Subchapter A. GENERAL PROVISIONS
Sec.
913.1. Legal base and purpose.
913.2. Affected parties.
913.3. Definitions.§ 913.1. Legal base and purpose.
(a) This chapter is promulgated by the Council under section 6 of the Health Care Cost Containment Act (35 P. S. § 449.6).
(b) This chapter establishes data elements, submission schedules and data element formats for the collection of the data elements from payors as specified in section 6 of the act.
§ 913.2. Affected parties.
This chapter applies to payors for covered services rendered in health care facilities licensed by the Commonwealth.
§ 913.3. 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).
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, freestanding emergency rooms and other facilities providing ambulatory care which charge a separate facility charge.
Charge—The amount billed by a provider for specific goods or services provided to a patient, prior to adjustment for contractual allowances.
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.
Health care facility or 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.
Health care insurer—A person, corporation or other entity that offers administrative, indemnity or payment services for health care in exchange for a premium or service charge under a program of health care services, including:(i) An insurance company, association or exchange with a certificate of authority to issue health insurance policies in this Commonwealth under sections 616—630 of The Insurance Company Law of 1921 (40 P. S. § § 751—764(a)) but the policies may not include those providing supplemental or indemnity coverage, or both.
(ii) A hospital plan corporation as defined in 40 Pa.C.S. Chapter 61 (relating to hospital plan corporations).
(iii) A professional health services plan corporation as defined in 40 Pa.C.S. Chapter 63 (relating to professional health services plan corporations).
(iv) A health maintenance organization.
(v) A preferred provider organization.
(vi) A fraternal benefit society.
(vii) A beneficial society.
(viii) A third-party administrator.
Health maintenance organization—An organized system which combines the delivery and financing of health care and which provides basic health services to voluntarily enrolled subscribers for a fixed prepaid fee, as defined in the Health Maintenance Organization Act (40 P. S. § § 1551—1567).
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. The term includes institutions 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.
Payor—A person or entity, including health care insurers, purchasers, the Medical Assistance Program in the Department of Public Welfare, and the Federal Medicare Program, that makes direct payments to providers for covered services. With respect to an insurance company, association or exchange, the term includes only those insurers issuing health insurance policies in this Commonwealth under sections 616—630 of The Insurance Company Law of 1921. The health insurance policies may not include those providing supplemental or indemnity coverage, or both.
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 this 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 (63 P. S. § § 422.1—422.45).
Preferred provider organization—An arrangement between a health care insurer and providers of health care services which specifies rates of payment to the providers which differ from their usual and customary charges to the general public and which encourage enrollees to receive health services from the providers.
Provider—A hospital, ambulatory service facility or a physician.
Purchaser—Corporations, labor organizations and other entities that purchase benefits which provide covered services for their employes or members either through a health care insurer or by means of a self-funded program of benefits, and a certified bargaining representative that represents a group of employes for whom employers purchase a program of benefits which provide covered services. The term does not include health care insurers.
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