28 Pa. Code § 913.41. Definition for major ambulatory service.

§ 913.41. Definition for major ambulatory service.

(a)  The Council may issue interpretations of this subchapter, which apply to the question of which major ambulatory services are considered to be covered services and submission and modifications to schedules of data pertaining to them.
(b)  Interpretations issued under this section will be subject to modification by the Council in an adjudicative proceeding based on the particular facts and circumstances relevant to a service.

APPENDIX A

PENNSYLVANIA UNIFORM CLAIMS AND BILLING FORM
HOSPITAL/AMBULATORY SERVICE FACILITY PAYMENTS
AND PHYSICIAN PAYMENTS
REPORTING MANUAL
HC—87—101
VOLUME B
TABLE OF CONTENTS

I.
Facility and Physician Payments Reporting Manual.

II.
Header Record Manual.

III.
Trailer Record Manual.

IV.
Tape Format for Facility and Physician Payments Reporting.

INDEX

DATA ELEMENT NAME FIELD #

Certification/SSN/Health Insurance Claim Number 20

Date of Admission/Start of Care/Date of Service 6

Date of Discharge/End of Care/Last Date of Service 7

Identifier of Physician 10

Other Payments 15

Patient Control Number 17

Patient’s Birthdate 4

Patient - Uniform Identification 3

Patient Relationship to Insured 19

Patient’s Sex 5

Payor Group Number 16

Place of Service 2

Primary Payor Payments 14

Procedure Code 8

Procedure Coding Method Used 18

Record Type 1

Reserve Field 21

Total Charges 13

Type of Professional Service 11

Uniform Identifier of Health Care Facility 9

Units of Service 12


I. REPORTING MANUAL

FIELD: 1

REQUIRED: Facility and Physician Payments Reporting

DATA ELEMENT: Record Type

DEFINITION: Indicator distinguishing between the different types of records.

PROCEDURE: 1 = Facility payment record.

2 = Physician payment record.

3 = Continuing physician payment record. (When individual patient records contain more than one procedure/service, this field indicates that this record is a continuation of the previous record.)

4 = Continuing facility payment record. (When individual patient records contain more than one procedure/service, this field indicates that this record is a continuation of the previous record.)

5 = This record is a delivery which includes newborn payments.

FIELD SIZE: 1 field, 1 character

RECORD POSITION: 1

FORMAT: Numeric

FIELD: 2

REQUIRED: Facility and Physician Payments Reporting

DATA ELEMENT: Place of Service

DEFINITION: Type of setting.

PROCEDURE: 1 = Hospital Inpatient

2 = Hospital Outpatient

3 = Other Ambulatory Service Facility

4 = Unknown

FIELD SIZE: 1 field, 1 character

RECORD POSITION: 2

FORMAT: Numeric

FIELD: 3

REQUIRED: Facility and Physician Payments Reporting

DATA ELEMENT: Uniform Patient I.D.

DEFINITION: Patient’s Social Security Number.

PROCEDURES: Left justify. No dashes. If the patient’s Social Security Number is unknown, fill this field with zeroes.

FIELD SIZE: 1 field, 9 characters.

RECORD POSITION: 3—11

FORMAT: Numeric

REFERENCE: UB-82, Item 2a.

FIELD: 4

REQUIRED: Facility and Physician Payments Reporting

DATA ELEMENT: Patient’s Birthdate.

DEFINITION: The date of birth of the patient.

PROCEDURE: MMDDYYYY. If full birthdate is unknown, place the patient’s year of birth in this field. Right justify. No dashes.

FIELD SIZE: 1 field, 8 characters.

RECORD POSITION: 12—19

FORMAT: Numeric

REFERENCE: UB-82, Item 12 or HCFA 1500, Item 2

FIELD: 5

REQUIRED: Facility and Physician Payments Reporting

DATA ELEMENT: Patient’s Sex.

DEFINITION: The sex of the patient as recorded at the date of admission, outpatient service, or start of care.

PROCEDURE: M = Male or 1 = Male

F = Female 2 = Female

U = Unknown 3 = Unknown

M, F, U is the preferred method. Data submitted in the format of a 1, 2, or 3 will be converted to M, F, or U by the Council. Edit reports to data sources will contain M, F, U.

FIELD SIZE: 1 field, 1 character.

RECORD POSITION: 20

FORMAT: Alphanumeric

REFERENCE: UB-82, item 13 or HCFA 1500, item 5

FIELD: 6

REQUIRED: Facility and Physician Payments Reporting

DATA ELEMENT: Date of Admission/Start of Care/First Date of Service

DEFINITION: The date that the patient was admitted to the provider for inpatient care, outpatient services, start of care or the beginning date of the period covered by this bill.

PROCEDURE: MMDDYY.

FIELD SIZE: 1 field, 6 characters.

RECORD POSITION: 21—26

FORMAT: Numeric

REFERENCE: UB-82, item 15 or HCFA 1500, item 20 (the first 6 characters of this field.)

FIELD: 7

REQUIRED: Facility and Physician Payments Reporting

DATA ELEMENT: Date of Discharge/End of Care/Last Date of Service

DEFINITION: The ending service date of the period covered by this bill or the date that the patient was discharged from the provider’s care.

PROCEDURE: MMDDYY.

FIELD SIZE: 1 field, 6 characters.

RECORD POSITION: 27—32

FORMAT: Numeric

REFERENCE: UB-82, item 22 (the last 6 characters in this field.) or HCFA 1500, item 20 (the last 6 characters of this field.)

FIELD: 8

REQUIRED: Physician Payments Reporting Only (Blank fill for Facility Payments Records.)

DATA ELEMENT: Procedure Code

DEFINITION: Surgical Procedure Code, if any. Other procedure codes when available.

PROCEDURE: The code structure must be consistent with the information provided in field 18. This field is required if field 11 is equal to an 02 or 05. This field is optional if field 11 is equal to an 01, 03, or 04. Use ICD-9-CM, HCPCS or CPT-4 codes. Left justify. Use decimal. Blank fill right. If unknown, blank fill.

FIELD SIZE: 1 field, 9 characters

RECORD POSITION: 33—41

FORMAT: Alphanumeric

REFERENCE: UB-82, item 84 or HCFA 1500, item 24d

FIELD: 9

REQUIRED: Facility Payments Reporting Only (Blank fill for Physician Payments Records.)

DATA ELEMENT: Uniform Identifier for Health Care Facility

DEFINITION: Medicaid Number, Federal Tax I.D. Number, or Medicare Number.

PROCEDURE: Character 1: 1 or A = Medicaid Number 2 or B = Tax I.D. Number 3 or C = Medicare Number

Characters 2—11: Medicaid Number, Tax I.D. Number, or Medicare Number. Left justify.

The Medicaid Number is the preferred number. Data Sources using other numbering systems must provide the Council with a Facility I.D. Dictionary on tape according to a format approved by the Council. The facility I.D. dictionary must have one number for each separately licensed facility.

FIELD SIZE: 1 field, 11 characters

RECORD POSITION: 42—52

FORMAT: Alphanumeric

REFERENCE: UB-82, item 6

FIELD: 10

REQUIRED: Physician Payments Reporting Only (Blank fill for Facility Payments Records.)

DATA ELEMENT: Identifier of Physician

DEFINITION: PA State License Number, Social Security Number, or Tax I.D. of the Physician. Other Unique Provider Numbers may be acceptable, however, prior approval must be obtained from the Council.

PROCEDURE: Character 1: 1 or A = PA State License 2 or B = S.S. Number 3 or C = Tax I.D. Number 4 or D = Unique Provider Number

Characters 2—10 = PA State License, S.S. Number, Tax I.D., Unique Provider Number

Characters 11—20 = Physician Last Name

Characters 21—22 = Physician First and Middle Initial

Left Justify, Blank fill. The Pa. State license number is the preferred number. Data sources using other numbering systems must provide the Council with a dictionary of physician I.D. numbers on tape according to a format approved by the Council. (The approved format is described in Appendix B.) The Physician I.D. dictionary must have one number for each separately licensed physician.

FIELD SIZE: 1 field, 22 characters

RECORD POSITION: 53—74

FORMAT: Alphanumeric

REFERENCE: HCFA 1500, item 33.

FIELD: 11

REQUIRED: Physician Payments Reporting Only (Zero fill for Facility Payments Records.)

DATA ELEMENT: Type of Professional Service

DEFINITION: The type of service that the physician performed for which payment is expected.

PROCEDURE: 01 = Medical, Consulting, Psychiatric (Includes drug abuse and alcohol treatment.) 02 = Surgical, Obstetrics 03 = Diagnostic, Radiologic 04 = Anesthetic 05 = Assisted in Surgery

FIELD SIZE: 1 field, 2 characters

RECORD POSITION: 75—76

FORMAT: Numeric

REFERENCE: HCFA 1500, item 24c

FIELD: 12

REQUIRED: Physician Payments Reporting Only (Zero fill for Facility Payments records.)

DATA ELEMENTS: Units of Service

DEFINITION: If available, enter the total number of identical procedures or services, such as hospital visits.

PROCEDURE: Right justify. Fill with zeroes left.

FIELD SIZE: 1 field, 3 characters

RECORD POSITION: 77—79

FORMAT: Numeric

REFERENCE: HCFA 1500, item 24g

FIELD: 13

REQUIRED: Facility and Physician Payments Reporting

DATA ELEMENT: Total Charges

DEFINITION: Total charges pertaining to the current billing period as entered in the statement covers period.

PROCEDURES: Facility total Charges = Place total charges as stated in the definition above. Physician total Charges = Place the total charge for the procedure or service indicated in fields 11 and 8. When the physician/professional or facility has provided more than one procedure or service, more than one record should be provided. The multiple records should be indicated as follows:

1. In field 1, place the number 3 or 4 which indicates that this record is a continuation of the previous record.

2. Complete the following fields:   a. 8 - Procedure Code   b.11 - Type of Professional Service.   c.13 - Total Charges   d.14 - Primary Payor Payments   e.15 - Other Payments

3. All other fields in this record should be duplicated depending upon the format of each field. Right justify. No decimal.

FIELD SIZE: 1 field, 8 characters Character 1—6 = dollars Character 7—8 = cents

RECORD POSITIONS: 80—87

FORMAT: Numeric

REFERENCE: UB-82, item 53 (Last line of this field.) or HCFA 1500, item 24f

FIELD: 14

REQUIRED: Facility and Physician Payments Reporting

DATA ELEMENT: Primary Payor Payments

DEFINITION: Total of all payments made by the payor to the health care facility or professional for services rendered to the patient for the episode of illness indicated in fields 6 and 7.

PROCEDURE: Facility payments = Place total Primary Payor Payments as stated in the definition above. Physician payments = Place the total Primary Payor Payments for the procedure or service indicated in fields 11 and 8. When the physician/professional or facility has provided more than one procedure or service, more than one record should be provided. The multiple records should be indicated as follows:

1. In field 1, place the number 3 or 4 which indicates that this record is a continuation of the previous record.

2. Complete the following fields:   a. 8 - Procedure Code   b.11 - Type of Professional Service   c.13 - Total Charges   d.14 - Primary Payor Payments   e.15 - Other Payments

3. All other fields in this record should be duplicated depending upon the format of each field. Right justify. No decimal.

FIELD SIZE: 1 field, 8 characters Character 1—6 = dollars Character 7—8 = cents

RECORD POSITION: 88—95

FORMAT: Numeric

REFERENCE: UB-82, item 55

FIELD: 15

REQUIRED: Facility and Physician Payments Reporting

DATA ELEMENT: Other Payments

DEFINITION: The sum of deductible amounts and co-pay amounts that are attributed to the patients responsibility or other secondary payors.

PROCEDURE: Facility other payments = Place total of Other Payments as stated in the definition above. Physician other payments = Place the total of Other Payments for the procedure or service indicated in fields 11 and 8. When the physician/professional or facility has provided more than one procedure or service, more than one record should be provided. The multiple records should be indicated as follows:

1. In field 1, place the number 3 or 4 which indicates that this record is a continuation of the previous record.

2. Complete the following fields:   a. 8 - Procedure Code   b.11 - Type of Professional Service   c.13 - Total Charges   d.14 - Primary Payor Payments   e.15 - Other Payments

3. All other fields in this record should be duplicated depending upon the format of each field. Right justify. No Decimal.

FIELD SIZE: 1 field 8 characters Character 1—6 = dollars Character 7—8 = cents

RECORD POSITION: 96—103

FORMAT: Numeric

FIELD: 16

REQUIRED: Facility and Physician Payments Reporting

DATA ELEMENT: Payor Group Number

DEFINITION: The identification number, control number, or code assigned by the carrier or plan administrator to identify the group under which the individual is covered.

PROCEDURE: Left justify.

FIELD SIZE: 1 field, 17 characters

RECORD POSITION: 104—120

FORMAT: Alphanumeric

REFERENCE: UB-82, item 70 or HCFA 1500, item 8

FIELD: 17

REQUIRED: Facility Payments Reporting Only (Blank fill for Physician Payments Records.)

DATA ELEMENT: Patient Control Number

DEFINITION: Patient’s unique alphanumeric number assigned by the carrier to facilitate retrieval of individual case records and posting of the payment. This field is optional.

PROCEDURE: Left justify.

FIELD SIZE: 1 field, 17 characters

RECORD POSITION: 121—137

FORMAT: Alphanumeric

FIELD: 18

REQUIRED: Facility and Physician Payments Reporting

DATA ELEMENT: Procedure Coding Method Used

DEFINITION: An indicator that identifies the coding method used for procedure coding on this bill.

PROCEDURE: 1—3 = Reserved for state assignment 4 = CPT-4 5 = HCPCS (HCFA Common Procedure Coding System) 6—8 = Reserved for National assignment 9 = ICD-9-CM

FIELD SIZE: 1 field, 1 character

RECORD POSITION: 138

FORMAT: Numeric

REFERENCE: UB-82, item 82

FIELD: 19

REQUIRED: Facility and Physician Payments Reporting

DATA ELEMENT: Patient’s Relationship to Insured

DEFINITION: A code indicating the relationship of the patient to the identified insured.

PROCEDURE: Use coding as follows: 1 = Self 2 = Spouse 3 = Child 4 = Other Right justify. Zero fill left.

FIELD SIZE: 1 field, 2 characters

RECORD POSITION: 139—140

FORMAT: Numeric

REFERENCE: UB-82, item 67 a or HCFA 1500, item 7

FIELD: 20

REQUIRED: Facility and Physician Payments Reporting

DATA ELEMENT: Certificate/Social Security Number/Health Insurance Claim/Identification Number.

DEFINITION: Insured’s unique identification number assigned by the payor organization.

PROCEDURE: Left justify.

FIELD SIZE: 1 field, 16 characters

RECORD POSITION: 141—156

FORMAT: Alphanumeric

REFERENCE: UB-82, item 68 or HCFA 1500, item 6

FIELD: 21

DATA ELEMENT: Reserve Field

DEFINITION: To be reserved for future use by the Council.

FIELD SIZE: 1 field filler, 144 characters

RECORD POSITION: 157—300

FORMAT: Alphanumeric

II. HEADER RECORD

FIELD: 1

DATA ELEMENT: Data Source Identifier

DEFINITION: Number identifying the data source. Third party payors - use your payor number.

PROCEDURE: Left justify. Blank fill right.

FIELD SIZE: 1 field, 25 characters

RECORD POSITION: 1—25

FORMAT: Alphanumeric

FIELD: 2

DATA ELEMENT: Data Source Name/Address

DEFINITIONS: Name and address of the data source.

PROCEDURE: Left justify. Fill with blanks right. Space between lines of name and address.

FIELD SIZE: 1 field, 4 lines, 100 characters

RECORD POSITION: 26—125

FORMAT: Alphanumeric

FIELD: 3

DATA ELEMENT: Period Covered First Day

DEFINITION: The first day of the quarter from which the data provided on this tape was contained.

PROCEDURE: MMDDYY.

FIELD SIZE: 1 field, 6 characters

RECORD POSITION: 126—131

FORMAT: Numeric

FIELD: 4

DATA ELEMENT: Period Covered Last Day

DEFINITION: The last day of the quarter from which the data provided on this tape was contained.

PROCEDURE: MMDDYY.

FIELD SIZE: 1 field, 6 characters

RECORD POSITION: 132—137

FORMAT: Numeric

FIELD: 5

DATA ELEMENT: Run Date

DEFINITION: The date that the data source produced this tape.

PROCEDURE: MMDDYY.

FIELD SIZE: 1 field, 6 characters

FIELD POSITION: 138—143

FORMAT: Numeric

FIELD: 6

DATA ELEMENT: Filler

FIELD SIZE: 1 field filler, 157 characters

RECORD POSITION: 144—300

FORMAT: Alphanumeric

III. TRAILER RECORD

FIELD: 1

DATA ELEMENT: Number of records on this tape.

DEFINITION: Total number of records contained on this tape, not including the Header and Trailer Records. This number should count each multi-page as one record.

PROCEDURE: Right justify.

FIELD SIZE: 1 field, 10 characters

RECORD POSITION: 1—10

FORMAT: Numeric

FIELD: 2

DATA ELEMENT: Number of Patients on This Tape.

DEFINITION: Total number of patients contained on this tape.

PROCEDURE: Right justify.

FIELD SIZE: 1 field, 10 characters

RECORD POSITION: 11—20

FORMAT: Numeric

FIELD: 3

DATA ELEMENT: Total Physician Charges

DEFINITION: Total of all Physician Charges on this tape.

PROCEDURE: Sum of all fields 13 (Total Charges) when field 1 is equal to 2. Right justify. The last two digits are for cents.

FIELD SIZE: 1 field, 11 characters

RECORD POSITION: 21—31

FORMAT: Numeric

FIELD: 4

DATA ELEMENT: Total Facility Charges

DEFINITION: Total of all Facility Charges on this tape.

PROCEDURE: Sum of all fields 13 (Total Charges) when field 1 is equal to 1. Right justify. The last two digits are for cents.

FIELD SIZE: 1 field, 11 characters

RECORD POSITION: 32—42

FORMAT: Numeric

FIELD: 5

DATA ELEMENT: Total Physician Payments

DEFINITION: Total of all Physician Payments on this tape.

PROCEDURE: Sum of all fields 14 (Primary Payor Payments) when field 1 is equal to 2. Right justify. The last two digits are for cents.

FIELD SIZE: 1 field, 11 characters

RECORD POSITION: 43—53

FORMAT: Numeric

FIELD: 6

DATA ELEMENT: Total Facility Payments

DEFINITION: Total of all Facility Payments on this tape.

PROCEDURE: Sum of all fields 14 (Primary Payor Payments) when field 1 is equal to 1. Right justify. The last two digits are for cents.

FIELD SIZE: 1 field, 11 characters

RECORD POSITION: 54—64

FORMAT: Numeric

FIELD: 7

DATA ELEMENT: Total Other Payments (Physician)

DEFINITION: Total of all Other Payments to Physicians on this tape.

PROCEDURE: Sum of all fields 15 (Other Payments) when field 1 is equal to 2. Right justify. The last two digits are for cents.

FIELD SIZE: 1 field, 11 characters

RECORD POSITION: 65—75

FORMAT: Numeric

FIELD: 8

DATA ELEMENT: Total Other Payments (Facility)

DEFINITION: Total of all Other Payments to Facilities on this tape.

PROCEDURE: Sum of all fields 15 (Other Payments) when field 1 is equal to 1.

FIELD SIZE: 1 field, 11 characters

RECORD POSITION: 76—86

FORMAT: Numeric

FIELD: 9

DATA ELEMENT: Filler

FIELD SIZE: 1 field filler, 214 characters

RECORD POSITION: 87—300

FORMAT: Alphanumeric

DATAELEMENT DATA ELEMENT DESCRIPTION POSITION PICTURE
FORMAT

FROM TO

HEADER RECORD

1
Data Source Identifier 1 25
X(25) Left justify. Blank fill right.

2
Data Source Name 26 125
X(100) 4 lines. 25 characters each.

3
Period Covered First Day 126 131
9(6) MMDDYY.

4
Period Covered Last Day 132 137
9(6) MMDDYY.

5
Run Date 138 143
9(6) MMDDYY. Date that this tape was created.

6
Filler 144 300
X(157)

TAPE FORMAT FOR
HOSPITAL/AMBULATORY SERVICE FACILITY PAYMENTS
AND PHYSICIAN PAYMENTS REPORTING
MANUAL HC-87-101B

DATAELEMENT DATA ELEMENT DESCRIPTION POSITION PICTURE
FORMAT

FROM TO

1
Record Type 1 9(1) 1 = Facility payments record. 2 = Physician payments record. 3 = Continuing physician payments record. 4 = Continuing facility payments record. 5 = Delivery/ newborn record.

2
Place of Service 2 9(1) 1 = Hospital Inpatient 2 = Hospital Outpatient 3 = Ambulatory Service Facility 4 = Unknown

3
Uniform Patient Identifier 3
11 9(9) If unknown, zero fill.

4
Patient’s Date of Birth 12
19 9(8) MMDDYYYY. If the patient date of birth is unknown, place the patient’s year of birth in this field. Right justify.

5
Patient’s Sex 20 X(1) M = Male, F = Female, U = Unknown 1 = Male, 2 = Female, 3 = Unknown.

6
Date of Admission/ Start of Care/Date of Service 21
26 9(6) MMDDYY.

7
Date of Discharge/ End of Care/Last Date of Service 27
32 9(6) MMDDYY.

8
Procedure Code 33
41 X(9) Procedure code. Left justify. Use decimal. See manual for instructions.

9
Uniform Identifier of Health Care Facility 42
52 X(11) Left justify. Blank fill right.

10
Identifier of Physician 53
74 X(22) Left justify. Blank fill. See Manual for instructions.

11
Type of Professional Service 75
76 9(2) Type of service performed by the professional: 01 = Medical, Consulting, Psychiatric, (Including drug abuse and alcohol treatment.) 02 = Surgical, Obstetrics 03 = Diagnostic, Radiologic 04 = Anesthetic 05 = Assisted in surgery

12
Units of Service 77
79 9(3) Right justify. Fill with zeroes left.

13
Total Charges 80
87 9(8) 6 dollar characters, 2 cent characters. Right justify. No decimal.

14
Primary Payor Payments 88
95 9(8) 6 dollar characters, 2 cent characters. Right justify. No decimal.

15
Other Payments 96
103 9(8) 6 dollar characters, 2 cent characters. Right justify. No decimal.

16
Payor Group Number 104
120 X(17) Left justify.

17
Patient Control Number 121
137 X(17) Left justify.

18
Procedure Coding Method Used 138 9(1) 1 - 3 Reserved for state assignment. 4 = CPT-4 5 = HCPCS 6 - 8 = Reserved for national assignment. 9 = ICD-9-CM

19
Patient’s Relation- ship to Insured 139
140 9(2) Right justify. 1 = Self 2 = Spouse 3 = Child 4 = Other

20
Certification/SSN/ Health Insurance Claim Number 141
156 X(16) Left justify.

21
Reserve Field 157
300 X(144) To be reserved for future use by the Council.

*All numeric fields should be initialized to 0, and alpha numeric fields initialized to blank, before writing data to tape. Therefore, these characters (or blanks) will remain in fields where data is missing.

DATAELEMENT DATA ELEMENT DESCRIPTION POSITION PICTURE
FORMAT

FROM TO

TRAILER RECORD

1
Number of Records on This Tape 1
10 9(10) Total Number of patient discharge records on this tape.

2
Number of Patients on This Tape 11
20 9(10) Total number of patients on this tape.

3
Total Physician Charges 21
31 9(11) Total of all physician charges on this tape.

4
Total Facility Charges 32
42 9(11) Total of all facility charges on this tape.

5
Total Physician Payments 43
53 9(11) Total of all physician payments on this tape.

6
Total Facility Payments 54
64 9(11) Total of all facility payments on this tape.

7
Total Other Payments (Physician) 65
75 9(11) Total of all physician other payments on this tape.

8
Total Other Payments (Facility) 76
86 9(11) Total of all facility other payments on this tape.

9
Filler 87
300 9(214)

APPENDIX B
FORMAT OF DICTIONARY FOR THE IDENTIFICATION OF
PHYSICIANS AND FACILITIES

DATAELEMENT DATA ELEMENT DESCRIPTION POSITION PICTURE
FORMAT

FROM TO

1
Record Type 1 9(1) 1 = Physician Identifier record 2 = Facility Identifier record

2
Identifier Type 2 9(1) 1 = Tax I.D. Number 2 = Medicare I.D. Number/Social Security Number 3 = Unique Number for Physician (only)

3
Identifier Number 3
20 X(17) Number identifying the physician or facility. Left justify. Blank fill right.

4
Physician/Facility Name 21
65 X(45) The Name of the facility or the name of the physician. If name of the physician, place in order as follows: Last name followed by a space, first name followed by a space, middle initial. Blank fill right.

5
Physician/Facility Address 66
150 X(85) Left justify. Blank fill right. (Include street address, city, state, zip.)

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I.	Facility and Physician Payments Reporting Manual.
II.	Header Record Manual.
III.	Trailer Record Manual.
IV.	Tape Format for Facility and Physician Payments Reporting.

DATA ELEMENT NAME	FIELD #
Certification/SSN/Health Insurance Claim Number	20
Date of Admission/Start of Care/Date of Service	6
Date of Discharge/End of Care/Last Date of Service	7
Identifier of Physician	10
Other Payments	15
Patient Control Number	17
Patient’s Birthdate	4
Patient - Uniform Identification	3
Patient Relationship to Insured	19
Patient’s Sex	5
Payor Group Number	16
Place of Service	2
Primary Payor Payments	14
Procedure Code	8
Procedure Coding Method Used	18
Record Type	1
Reserve Field	21
Total Charges	13
Type of Professional Service	11
Uniform Identifier of Health Care Facility	9
Units of Service	12

FIELD: 1
REQUIRED:	Facility and Physician Payments Reporting
DATA ELEMENT:	Record Type
DEFINITION:	Indicator distinguishing between the different types of records.
PROCEDURE:	1 = Facility payment record.
	2 = Physician payment record.
	3 = Continuing physician payment record. (When individual patient records contain more than one procedure/service, this field indicates that this record is a continuation of the previous record.)
	4 = Continuing facility payment record. (When individual patient records contain more than one procedure/service, this field indicates that this record is a continuation of the previous record.)
	5 = This record is a delivery which includes newborn payments.
FIELD SIZE:	1 field, 1 character
RECORD POSITION:	1
FORMAT:	Numeric
FIELD: 2
REQUIRED:	Facility and Physician Payments Reporting
DATA ELEMENT:	Place of Service
DEFINITION:	Type of setting.
PROCEDURE:	1 = Hospital Inpatient
	2 = Hospital Outpatient
	3 = Other Ambulatory Service Facility
	4 = Unknown
FIELD SIZE:	1 field, 1 character
RECORD POSITION:	2
FORMAT:	Numeric
FIELD: 3
REQUIRED:	Facility and Physician Payments Reporting
DATA ELEMENT:	Uniform Patient I.D.
DEFINITION:	Patient’s Social Security Number.
PROCEDURES:	Left justify. No dashes. If the patient’s Social Security Number is unknown, fill this field with zeroes.
FIELD SIZE:	1 field, 9 characters.
RECORD POSITION:	3—11
FORMAT:	Numeric
REFERENCE:	UB-82, Item 2a.
FIELD: 4
REQUIRED:	Facility and Physician Payments Reporting
DATA ELEMENT:	Patient’s Birthdate.
DEFINITION:	The date of birth of the patient.
PROCEDURE:	MMDDYYYY. If full birthdate is unknown, place the patient’s year of birth in this field. Right justify. No dashes.
FIELD SIZE:	1 field, 8 characters.
RECORD POSITION:	12—19
FORMAT:	Numeric
REFERENCE:	UB-82, Item 12 or HCFA 1500, Item 2
FIELD: 5
REQUIRED:	Facility and Physician Payments Reporting
DATA ELEMENT:	Patient’s Sex.
DEFINITION:	The sex of the patient as recorded at the date of admission, outpatient service, or start of care.
PROCEDURE:	M = Male or 1 = Male
	F = Female 2 = Female
	U = Unknown 3 = Unknown
	M, F, U is the preferred method. Data submitted in the format of a 1, 2, or 3 will be converted to M, F, or U by the Council. Edit reports to data sources will contain M, F, U.
FIELD SIZE:	1 field, 1 character.
RECORD POSITION:	20
FORMAT:	Alphanumeric
REFERENCE:	UB-82, item 13 or HCFA 1500, item 5
FIELD: 6
REQUIRED:	Facility and Physician Payments Reporting
DATA ELEMENT:	Date of Admission/Start of Care/First Date of Service
DEFINITION:	The date that the patient was admitted to the provider for inpatient care, outpatient services, start of care or the beginning date of the period covered by this bill.
PROCEDURE:	MMDDYY.
FIELD SIZE:	1 field, 6 characters.
RECORD POSITION:	21—26
FORMAT:	Numeric
REFERENCE:	UB-82, item 15 or HCFA 1500, item 20 (the first 6 characters of this field.)
FIELD: 7
REQUIRED:	Facility and Physician Payments Reporting
DATA ELEMENT:	Date of Discharge/End of Care/Last Date of Service
DEFINITION:	The ending service date of the period covered by this bill or the date that the patient was discharged from the provider’s care.
PROCEDURE:	MMDDYY.
FIELD SIZE:	1 field, 6 characters.
RECORD POSITION:	27—32
FORMAT:	Numeric
REFERENCE:	UB-82, item 22 (the last 6 characters in this field.) or HCFA 1500, item 20 (the last 6 characters of this field.)
FIELD: 8
REQUIRED:	Physician Payments Reporting Only (Blank fill for Facility Payments Records.)
DATA ELEMENT:	Procedure Code
DEFINITION:	Surgical Procedure Code, if any. Other procedure codes when available.
PROCEDURE:	The code structure must be consistent with the information provided in field 18. This field is required if field 11 is equal to an 02 or 05. This field is optional if field 11 is equal to an 01, 03, or 04. Use ICD-9-CM, HCPCS or CPT-4 codes. Left justify. Use decimal. Blank fill right. If unknown, blank fill.
FIELD SIZE:	1 field, 9 characters
RECORD POSITION:	33—41
FORMAT:	Alphanumeric
REFERENCE:	UB-82, item 84 or HCFA 1500, item 24d
FIELD: 9
REQUIRED:	Facility Payments Reporting Only (Blank fill for Physician Payments Records.)
DATA ELEMENT:	Uniform Identifier for Health Care Facility
DEFINITION:	Medicaid Number, Federal Tax I.D. Number, or Medicare Number.
PROCEDURE:	Character 1: 1 or A = Medicaid Number 2 or B = Tax I.D. Number 3 or C = Medicare Number
	Characters 2—11: Medicaid Number, Tax I.D. Number, or Medicare Number. Left justify.
	The Medicaid Number is the preferred number. Data Sources using other numbering systems must provide the Council with a Facility I.D. Dictionary on tape according to a format approved by the Council. The facility I.D. dictionary must have one number for each separately licensed facility.
FIELD SIZE:	1 field, 11 characters
RECORD POSITION:	42—52
FORMAT:	Alphanumeric
REFERENCE:	UB-82, item 6
FIELD: 10
REQUIRED:	Physician Payments Reporting Only (Blank fill for Facility Payments Records.)
DATA ELEMENT:	Identifier of Physician
DEFINITION:	PA State License Number, Social Security Number, or Tax I.D. of the Physician. Other Unique Provider Numbers may be acceptable, however, prior approval must be obtained from the Council.
PROCEDURE:	Character 1: 1 or A = PA State License 2 or B = S.S. Number 3 or C = Tax I.D. Number 4 or D = Unique Provider Number
	Characters 2—10 = PA State License, S.S. Number, Tax I.D., Unique Provider Number
	Characters 11—20 = Physician Last Name
	Characters 21—22 = Physician First and Middle Initial
	Left Justify, Blank fill. The Pa. State license number is the preferred number. Data sources using other numbering systems must provide the Council with a dictionary of physician I.D. numbers on tape according to a format approved by the Council. (The approved format is described in Appendix B.) The Physician I.D. dictionary must have one number for each separately licensed physician.
FIELD SIZE:	1 field, 22 characters
RECORD POSITION:	53—74
FORMAT:	Alphanumeric
REFERENCE:	HCFA 1500, item 33.
FIELD: 11
REQUIRED:	Physician Payments Reporting Only (Zero fill for Facility Payments Records.)
DATA ELEMENT:	Type of Professional Service
DEFINITION:	The type of service that the physician performed for which payment is expected.
PROCEDURE:	01 = Medical, Consulting, Psychiatric (Includes drug abuse and alcohol treatment.) 02 = Surgical, Obstetrics 03 = Diagnostic, Radiologic 04 = Anesthetic 05 = Assisted in Surgery
FIELD SIZE:	1 field, 2 characters
RECORD POSITION:	75—76
FORMAT:	Numeric
REFERENCE:	HCFA 1500, item 24c
FIELD: 12
REQUIRED:	Physician Payments Reporting Only (Zero fill for Facility Payments records.)
DATA ELEMENTS:	Units of Service
DEFINITION:	If available, enter the total number of identical procedures or services, such as hospital visits.
PROCEDURE:	Right justify. Fill with zeroes left.
FIELD SIZE:	1 field, 3 characters
RECORD POSITION:	77—79
FORMAT:	Numeric
REFERENCE:	HCFA 1500, item 24g
FIELD: 13
REQUIRED:	Facility and Physician Payments Reporting
DATA ELEMENT:	Total Charges
DEFINITION:	Total charges pertaining to the current billing period as entered in the statement covers period.
PROCEDURES:	Facility total Charges = Place total charges as stated in the definition above. Physician total Charges = Place the total charge for the procedure or service indicated in fields 11 and 8. When the physician/professional or facility has provided more than one procedure or service, more than one record should be provided. The multiple records should be indicated as follows:
	1. In field 1, place the number 3 or 4 which indicates that this record is a continuation of the previous record.
	2. Complete the following fields: a. 8 - Procedure Code b.11 - Type of Professional Service. c.13 - Total Charges d.14 - Primary Payor Payments e.15 - Other Payments
	3. All other fields in this record should be duplicated depending upon the format of each field. Right justify. No decimal.
FIELD SIZE:	1 field, 8 characters Character 1—6 = dollars Character 7—8 = cents
RECORD POSITIONS:	80—87
FORMAT:	Numeric
REFERENCE:	UB-82, item 53 (Last line of this field.) or HCFA 1500, item 24f
FIELD: 14
REQUIRED:	Facility and Physician Payments Reporting
DATA ELEMENT:	Primary Payor Payments
DEFINITION:	Total of all payments made by the payor to the health care facility or professional for services rendered to the patient for the episode of illness indicated in fields 6 and 7.
PROCEDURE:	Facility payments = Place total Primary Payor Payments as stated in the definition above. Physician payments = Place the total Primary Payor Payments for the procedure or service indicated in fields 11 and 8. When the physician/professional or facility has provided more than one procedure or service, more than one record should be provided. The multiple records should be indicated as follows:
	1. In field 1, place the number 3 or 4 which indicates that this record is a continuation of the previous record.
	2. Complete the following fields: a. 8 - Procedure Code b.11 - Type of Professional Service c.13 - Total Charges d.14 - Primary Payor Payments e.15 - Other Payments
	3. All other fields in this record should be duplicated depending upon the format of each field. Right justify. No decimal.
FIELD SIZE:	1 field, 8 characters Character 1—6 = dollars Character 7—8 = cents
RECORD POSITION:	88—95
FORMAT:	Numeric
REFERENCE:	UB-82, item 55
FIELD: 15
REQUIRED:	Facility and Physician Payments Reporting
DATA ELEMENT:	Other Payments
DEFINITION:	The sum of deductible amounts and co-pay amounts that are attributed to the patients responsibility or other secondary payors.
PROCEDURE:	Facility other payments = Place total of Other Payments as stated in the definition above. Physician other payments = Place the total of Other Payments for the procedure or service indicated in fields 11 and 8. When the physician/professional or facility has provided more than one procedure or service, more than one record should be provided. The multiple records should be indicated as follows:
	1. In field 1, place the number 3 or 4 which indicates that this record is a continuation of the previous record.
	2. Complete the following fields: a. 8 - Procedure Code b.11 - Type of Professional Service c.13 - Total Charges d.14 - Primary Payor Payments e.15 - Other Payments
	3. All other fields in this record should be duplicated depending upon the format of each field. Right justify. No Decimal.
FIELD SIZE:	1 field 8 characters Character 1—6 = dollars Character 7—8 = cents
RECORD POSITION:	96—103
FORMAT:	Numeric
FIELD: 16
REQUIRED:	Facility and Physician Payments Reporting
DATA ELEMENT:	Payor Group Number
DEFINITION:	The identification number, control number, or code assigned by the carrier or plan administrator to identify the group under which the individual is covered.
PROCEDURE:	Left justify.
FIELD SIZE:	1 field, 17 characters
RECORD POSITION:	104—120
FORMAT:	Alphanumeric
REFERENCE:	UB-82, item 70 or HCFA 1500, item 8
FIELD: 17
REQUIRED:	Facility Payments Reporting Only (Blank fill for Physician Payments Records.)
DATA ELEMENT:	Patient Control Number
DEFINITION:	Patient’s unique alphanumeric number assigned by the carrier to facilitate retrieval of individual case records and posting of the payment. This field is optional.
PROCEDURE:	Left justify.
FIELD SIZE:	1 field, 17 characters
RECORD POSITION:	121—137
FORMAT:	Alphanumeric
FIELD: 18
REQUIRED:	Facility and Physician Payments Reporting
DATA ELEMENT:	Procedure Coding Method Used
DEFINITION:	An indicator that identifies the coding method used for procedure coding on this bill.
PROCEDURE:	1—3 = Reserved for state assignment 4 = CPT-4 5 = HCPCS (HCFA Common Procedure Coding System) 6—8 = Reserved for National assignment 9 = ICD-9-CM
FIELD SIZE:	1 field, 1 character
RECORD POSITION:	138
FORMAT:	Numeric
REFERENCE:	UB-82, item 82
FIELD: 19
REQUIRED:	Facility and Physician Payments Reporting
DATA ELEMENT:	Patient’s Relationship to Insured
DEFINITION:	A code indicating the relationship of the patient to the identified insured.
PROCEDURE:	Use coding as follows: 1 = Self 2 = Spouse 3 = Child 4 = Other Right justify. Zero fill left.
FIELD SIZE:	1 field, 2 characters
RECORD POSITION:	139—140
FORMAT:	Numeric
REFERENCE:	UB-82, item 67 a or HCFA 1500, item 7
FIELD: 20
REQUIRED:	Facility and Physician Payments Reporting
DATA ELEMENT:	Certificate/Social Security Number/Health Insurance Claim/Identification Number.
DEFINITION:	Insured’s unique identification number assigned by the payor organization.
PROCEDURE:	Left justify.
FIELD SIZE:	1 field, 16 characters
RECORD POSITION:	141—156
FORMAT:	Alphanumeric
REFERENCE:	UB-82, item 68 or HCFA 1500, item 6
FIELD: 21
DATA ELEMENT:	Reserve Field
DEFINITION:	To be reserved for future use by the Council.
FIELD SIZE:	1 field filler, 144 characters
RECORD POSITION:	157—300
FORMAT:	Alphanumeric

II. HEADER RECORD
FIELD: 1
DATA ELEMENT:	Data Source Identifier
DEFINITION:	Number identifying the data source. Third party payors - use your payor number.
PROCEDURE:	Left justify. Blank fill right.
FIELD SIZE:	1 field, 25 characters
RECORD POSITION:	1—25
FORMAT:	Alphanumeric
FIELD: 2
DATA ELEMENT:	Data Source Name/Address
DEFINITIONS:	Name and address of the data source.
PROCEDURE:	Left justify. Fill with blanks right. Space between lines of name and address.
FIELD SIZE:	1 field, 4 lines, 100 characters
RECORD POSITION:	26—125
FORMAT:	Alphanumeric
FIELD: 3
DATA ELEMENT:	Period Covered First Day
DEFINITION:	The first day of the quarter from which the data provided on this tape was contained.
PROCEDURE:	MMDDYY.
FIELD SIZE:	1 field, 6 characters
RECORD POSITION:	126—131
FORMAT:	Numeric
FIELD: 4
DATA ELEMENT:	Period Covered Last Day
DEFINITION:	The last day of the quarter from which the data provided on this tape was contained.
PROCEDURE:	MMDDYY.
FIELD SIZE:	1 field, 6 characters
RECORD POSITION:	132—137
FORMAT:	Numeric
FIELD: 5
DATA ELEMENT:	Run Date
DEFINITION:	The date that the data source produced this tape.
PROCEDURE:	MMDDYY.
FIELD SIZE:	1 field, 6 characters
FIELD POSITION:	138—143
FORMAT:	Numeric
FIELD: 6
DATA ELEMENT:	Filler
FIELD SIZE:	1 field filler, 157 characters
RECORD POSITION:	144—300
FORMAT:	Alphanumeric
III. TRAILER RECORD
FIELD: 1
DATA ELEMENT:	Number of records on this tape.
DEFINITION:	Total number of records contained on this tape, not including the Header and Trailer Records. This number should count each multi-page as one record.
PROCEDURE:	Right justify.
FIELD SIZE:	1 field, 10 characters
RECORD POSITION:	1—10
FORMAT:	Numeric
FIELD: 2
DATA ELEMENT:	Number of Patients on This Tape.
DEFINITION:	Total number of patients contained on this tape.
PROCEDURE:	Right justify.
FIELD SIZE:	1 field, 10 characters
RECORD POSITION:	11—20
FORMAT:	Numeric
FIELD: 3
DATA ELEMENT:	Total Physician Charges
DEFINITION:	Total of all Physician Charges on this tape.
PROCEDURE:	Sum of all fields 13 (Total Charges) when field 1 is equal to 2. Right justify. The last two digits are for cents.
FIELD SIZE:	1 field, 11 characters
RECORD POSITION:	21—31
FORMAT:	Numeric
FIELD: 4
DATA ELEMENT:	Total Facility Charges
DEFINITION:	Total of all Facility Charges on this tape.
PROCEDURE:	Sum of all fields 13 (Total Charges) when field 1 is equal to 1. Right justify. The last two digits are for cents.
FIELD SIZE:	1 field, 11 characters
RECORD POSITION:	32—42
FORMAT:	Numeric
FIELD: 5
DATA ELEMENT:	Total Physician Payments
DEFINITION:	Total of all Physician Payments on this tape.
PROCEDURE:	Sum of all fields 14 (Primary Payor Payments) when field 1 is equal to 2. Right justify. The last two digits are for cents.
FIELD SIZE:	1 field, 11 characters
RECORD POSITION:	43—53
FORMAT:	Numeric
FIELD: 6
DATA ELEMENT:	Total Facility Payments
DEFINITION:	Total of all Facility Payments on this tape.
PROCEDURE:	Sum of all fields 14 (Primary Payor Payments) when field 1 is equal to 1. Right justify. The last two digits are for cents.
FIELD SIZE:	1 field, 11 characters
RECORD POSITION:	54—64
FORMAT:	Numeric
FIELD: 7
DATA ELEMENT:	Total Other Payments (Physician)
DEFINITION:	Total of all Other Payments to Physicians on this tape.
PROCEDURE:	Sum of all fields 15 (Other Payments) when field 1 is equal to 2. Right justify. The last two digits are for cents.
FIELD SIZE:	1 field, 11 characters
RECORD POSITION:	65—75
FORMAT:	Numeric
FIELD: 8
DATA ELEMENT:	Total Other Payments (Facility)
DEFINITION:	Total of all Other Payments to Facilities on this tape.
PROCEDURE:	Sum of all fields 15 (Other Payments) when field 1 is equal to 1.
FIELD SIZE:	1 field, 11 characters
RECORD POSITION:	76—86
FORMAT:	Numeric
FIELD: 9
DATA ELEMENT:	Filler
FIELD SIZE:	1 field filler, 214 characters
RECORD POSITION:	87—300
FORMAT:	Alphanumeric

DATAELEMENT	DATA ELEMENT DESCRIPTION	POSITION		PICTURE	FORMAT
		FROM	TO
HEADER RECORD
1	Data Source Identifier	1	25	X(25)	Left justify. Blank fill right.
2	Data Source Name	26	125	X(100)	4 lines. 25 characters each.
3	Period Covered First Day	126	131	9(6)	MMDDYY.
4	Period Covered Last Day	132	137	9(6)	MMDDYY.
5	Run Date	138	143	9(6)	MMDDYY. Date that this tape was created.
6	Filler	144	300	X(157)