§ 912.3. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
Act—The Health Care Cost Containment Act (35 P. S. § § 449.1—449.19).
Additional data elements—Data, redefinitions of data or methodologies to calculate data to be added to the Pennsylvania Uniform Claims and Billing Form format.
Ambulatory service facility—A facility licensed in this Commonwealth, not part of a hospital, which provides medical, diagnostic or surgical treatment to patients not requiring hospitalization. The term includes, but is not limited to, ambulatory surgical facilities, ambulatory imaging or diagnostic centers, birthing centers, free-standing emergency rooms and other facilities providing ambulatory care which charge a separate facility charge. The term does not include the offices of private physicians or dentists, whether for individual or group practices.
Charge—The amount billed by a provider for specific goods or services provided to a patient, prior to adjustment for contractual allowances.
Council—The Health Care Cost Containment Council.
Covered services—Health care services or procedures connected with episodes of illness that require either inpatient hospital care or major ambulatory service, such as surgical, medical or major radiological procedures, including initial and follow-up outpatient services associated with the episode of illness before, during or after inpatient hospital care or major ambulatory service. The term does not include routine outpatient services connected with episodes of illness that do not require hospitalization or major ambulatory service.
Data elements—Data identified by the Council to be submitted to the Council as part of the Pennsylvania Uniform Claims and Billing Form format.
Executive Director—The Executive Director of the Council.
General hospital—A hospital equipped and staffed for the treatment of medical or surgical conditions, or both, in the acute or chronic stages, on an inpatient basis of 24 or more hours. The term includes hospitals that treat children as their specialty.
Health care facility—The term includes the following:(i) A general or special hospital, including tuberculosis and psychiatric hospitals.
(ii) Ambulatory service facilities as defined in this section.
Hospital—An institution, licensed in this Commonwealth, which is a general, tuberculosis, mental, chronic disease or other type of hospital, or kidney disease treatment center, whether profit or nonprofit, including those operated by an agency of State or local government.
Major ambulatory service—Surgical or medical procedures, including diagnostic and therapeutic radiological procedures, commonly performed in hospitals or ambulatory service facilities, which are not of a type commonly performed or which cannot be safely performed in physicians’ offices and which require special facilities, such as operating rooms or suites or special equipment, such as fluoroscopic equipment or computed tomographic scanners, or a postprocedure recovery room or short term convalescent room.
Pennsylvania Uniform Claims and Billing Form format—The Uniform Hospital Billing Form UB-82/HCFA-1450, and the HCFA 1500, or their successors, as developed by the National Uniform Billing Committee, with additional fields as necessary to provide the data in section 6(c) and (d) of the act (35 P. S. § 449.6(c) and (d)).
Physician—An individual licensed under the laws of the Commonwealth to practice medicine and surgery within the scope of the Osteopathic Medical Practice Act (63 P. S. § § 271.1—271.18) or the Medical Practice Act of 1985 (63 P. S. § § 422.1—422.45).
Provider—A hospital, ambulatory service facility or physician.
Provider quality—The extent to which a provider renders care that, within the capabilities of modern medicine, obtains for patients medically acceptable health outcomes and prognoses, adjusted for patient severity, and treats patients compassionately and responsively.
Provider service effectiveness—The effectiveness of services rendered by a provider, determined by measurement of the medical outcome of patients grouped by severity receiving those services.
Raw data or data—Data collected by the Council under section 6 of the act in the form initially received.
Region—A geographical area of contiguous counties formed to provide a basis for implementing data collection activities and reporting according to the following:(i) Region 1 (Western Southwest)—Allegheny, Armstrong, Beaver, Fayette, Green, Washington and Westmoreland Counties.
(ii) Region 2 (Northwest)—Butler, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Forest, Jefferson, Lawrence, McKean, Mercer, Potter, Venango and Warren Counties.
(iii) Region 3 (Eastern Southwest)—Bedford, Blair, Cambria, Indiana and Somerset Counties.
(iv) Region 4 (North Central)—Centre, Clinton, Columbia, Lycoming, Mifflin, Montour, Northumberland, Snyder, Tioga and Union Counties.
(v) Region 5 (South Central)—Adams, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Juniata, Lancaster, Lebanon, Perry and York Counties.
(vi) Region 6 (Northeast)—Bradford, Lackawanna, Luzerne, Monroe, Pike, Sullivan, Susquehanna, Wayne and Wyoming Counties.
(vii) Region 7 (Eastern)—Berks, Carbon, Lehigh, Northampton and Schuylkill Counties.
(viii) Region 8 (Suburban Southeast)—Bucks, Chester, Delaware and Montgomery Counties.
(ix) Region 9 (Southeast—Philadelphia)—Philadelphia County.
Short term procedure unit—A unit organized for the delivery of nonemergency surgical services to patients who do not remain in the hospital overnight.
Special hospital—A hospital equipped and staffed for the treatment of disorders within the scope of specific medical specialties or for the treatment of limited classifications of diseases in their acute or chronic stages on an inpatient basis of 24 or more hours. The term includes psychiatric and rehabilitation hospitals.
Specialty unit—A functional unit of a hospital that provides drug and alcohol rehabilitation, rehabilitative and psychiatric services.
Authority The provisions of this § 912.3 amended under section 5(b) of the Health Care Cost Containment Act (35 P. S. § 449.5(b)).
Source The provisions of this § 912.3 adopted January 29, 1988, effective January 30, 1988, 18 Pa.B. 459; amended April 8, 1988, effective March 1, 1988, 18 Pa.B. 1607; amended October 1, 1999, effective October 2, 1999, 29 Pa.B. 5093. Immediately preceding text appears at serial pages (242560) to (242562).
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