RULES AND REGULATIONS
Title 28--HEALTH AND SAFETY
HEALTH CARE COST CONTAINMENT COUNCIL
[28 PA. CODE CH. 912]
Uniform Claims and Billing Forms Reporting Manual
[33 Pa.B. 2865] The Health Care Cost Containment Council (Council), under the authority of section 5(b) of the Pennsylvania Health Care Cost Containment Act (act) (35 P. S. § 449.5(b)), amends Chapter 912, Appendix A (relating to Pennsylvania Uniform Claims and Billing Forms Reporting Manual) to read as set forth in Annex A.
Notice of proposed rulemaking is omitted in accordance with section 204(3) of the act of July 31, 1968 (P. L. 769, No. 240) (45 P. S. § 1204(3)) (CDL). In accordance with section 204(3) of the CDL, notice of proposed rulemaking may be omitted when the agency, for good cause, finds that public notice of its intention to amend an administrative regulation is unnecessary under the circumstances.
Purpose
The purpose of this final-omitted rulemaking is to conform the data reporting requirements in Appendix A to the data reporting requirements in the text of Chapter 912 (relating to data reporting requirements). The text of Chapter 912 was amended at 29 Pa.B. 5093 (October 2, 1999) by removing all specific references to the MedisGroups methodology. The purpose of the 1999 amendment was to give the Council greater flexibility in selecting a methodology for measuring provider quality and provider service effectiveness. Although it was the Council's stated intention to remove all references to the MedisGroups methodology from the regulations in 1999, four references to the methodology inadvertently remained in Appendix A. This final-omitted rulemaking is promulgated to finish the regulatory changes initiated in 1999 by deleting the remaining references to MedisGroups that inadvertently remained in Appendix A after the 1999 amendments to Chapter 912.
Explanation of Regulatory Requirements
Section 5(d)(4) of the act (35 P. S. § 449.5(d)) directs the Council to ''Adopt and implement a methodology to collect and disseminate data reflecting [health care] provider service effectiveness.'' Section 6(d) of the act (35 P. S. § 449.6(d)) permits the Council to ''adopt a Nationally recognized methodology of quantifying and collecting the data.'' In 1987, the Council selected the MedisGroups methodology offered by MediQual Systems, Inc. In 1988, the MedisGroups methodology was incorporated by name into Chapter 912 and Appendix A. To afford the Council the flexibility to utilize a vendor other than MediQual Systems, Inc. if a more effective and economical system became available from another source, the Council amended its regulations in 1999 by deleting all references to MedisGroups from Chapter 912. Although it was the Council's stated intention to eliminate all references to MedisGroups from the regulations in 1999, four additional references to the MedisGroups methodology were in Appendix A that were not identified or deleted at that time. This oversight was recently brought to the attention of the Council. This final-omitted rulemaking deletes the remaining references to MedisGroups from Appendix A, completing the regulatory changes initiated in 1999.
Fiscal Impact
The regulated community (hospitals and other health care providers) will not incur additional costs on account of this final-omitted rulemaking, nor will it require the Council or any other State agency or local government to incur additional costs. At the present time, the Council continues to utilize the MedisGroups methodology for reporting. The authority for the Council to select another vendor if deemed desirable was created by the 1999 rulemaking; this is a ministerial change that does nothing more than conform the text of the forms' reporting manual to the existing text of the regulation. Therefore, there is no fiscal impact on government or the regulated community.
Effectiveness/Sunset Date
This final-omitted rulemaking is effective upon publication in the Pennsylvania Bulletin. No sunset date has been assigned. The Council constantly monitors its regulations to insure maximum effectiveness and to implement changes as necessary.
Paperwork
Adoption of this final-omitted rulemaking will not require any additional paperwork for hospitals and other regulated health care providers since it merely conforms the reporting manual to the requirements of the existing regulation.
Persons Regulated
Approximately 200 hospitals are required to submit health care provider service effectiveness data to the Council.
Contact Person
Questions regarding the final-omitted rulemaking should be addressed to Marc P. Volavka, Executive Director, Health Care Cost Containment Council, Suite 400, 225 Market Street, Harrisburg, PA 17101.
Regulatory Review
Under section 5.1(c) of the Regulatory Review Act (71 P. S. § 745.5a(c)), the Council submitted copies of this final-omitted rulemaking to the Independent Regulatory Review Commission (IRRC) and to the Chairpersons of the House Health and Human Services Committee and the Senate Public Health and Welfare Committee on April 22, 2003. On the same date, the final-omitted rulemaking was submitted to the Office of the Attorney General for review and approval under the Commonwealth Attorneys Act (71 P. S. §§ 732-101--732-506).
Under section 5.1(e) and (j.2) of the Regulatory Review Act, on May 12, 2003, this final-omitted rulemaking was deemed approved by the House and Senate Committees. Under section 5.1(e) of the Regulatory Review Act, on May 29, 2003, IRRC met and approved this final-omitted rulemaking.
Findings
The Council finds that:
(1) There is good cause to amend Appendix A, effective upon publication of the final-omitted rulemaking. Deferral of the effective date of this final-omitted rulemaking is unnecessary and would not serve the public interest. Under section 204(3) of the CDL, there is no purpose to be served by deferring the effective date.
(2) There is good cause to forego public notice of the intention to amend Appendix A because notice of the amendment under the circumstances is unnecessary for the following reasons:
(i) The amendments made merely conform the reporting forms and the manual advising the regulated community how to fill in the report forms; they do not change the substance of what the regulations require the regulated community to do or to be reported.
(ii) The amendments to Appendix A complete the regulatory changes initiated in 1999, when the references to MedisGroups were eliminated from the text of Chapter 912. The 1999 amendments were published as proposed rulemaking. Comments from several interested parties in the regulated community were received, reviewed and responded to during the course of the 1999 rulemaking. Additional public comment concerning the ministerial changes being made by this final-omitted rulemaking to conform the report form and reporting manual to what the regulations already permit is unnecessary.
(iii) Additional public comment cannot change the fact that Chapter 912, which has already been amended, sets forth the requirements of what is to be reported and Appendix A only advises the regulated community how those reports should be made.
Order
The Council, acting under the authorizing statutes, orders that:
(a) The regulations of the Council, 28 Pa. Code Chapter 912, are amended by amending Appendix A to read as set forth in Annex A, with ellipses referring to the existing text of the regulations.
(b) The Council shall submit this order and Annex A to the Office of Attorney General for approval as to form and legality as required by law.
(c) The Council shall certify this order and Annex A and deposit them with the Legislative Reference Bureau as required by law.
(d) This order shall take effect upon its publication in the Pennsylvania Bulletin.
MARC P. VOLAVKA,
Executive Director(Editor's Note: For the text of the order of the Independent Regulatory Review Commission, relating to this document, see 33 Pa.B. 2831 (June 14, 2003).)
Fiscal Note: 100-16. No fiscal impact; (8) recommends adoption.
Annex A
TITLE 28. HEALTH AND SAFETY
PART VI. HEALTH CARE COST CONTAINMENT COUNCIL
CHAPTER 912. DATA REPORTING REQUIREMENTS
APPENDIX A
Pennsylvania Uniform Claims and Billing Forms Reporting Manual * * * * *
Index by Data Element Name
Data Element Name Field # UB-92 Form Locater Admission Date 5 6 Admission Hour 40 18 Admission--Type of 26 19 Admission--Source of 27 20 Admitting Diagnosis 36 76 Certification/SSN/ Health
Insurance Claim Number
29a--c 60 Discharge Date 6 6 Discharge Hour 41 21 Diagnosis Related Group (DRG) 24 2h E-Code 37 77 Employer Name 32a--c 65 Employment Status 34a--c 64 Estimated Amount Due 14g 55 Federal Tax ID 39 5 HCPCS/Rates 13a--w6 44 Hispanic/Latino Origin or Descent 35a 2i Non-Covered Charges 13a--w5 48 Patient Discharge Status 20 22 Patient Date of Birth 2 14 Patient Control Number 23 3 Patient--Uniform Identification 1 2a Patient Race 35b 2j Patient Relationship to Insured 28a--c 59 Patient Sex 3 15 Patient Zip Code 4 13 Payor Group Number 19 62 Payor Identification 14b 50 Physician Identification--Attending 11 82 Physician Identification--Operating 12 83 Physician Identification--Referring 38 82 Principal Diagnosis 7a 67 Principal Procedure Code and Date 8a, 8b 80 Prior Payments--Payor and Patient 14f 54 Procedure Coding Method Used 25 79 Provider Quality 21a 2d Provider Service Effectiveness 21b 2e Revenue Code 13a--w2 42 Reserve Field 21e HC4 Secondary Diagnosis 7b--i 68--75 Secondary Procedure Code and Date 9 81 Service Date 13a--w7 45 Total Charges 13a--w4 47 Type of Bill 22 4 Uniform Identifier of Health Care Facility 10 2b Uniform Identifier of Primary Payor 17 2c Units of Service 13a--w3 46 Unusual Occurrence--Nosocomial Infection 21c 2f Unusual Occurrence--Readmission 21d 29
Index by Field Number
Data Element Name Field # UB-92 Form Locater Patient--Uniform Identification 1 2a Patient Date of Birth 2 14 Patient Sex 3 15 Patient Zip Code 4 13 Admission Date 5 6 Discharge Date 6 6 Principal Diagnosis 7a 67 Secondary Diagnosis 7b--i 68--75 Principal Procedure Code and Date 8a, 8b 80 Secondary Procedure Code and Date 9 81 Uniform Identifier of Health Care Facility 10 2b Physician Identification--Attending 11 82 Physician Identification--Operating 12 83 Revenue Code 13a--w2 42 Units of Service 13a--w3 46 Total Charges 13a--w4 47 Non-Covered Charges 13a--w5 48 HCPCS/Rates 13a--w6 44 Service Date 13a--w7 45 Payor Identification 14b 50 Prior Payments--Payor and Patient 14f 54 Estimated Amount Due 14g 55 Uniform Identifier of Primary Payor 17 2c Payor Group Number 19 62 Patient Discharge Status 20 22 Provider Quality 21a 2d Provider Service Effectiveness 21b 2e Unusual Occurrence--Nosocomial Infection 21c 2f Unusual Occurrence--Readmission 21d 29 Reserve Field 21e Type of Bill 22 4 Patient Control Number 23 3 Diagnosis Related Group (DRG) 24 2h Procedure Coding Method Used 25 79 Admission--Type of 26 19 Admission--Source of 27 20 Patient Relationship to Insured 28a--c 59 Certification/SSN/Health Insurance
Claim Number
29a--c 60 Employer Name 32a--c 65 Employment Status 34a--c 64 Hispanic/Latino Origin or Descent 35a 2i Patient Race 35b 2j Admitting Diagnosis 36 76 E-Code 37 77 Physician Identification--Referring 38 82 Federal Tax ID 39 5 Admission Hour 40 18 Discharge Hour 41 21
Hospital and Ambulatory Service Facility Reporting Manual * * * * *
Field 21a
Revised 7/1/88, 6/21/03 Data Element: Provider Quality Definition: Provider quality consistent with section 6(d) of the act (35 P. S. § 449.6(d)) and with § 911.3 (relating to council adoption of methodology). Periodically, the Council will review the methodology, and if change is necessary, it will be made by majority vote of the Council at a public meeting. Notice of the change will be given to all appropriate data sources within 30 days and at least 180 days before the change is to be implemented. Field Size: 1 field, 1 character Record Position: 1577 Format: Alphanumeric Reference: UB-92, Item 2d (Pos 1 of 30 character field, lower line) __________
Field 21b Revised 7/1/88, 4/1/90, 6/21/03 Data Element: Provider Service Effectiveness Definition: Provider service effectiveness consistent with section 6(d) of the act (35 P. S. § 449.6(d)) and with § 911.3. Periodically, the Council will review the methodology, and if change is necessary, it will be made by majority vote of the Council at a public meeting. Notice of the change will be given to all appropriate data sources within 30 days and at least 180 days before the change is to be implemented. Field Size: 1 field, 1 character Record Position: 1578 Format: Alphanumeric Reference: UB-92, Item 2e (Pos 2 of 30 character field, lower line) __________
* * * * *
Hospital and Ambulatory Service Facility Tape Format
Data Data Element Position Picture Format Element Description From To * * * * * 21a Provider Quality 1577 X(1) Provider quality consistent with section 6(d) of the act and with § 911.3. Periodically, the Council will review the methodology, and if change is necessary, it will be made by majority vote of the Council at a public meeting. Notice of the change will be given to all appropriate data sources within 30 days and at least 180 days before the change is to be implemented. 21b Provider Service Effectiveness 1578 X(1) Provider service effectiveness consistent with section 6(d) of the act and with § 911.3. Periodically, the Council will review the methodology, and if change is necessary, it will be made by majority vote of the Council at a public meeting. Notice of the change will be given to all appropriate data sources within 30 days and at least 180 days before the change is to be implemented. * * * *
[Pa.B. Doc. No. 03-1174. Filed for public inspection June 20, 2003, 9:00 a.m.]
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