner may adopt rules regarding the electronic payment of medical bills by insurance carriers to health care providers. |
Rule |
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Subsection Text |
(b) Exemptions. (1) A health care provider is exempt from the requirement to submit medical bills electronically to an insurance carrier if: (A) the health care provider employs fewer than 10 full time employees; (B) the health care provider provided services to 32 or fewer injured employees during the preceding calendar year; or (C) the health care provider can sufficiently demonstrate electronic medical bill implementation will create an unreasonable financial hardship and can provide supporting documentation such as financial statements and other documentation which reflect the cost of implementation.
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