CHAPTER Ins 4200 UNIFORM REPORTING SYSTEM FOR UNINSURED
PATIENT ENCOUNTER DATA
Authority: RSA 400-A:15,
PART Ins 4201 GENERAL REQUIREMENTS
Ins 4201.01 Purpose
and Scope. This chapter contains the
provisions for submission of data on all encounters for health care by
uninsured patients from hospitals, community health centers, and hospital owned
or controlled physician practices and other providers.
Source. #9806, eff 11-1-10
Ins 4201.02 Definitions. For the purposes of this chapter:
(a)
"Agent" means a person engaged under contractual agreement
with the department for the performance of services.
(d)
"Commissioner" means the
(e) "Community
health centers" means non-profit community based providers of
comprehensive primary and preventive healthcare services to the state's
uninsured and Medicaid populations regardless of the patient's ability to pay,
and are governed by boards of directors that are at least 51 percent composed
of health center patients, and federally qualified community health centers as
defined by section 330 of the Federal Public Health Service Act, 42 U.S.C.
section 254b.
(h) "Data"
means factual information that can be used as a basis for measuring or
calculating.
(i)
"Database" means a collection of data organized especially for
search and retrieval.
(j) "Data
set" means a collection of individual or provider data records.
(k)
"Department" means the
(l) "DHHS"
means the
(m) “Encounter”
means all healthcare services delivered
each day to a patient. Each day that
services are delivered shall constitute a separate encounter.
(q) "Healthcare
provider" means physicians and all other entities practicing or providing
healthcare services in the state of
(1) Nurses;
(2) Podiatrists;
(3) Optometrists;
(4) Pharmacists;
(5) Chiropractors;
(6) Physical therapists;
(7) Dentists;
(8) Psychologists;
(9) Licensed clinical social workers;
(10) Marriage and family therapists;
(11) Professional counselors;
(12) Physicians' assistants;
(13) Home healthcare; and
(4) Laboratories.
(r) "Hospital
owned or controlled physician practices" means all physician practices
that are owned or controlled by a hospital or a financial intermediary of a
hospital.
(s) "Hospital
owned or controlled healthcare providers" means all healthcare providers
that are owned or controlled by a hospital or a financial intermediary of a
hospital.
(u) "Licensed healthcare
providers" means providers as defined by RSA 151-C:2 XXX, that are
employed or legally controlled by a hospital with the exception of long-term
care facilities.
(v) "Licensed
hospitals" means hospitals as defined in RSA 151-C:2, XX.
(x) "Patient"
means any person who receives healthcare services.
(y) "Patient
encounter data" means data on patients and the healthcare services
received by patients at a unique encounter for healthcare services.
(z) “Uninsured patient
encounter data” means encounter data for patients who have not provided
evidence of insurance.
Source. #9806, eff 11-1-10
PART Ins 4202 UNINSURED PATIENT ENCOUNTER DATA SET
SUBMISSION REQUIREMENTS
Ins 4202.01 Entities
Required to Submit Uninsured Encounter Data Sets. All licensed hospitals, community health
centers, hospital owned or controlled physician practices, and hospital owned or
controlled licensed healthcare service providers shall be required to submit
patient encounter data sets to the department.
Hospitals and community health centers shall submit by January 15th of
each year, a list of all of their healthcare service provider organizations for
anytime during the previous calendar year that are required to provide
uninsured encounter data. For any
healthcare service provider not in operation for the entirety of the previous
year, dates of operation shall be provided.
The list shall include the name and street address of each healthcare
service provider organization.
Source. #9806, eff 11-1-10
Ins 4202.02 Uninsured
Encounter Data Set Submission Description.
Beginning with encounters occurring on January 1, 2011, hospitals and
community health centers shall submit to the department, or its designee, a
completed healthcare data set for all encounters for healthcare services with
uninsured patients. Each hospital shall
ensure submittal of all uninsured patient encounter data of the hospital, and
all licensed
healthcare providers directly owned or controlled by the hospital or a
financial intermediary of the hospital.
Data already submitted by hospitals under RSA 126:25, or subject to
reporting under RSA 126:25, shall not be reported.
Source. #9806, eff 11-1-10
Ins 4202.03 General
Requirements for Data Set Submission.
(a) For hospital
based services that are normally billed to third-party payers using the UB-04
form, hospitals shall submit data to the department, or its agent, using a
format compliant with the "Official UB-04 Data Specifications Manual"
published by the National Uniform Billing Committee. The "Official UB-04
Data Specifications Manual" shall be the code source to be utilized for
encounter data submission by the hospital for its hospital based services.
(b) For non-hospital
based services that are normally billed to third-party payers using the CMS-1500
claim form, hospitals and community health centers shall submit data to the
department, or its agent using a format compliant with the Medicare Claims
Processing Manual, Form CMS 1500, Data Set (08-05).
(c) Data submissions
shall be made to the department, or its agent, utilizing secure socket layer
(SSL) protocol. E-mail attachments and
paper submissions shall not be acceptable.
(d) Hospitals and
community health centers shall make every effort to report the data fields
outlined in these requirements if the data field is present in any part of
their data systems, even in circumstances where the data needs to be integrated
from multiple systems.
(e) Hospitals and
community health centers shall assign, according to a standard algorithm
provided by the department, or its designee, a unique identification code to
each of their uninsured patients using the following criteria:
(1) If the patient's social security number is not
collected by the hospital or community health center, an encrypted version of
the patient's name shall be used in its place as the unique identification
code; and
(2) For encrypting the social security number of
the patient, the hospital and community health center shall utilize a standard
methodology provided by the department.
(f) The required
source codes are found in Appendix I. If
codes specified in these rules are updated by the code source, whether the
update includes new codes or a modification of descriptions, the changes
provided by the source preempt the definitions and descriptors provided in
these rules.
(g) Specific/Unique
Coding. With the exception of provider
codes and provider specialty codes, specific or unique coding systems shall not
be permitted as part of the healthcare data set submission.
(h) Annual
Submission of Data. Hospitals and
community health centers shall submit a healthcare data set annually that
includes all uninsured patient encounters for that calendar year. The data set for the preceding calendar year
shall be submitted by April 1 of each year.
(i) Each data file
submission shall be an ASCII file, variable field length, and asterisk
delimited. When asterisks are used in
any field values, they shall be enclosed in double quotes.
Source. #9806, eff 11-1-10
Ins 4202.04 Required
Data Elements for Submissions Made Pursuant to Ins 4202.03.
Hospitals and community health centers shall submit header
and trailer records and uninsured patient encounter data set records using the
following specifications in submitting their healthcare uninsured patient
encounter data set:
(a) The file header
record layout shall be submitted using the following data elements:
(1) HD001.
This element is named "record type". The data type of this element is text. Its length is 2. Hospitals and community health centers shall
code as “HD”;
(2) HD002.
This element is named "type of file". The data type of this element is text. Its length is 2. Hospitals and community health centers shall
code as “UP”;
(3) HD003.
This element is named "period beginning date". The data type of this element is integer. Its length is 6. Hospitals and community health centers shall
code according to CCYYMM;
(4) HD004.
This element is named "period ending date". The data type of this element is integer. Its length is 6. Hospitals and community health centers shall
code according to CCYYMM;
(5) HD005.
This element is named "record count". The data type of this element is
integer. Its length is 10. Hospitals and community health centers shall
code according to total number of records submitted in this file, with the
header and trailer record excluded from the count; and
(6) HD006.
This element is named "comments". The data type of this element is text. Its length is 80. Hospitals and community health centers shall
code according to their own option.
(b) The file header
record layout shall conform to the following:
Table 4200.1 File Header Record Layout
|
Data Element # |
Element |
Type |
Maximum Length |
Description/Codes/Sources |
|
|
|
|
|
|
|
HD001 |
Record Type |
Text |
2 |
HD |
|
|
|
|
|
|
|
HD002 |
Type of File |
Text |
2 |
UP |
|
|
|
|
|
|
|
HD003 |
Period Beginning Date |
Integer |
6 |
CCYYMM |
|
|
|
|
|
|
|
HD004 |
Period Ending Date |
Integer |
6 |
CCYYMM |
|
|
|
|
|
|
|
HD005 |
Record Count |
Integer |
10 |
Total number of records
submitted in this file |
|
|
|
|
|
|
|
HD006 |
Comments |
Text |
80 |
Submitter may use this
code according to their own option |
|
|
|
|
|
|
(c) The trailer
header record layout shall be submitted using the following data elements:
(1) TR001.
This element is named "record type". The data type of this element is text. Its length is 2. Hospitals and community health centers shall
code as “TR”;
(2) TR002.
This element is named "type of file". The data type of this element is text. Its length is 2. Hospitals and community health centers shall
code as “UP”;
(3) TR003.
This element is named "period beginning date". The data type of this element is integer. Its length is 6. Hospitals and community health centers shall code
according to CCYYMM, beginning of period for services, beginning of month of
first service;
(4) TR004.
This element is named "period ending date". The data type of this element is integer. Its length is 6. Hospitals and community health centers shall
code according to CCYYMM, end of period for services; and
(5) TR005.
This element is named "date processed". The data type of this element is date. Its length is 8. Hospitals and community health centers shall
code according to CCYYMMDD, the date the file was created.
(d) The trailer
record layout shall conform to the following:
Table 4200.2 Trailer Record Layout
|
Data Element # |
Element |
Type |
Maximum Length |
Description/Codes/Sources |
|
|
|
|
|
|
|
TR001 |
Record Type |
Text |
2 |
TR |
|
|
|
|
|
|
|
TR002 |
Type of File |
Text |
2 |
UP |
|
|
|
|
|
|
|
TR003 |
Period Beginning Date |
Integer |
6 |
CCYYMM |
|
|
|
|
|
|
|
TR004 |
Period Ending Date |
Integer |
6 |
CCYYMM |
|
|
|
|
|
|
|
TR005 |
Date Processed |
Date |
8 |
CCYYMMDD |
|
|
|
|
|
|
(f) The uninsured
patient encounter data set record layout shall be submitted using the following
general specifications:
(1) Filled Fields. All fields shall be filled where
applicable. Non-applicable text and date
fields shall be set to null.
Non-applicable integer and decimal fields shall be filled with one zero
and shall not include decimal points;
(2) Position.
All text fields shall be left justified.
All integer and decimal fields shall be right justified; and
(3) Signs.
All signs (+ or -) shall appear in the left-most position of all integer
and decimal fields. Over-punched signed
integers or decimals shall not be utilized.
(g) The uninsured patient
encounter data set shall be submitted using the following data elements for
each service provided during a unique encounter (multiple lines per encounter
as needed to describe all services provided during the encounter).
(1) UP001.
This element is named "record type". The data type of this element is text. Its length is 2. Hospitals and community health centers shall
code as “UP”;
(2) UP002.
This element is named "insurance type". The data type of this element is text. Its length is 2. Hospitals and community health centers shall
code as code “12”, uninsured;
(3) UP003.
This element is named "encrypted patient last name". The data type of this element is text. Its length is 128;
(4) UP004.
This element is named "encrypted patient first name". The data type of this element is text. Its length is 128;
(5) UP005.
This element is named "encrypted patient middle initial". The data type of this element is text. Its length is 1;
(6) UP006.
This element is named "unique member identification
code". The data type of this
element is text. Its length is 100. This element shall be assigned by each
hospital and community health center and shall remain for each person for the
entire period of service for that individual;
(7) UP007.
This element is named "medical record number". The data type of this element is text. Its length is 100. Hospitals and community health centers shall
code according to the medical record number;
(8) UP008.
This element is named "gender". The data type of this element is text. Its length is one. Hospitals and community health centers shall
code according to:
a. M = Male;
b. F = Female; and
c. U = Unknown.
(9) UP009.
This element is named "uninsured person year and month of
birth". The data type of this
element is text. Its length is 6. Hospitals and community health centers shall
code according to CCYYMM;
(10) UP010.
This element is named "uninsured person city name". The data type of this element is text. Its length is 30. Hospitals and community health centers shall
code according to the city location of the member;
(11) UP011.
This element is named "uninsured person state or
province". The data type of this
element is text. Its length is 2. Hospitals and community health centers shall
code as defined by the U.S. Postal Service;
(12) UP012.
This element is named "uninsured person zip code". The data type of this element is text. Its length is 11. Hospitals and community health centers shall
code according to ZIP code of member, which may include non-US codes. Hospitals and community health centers shall
not include the dash in the coding;
(13) UP013. This element is named "Race
1". The data type of this
element is text. Its length is 20. Coding for this element shall:
a. Be based on the hospital's code; or
b. Be based on the community health center's
code; and
c. The coding sourcebooks shall be
submitted.
d. Hospitals and community health centers may
alternatively code as follows:
1. R1 = American Indian/Alaskan Native;
2. R2 = Asian;
3. R3 = Black/African American;
4. R4 = Native Hawaiian or other Pacific
Islander;
5. R5 = White;
6. R7 = Refused/declined to provide;
7. R8 = Unknown; and
8. R9 = Other Race.
(14) UP014. This element is named "Race 2". The data type of this element is text. Its length is 20. Hospitals and community health centers shall
code in the same manner as UP013;
(15) UP015.
This element is named "Hispanic indicator". The data type of this element is text. Its length is one. Hospitals and community health centers shall
code according to:
a. Y = Yes Patient is Hispanic/Latino/Spanish
b. N = No Patient is not
Hispanic/Latino/Spanish; and
c. U = Unknown.
(16) UP016.
This element is named "date service received". The data type of this element is date. Its length is 8. Hospitals and community health centers shall
code according to CCYYMMDD. The date
service is received shall be the unique encounter date;
(17) UP017.
This element is named "service provider tax ID number". The data type of this element is text. Its length is 10. Hospitals and community health centers shall
code using the federal taxpayer's identification number;
(18) UP018.
This element is named "national service provider ID". The data type of this element is text. Its length is 20. Hospitals and community health centers shall
code using the appropriate federal national provider identification number;
(19) UP019.
This element is named "service provider location name". The data type of this element is text. Its length is 100. Hospitals and community health centers shall
code according to the service provider location that is used to identify the
service provider;
(20) UP020.
This element is named "service provider street address". The data type of this element is text. Its length is 100. Hospitals and community health centers shall
code using the service provider's street address;
(21) UP021.
This element is named "service provider city name". The data type of this element is text. Its length is 128. Hospitals and community health centers shall
code according to the street address of the rendering provider and the practice
location;
(22) UP022.
This element is named "service provider state". The data type of this element is text. Its length is 2. Hospitals and community health centers shall
code as defined by the US Postal Service;
(23) UP023.
This element is named "service provider ZIP Code". The data type of this element is text. Its length is 11. Hospitals and community health centers shall
code according to ZIP code of provider, which may include non-US codes. Hospitals and community health centers shall
not use the dash in coding;
(24) UP024.
This element is named "service provider organization
name". The data type of this
element is text. Its length is 100. Hospitals and community health centers shall
code using the full name of the provider organization;
(25) UP025.
This element is named "service healthcare provider
specialty". The data type of this
element is text. Its length is 10. Hospitals and community health centers shall
code for the specialty for the healthcare service provider;
(26) UP026.
This element is named "facility type professional". The data type of this element is text. Its length is 2. Hospitals and community health centers shall
code facility type according to the Medicare Claims Processing Manual Form,
CMS-1500 data set;
Table 4200.3 Facility Type
|
Code |
Facility |
|
|
|
|
18 |
Unassigned |
|
19 |
Unassigned |
|
20 |
Urgent Care Facility Location, distinct from a
hospital emergency room, an office, or a clinic, whose purpose is to diagnose
and treat illness or injury for unscheduled, ambulatory patients seeking
immediate medical attention |
|
21 |
A facility, other than
psychiatric, which primarily provides diagnostic; therapeutic (both surgical and
nonsurgical), and rehabilitation services by, or under, the supervision of
physicians to patients admitted for a variety of medical conditions. |
|
22 |
A portion of a hospital
which provides diagnostic, therapeutic (both surgical and nonsurgical), and
rehabilitation services to sick or injured persons who do not require
hospitalization or institutionalization |
|
23 |
Emergency Room - Hospital A portion of a hospital
where emergency diagnosis and treatment of illness or injury is provided |
|
24 |
Ambulatory Surgical Center A freestanding facility,
other than a physician's office, where surgical and diagnostic services are
provided on an ambulatory basis |
|
25 |
Birthing Center A facility, other than a hospital's
maternity facilities or a physician's office, which provides a setting for
labor, delivery, and immediate postpartum care as well as immediate care of
newborn infants |
|
26 |
Military Treatment Facility A medical facility
operated by one or more of the Uniformed Services, Military Treatment
Facility (MTF) also refers to certain former U.S. Public Health Service
(USPHS) facilities now designated as Uniformed Service Treatment Facilities
(USTF) |
|
27 |
Unassigned |
|
28 |
Unassigned |
|
29 |
Unassigned |
|
30 |
Unassigned |
|
31 |
Skilled Nursing Facility A facility which primarily
provides inpatient skilled nursing care and related services to patients who
require medical, nursing, or rehabilitative services but does not provide the
level of care or treatment available in a hospital |
|
32 |
Nursing Facility A facility which primarily
provides to residents skilled nursing care and related services for the
rehabilitation of injured, disabled, or sick persons, or, on a regular basis,
health-related care services above the level of custodial care to other than
mentally retarded individuals |
|
33 |
Custodial Care Facility A facility which provides
room, board and other personal assistance services, generally on a long-term basis,
and which does not include a medical component |
|
34 |
Hospice A facility, other than a
patient's home, in which palliative and supportive care for terminally ill
patients and their families are provided |
|
35 |
Unassigned |
|
36 |
Unassigned |
|
37 |
Unassigned |
|
38 |
Unassigned |
|
39 |
Unassigned |
|
40 |
Unassigned |
|
41 |
Ambulance - Land A land vehicle
specifically designed, equipped and staffed for lifesaving and transporting
the sick or injured |
|
42 |
Ambulance - Air or Water An air or water vehicle
specifically designed, equipped and staffed for lifesaving and transporting
the sick or injured |
|
43 |
Unassigned |
|
44 |
Unassigned |
|
45 |
Unassigned |
|
46 |
Unassigned |
|
47 |
Unassigned |
|
48 |
Unassigned |
|
49 |
Independent Clinic A location, not part of a
hospital and not described by any other Place of Service code, that is
organized and operated to provide preventive, diagnostic, therapeutic,
rehabilitative, or palliative services to outpatients only |
|
50 |
Federally Qualified A facility located in a
medically underserved area that provides Medicare beneficiaries preventive
primary medical care under the general direction of a physician |
|
51 |
Inpatient Psychiatric Facility A facility that provides
inpatient psychiatric services for the diagnosis and treatment of mental
illness on a 24-hour basis, by or under the supervision of a physician |
|
52 |
Psychiatric Facility-Partial Hospitalization A facility for the diagnosis
and treatment of mental illness that provides a planned therapeutic program
for patients who do not require full time hospitalization, but who need
broader programs than are possible from outpatient visits to a hospital-based
or hospital-affiliated facility |
|
53 |
Community Mental A facility that provides
the following services: outpatient
services, including specialized outpatient services for children, the
elderly, individuals who are chronically ill, and residents of the CMHC's mental
health services area who have been discharged from inpatient treatment at a
mental health facility; 24 hour a day emergency care services; day treatment,
other partial hospitalization services, or psychosocial rehabilitation
services, screening for patients being considered for admission to State
mental health facilities to determine the appropriateness of such admission;
and consultation and education services |
|
54 |
Intermediate Care Facility/Mentally Retarded A facility which primarily
provides health-related care and services above the level of custodial care
to mentally retarded individuals but does not provide the level of care or
treatment available in a hospital or SNF |
|
55 |
Residential Substance Abuse Treatment Facility A facility which provides
treatment for substance (alcohol and drug) abuse to live-in residents who do
not require acute medical care.
Services include individual and group therapy and counseling, family
counseling, laboratory tests, drugs and supplies, psychological testing, and
room and board |
|
56 |
Psychiatric Residential A facility or distinct
part of a facility for psychiatric care which provides a total 24-hour
therapeutically planned and professional staffed group living and learning
environment |
|
57 |
Non-residential Substance Abuse Treatment Facility A location which provides
treatment for substance (alcohol and drug) abuse on an ambulatory basis. Services include individual and group therapy
and counseling, family counseling, laboratory tests, drugs and supplies, and
psychological testing |
|
58 |
Unassigned |
|
59 |
Unassigned |
|
60 |
A location where providers
administer pneumococcal pneumonia and influenza virus vaccinations and submit
these services as electronic media claims, paper claims, or using the roster
billing method. This generally takes
place in a mass immunization setting such as, a public health center,
pharmacy, or mall but may include a physician office setting |
|
61 |
Comprehensive Inpatient Rehabilitation Facility A facility that provides
comprehensive rehabilitation services under the supervision of a physician to
inpatients with physical disabilities.
Services include physical therapy, occupational therapy, speech
pathology, social or psychological services, and orthotics and prosthetics
services |
|
62 |
Comprehensive Outpatient Rehabilitation Facility A facility that provides
comprehensive rehabilitation services under the supervision of a physician to
outpatients with physical disabilities.
Services include physical therapy, occupational therapy, and speech
pathology services |
|
63 |
Unassigned |
|
64 |
Unassigned |
|
65 |
End-State Renal Disease Treatment Facility A facility other than a
hospital, which provides dialysis treatment, maintenance, and/or training to
patients or caregivers on an ambulatory or home-care basis |
|
66 |
Unassigned |
|
67 |
Unassigned |
|
68 |
Unassigned |
|
69 |
Unassigned |
|
70 |
Unassigned |
|
71 |
State or Local Public Health Clinic A facility maintained by
either State of local health departments that provides ambulatory primary
medical care under the general direction of a physician |
|
72 |
Rural Health Clinic A certified facility which
is located in a rural medically underserved area that provides ambulatory
primary medical care under the general direction of a physician |
|
73 |
Unassigned |
|
74 |
Unassigned |
|
75 |
Unassigned |
|
76 |
Unassigned |
|
77 |
Unassigned |
|
78 |
Unassigned |
|
79 |
Unassigned |
|
80 |
Unassigned |
|
81 |
Independent Laboratory A laboratory certified to
perform diagnostic and/or clinical tests independent of an institution or a
physician's office |
|
82 |
Unassigned |
|
83 |
Unassigned |
|
84 |
Unassigned |
|
85 |
Unassigned |
|
86 |
Unassigned |
|
87 |
Unassigned |
|
88 |
Unassigned |
|
89 |
Unassigned |
|
90 |
Unassigned |
|
91 |
Unassigned |
|
92 |
Unassigned |
|
93 |
Unassigned |
|
94 |
Unassigned |
(27) UP027.
This element is named "E-code". The data type of this element is text. Its length is 5. Where known, hospitals and community health centers
shall use this code to describe an injury, poisoning or adverse effect,
ICD-9-CM without coding decimal points;
(28) UP028.
This element is named "principal diagnosis". The data type of this element is text. Its length is 5. Hospitals and community health centers shall
code the principal diagnosis given on the claim header using ICD-9-CM without
coding decimal points;
(29) UP029.
This element is named "other diagnosis – 1". The data type of this element is text. Its length is 5. Hospitals and community health centers shall code using ICD-9-CM without coding
decimal points;
(30) UP030.
This element is named "other diagnosis – 2". The data type of this element is text. Its length is 5. Hospitals and community health centers shall
code using ICD-9-CM without coding decimal points;
(31) UP031.
This element is named "other diagnosis – 3". The data type of this element is text. Its length is 5. Hospitals and community health centers shall
code using ICD-9-CM without coding decimal points;
(32) UP032.
This element is named "other diagnosis – 4". The data type of this element is text. Its length is 5. Hospitals and community health centers shall
code using ICD-9-CM without coding decimal points;
(33) UP033.
This element is named "other diagnosis – 5". The data type of this element is text. Its length is 5. Hospitals and community health centers shall
code using ICD-9-CM without coding decimal points;
(34) UP034.
This element is named "revenue code". The data type of this element is text. Its length is 4. For services rendered in facilities using
national uniform billing committee codes hospitals and community health centers
shall code using leading zeroes, left-justified, and four digits;
(35) UP035.
This element is named "procedure code". The data type of this element is text. Its length is 5. Hospitals and community health centers shall
code according to the Health Care Common Procedural Coding System (HCPCS). This includes the CPT codes of the American
Medical Association. When the hospital
and community health center utilizes a local code system for procedure codes, a
reference table shall be submitted;
(36) UP036.
This element is named "procedure modifier – 1". The data type of this element is text. Its length
is 2. Hospitals and community health
centers shall code using a procedure modifier when a modifier clarifies or
improves the reporting accuracy of the associated procedure code. When the hospital and community health center
utilizes a local code system for procedure codes, a reference table shall be
submitted;
(37) UP037.
This element is named "procedure modifier – 2". The data type of this element is text. Its length is 2. Hospitals and community health centers shall
code using a procedure modifier required when a modifier clarifies or improves
the reporting accuracy of the associated procedure code. When the hospital and community health center
utilizes a local code system for procedure codes, a reference table shall be
submitted;
(38) UP038.
This element is named "quantity". The data type of this element is
integer. Its length is 3. Hospitals and community health centers shall
code according to the count of services performed, which shall be set equal to
one on all observation bed service lines and should be set equal to zero on all
other room and board service lines, regardless of the length of stay;
(39) UP039.
This element is named "charge amount". The data type of this element is
decimal. Its length is 10. Hospitals and community health centers shall
code according to the charge prior to any uninsured discounts without coding
decimal points;
(40) UP040.
This element is named "paid amount". The data type of this element is
decimal. Its length is 10. This element includes all payments made by
the uninsured person during the calendar year reported in the data set;
(41) UP041.
This element is named "record type". The data type of this element is text. Its
length is 2. Its value is literally
"UP"; and
(42) UP042.
This element is named "uninsured identification code". The data type of this element is text. Its length is 128. Hospitals and community health centers shall
code according to the encrypted uninsured person social security number if
available.
(h) The uninsured
patient encounter data elements shall conform to the following:
Table 4200.4
Data Elements
|
Data Element # |
Data Element Name |
Type |
Maximum Length |
Description/Codes/Sources |
|
|
|
|
|
|
|
UP001 |
Record Type |
Text |
2 |
UP |
|
|
|
|
|
|
|
UP002 |
Insurance Type |
Text |
2 |
"12" Uninsured |
|
|
|
|
|
|
|
UP003 |
Encrypted Patient Last
Name |
Text |
128 |
Encrypted patient last
name |
|
|
|
|
|
|
|
UP004 |
Encrypted Patient First
Name |
Text |
128 |
Encrypted patient first
name |
|
|
|
|
|
|
|
UP005 |
Encrypted Patient Middle
Initial |
Text |
1 |
Encrypted patient middle
initial |
|
|
|
|
|
|
|
UP006 |
Unique Member
Identification Code |
Text |
100 |
Unique member
identification code |
|
|
|
|
|
|
|
UP007 |
Medical Record Number |
Text |
100 |
Medical record number |
|
|
|
|
|
|
|
UP008 |
Gender |
Text |
1 |
M = Male F = Female U = Unknown |
|
|
|
|
|
|
|
UP009 |
Uninsured Person Year
& Month of Birth |
Text |
6 |
CCYYMM |
|
|
|
|
|
|
|
UP010 |
|
Text |
30 |
City location |
|
|
|
|
|
|
|
UP011 |
|
Text |
2 |
|
|
|
|
|
|
|
|
UP012 |
Uninsured Person Zip Code |
Text |
11 |
ZIP Code |
|
|
|
|
|
|
|
UP013 |
Race 1 |
Text |
20 |
Based on respective codes;
or: R1 = American
Indian/Alaskan Native R2 = Asian R3 = Black/African
American R4 = Native Hawaiian or
other Pacific Islander R5 = White R7 = Refused/declined to
provide R8 = Unknown R9 = Other Race |
|
|
|
|
|
|
|
UP014 |
Race 2 |
Text |
20 |
Same codes as UP013 |
|
|
|
|
|
|
|
UP015 |
Hispanic Indicator |
Text |
1 |
Y = Yes Patient is
Hispanic/Latino/Spanish N = No Patient is not
Hispanic/Latino/Spanish U = Unknown |
|
|
|
|
|
|
|
UP016 |
Date Service Received |
Date |
8 |
CCYYMMDD |
|
|
|
|
|
|
|
UP017 |
Service Provider Tax ID
Number |
Text |
10 |
Federal taxpayer ID number |
|
|
|
|
|
|
|
UP018 |
National Service Provider
ID |
Text |
20 |
Federal national provider ID
number |
|
|
|
|
|
|
|
UP019 |
Service Provider Location
Name |
Text |
100 |
|
|
|
|
|
|
|
|
UP020 |
|
Text |
100 |
Street address |
|
|
|
|
|
|
|
UP021 |
|
Text |
128 |
|
|
|
|
|
|
|
|
UP022 |
|
Text |
2 |
US Postal Service Code |
|
|
|
|
|
|
|
UP023 |
Service Provider ZIP Code |
Text |
11 |
|
|
|
|
|
|
|
|
UP024 |
Service Provider
Organization Name |
Text |
100 |
|
|
|
|
|
|
|
|
UP025 |
Service Healthcare
Provider Specialty |
Text |
10 |
Specialty Code |
|
|
|
|
|
|
|
UP026 |
Facility Type Professional |
Text |
2 |
CMS-1500 Data Set (Table
4100.3 Facility Type) |
|
|
|
|
|
|
|
UP027 |
E-code |
Text |
5 |
ICD-9-CM |
|
|
|
|
|
|
|
UP028 |
Principal Diagnosis |
Text |
6 |
ICD-9-CM |
|
|
|
|
|
|
|
UP029 |
Other Diagnosis - 1 |
Text |
5 |
ICD-9-CM |
|
|
|
|
|
|
|
UP030 |
Other Diagnosis - 2 |
Text |
5 |
ICD-9-CM |
|
|
|
|
|
|
|
UP031 |
Other Diagnosis - 3 |
Text |
5 |
ICD-9-CM |
|
|
|
|
|
|
|
UP032 |
Other Diagnosis - 4 |
Text |
5 |
ICD-9-CM |
|
|
|
|
|
|
|
UP033 |
Other Diagnosis - 5 |
Text |
5 |
ICD-9-CM |
|
|
|
|
|
|
|
UP034 |
Revenue Code |
Text |
4 |
National uniform billing
committee codes |
|
|
|
|
|
|
|
UP035 |
Procedure Code |
Text |
5 |
Health Care Common
Procedural Coding System (HCPCS); CPT Codes - American Medical Association |
|
|
|
|
|
|
|
UP036 |
Procedure Modifier - 1 |
Text |
2 |
|
|
|
|
|
|
|
|
UP037 |
Procedure Modifier - 2 |
Text |
2 |
|
|
|
|
|
|
|
|
UP038 |
Quantity |
Text |
3 |
|
|
|
|
|
|
|
|
UP039 |
Charge Amount |
Decimal |
10 |
|
|
|
|
|
|
|
|
UP040 |
Paid Amount |
Decimal |
10 |
|
|
|
|
|
|
|
|
UP041 |
Record Type |
Text |
2 |
UP |
|
|
|
|
|
|
|
UP042 |
Uninsured Identification
Code |
Text |
128 |
Encrypted social security
number |
|
|
|
|
|
|
Source. #9806, eff 11-1-10
Ins 4202.05 Registration.
(a) Each hospital
and community health center that is subject to the submission requirements
shall submit a registration to the department, or its designee, within one month
of the effective date of these rules, and annually thereafter, with the
following information:
(1) The hospital's name and mailing address;
(2) The community health center's name and
mailing address;
(3) The name and mailing address of all healthcare
providers included in the report;
(4) The national provider identification number
of each healthcare provider who is included in the report; and
(5) The name, e-mail address, and mailing address
of the person completing the registration.
(b) Healthcare
providers that are owned or legally controlled by a hospital shall be
identified by the hospital and the report shall specifically describe the
relationship.
(c) Healthcare
facilities that become operational at a later date shall submit a registration
within one month of becoming operational, and annually thereafter.
(d) When any of the
information in Ins 4202.05 (a)-(c) changes, hospitals shall submit the new
information within 30 days of the change.
Source. #9806, eff 11-1-10
Ins 4202.06 Transmittal
Record. With each submission of
data, a transmittal record shall also be supplied that contains the following
information:
(a) Submitting
hospital or community health center;
(b) If different
from submitting healthcare facility, the name and address of the location where
the encounters in the submitted records occurred;
(c) File name;
(d) Contact person
name;
(e) Contact person
address;
(f) Contact person
telephone number;
(g) Contact person
e-mail address;
(h) Period beginning
date;
(i) Period ending
date;
(j) Record count;
(k) Date processed;
(l) Submission date;
and
(m) Explanatory
notes to assist with processing of the file.
Source. #9806, eff 11-1-10
Ins 4202.07 Submission
of Test Data.
(a) Each hospital or
community health center shall submit to the department, or its agent, a test data
submission for the purpose of determining compliance with the required data
submission standards.
(b) Each test data
submission shall contain 3 months worth of encounter data.
(c) Test data
submission shall be required:
(1) At least 3 months prior to the first required
data submission date;
(2) When a facility changes systems or processes;
and
(3) When any substantial changes are made to
these rules.
Source. #9806, eff 11-1-10
Ins 4202.08 Submission
Periods. The submission period for healthcare
facilities submission of data sets shall, at a minimum, be annually.
Source. #9806, eff 11-1-10
Ins 4202.09 Submission
Compliance. With each submission, healthcare data
sets shall comply with the following reporting requirements:
(a) The applicable
code for each data element shall be within the eligible values of the element;
(b) Coding values
indicating "data not available", "data unknown", or the
equivalent shall not be used for individual data elements unless specified as
an eligible value for the element.
(c) Patient sex,
diagnosis and procedure codes, date of birth, and all other data fields shall be
consistent within an individual record;
(d) No duplicate records shall be submitted; and
(e) The volume of
records submitted by type of bill shall be within 10 percent of the immediately
proceeding submission, and if not, healthcare facilities shall provide
information to the department explaining the change in volume.
Source. #9806, eff 11-1-10
Ins 4202.10 Non-Compliant
Data Submission.
(a) Each hospital or
community health center shall be notified when data submissions do not meet the
standards described in this rule, including the specific file and data elements
that do not meet the standards.
(b) Each hospital or
community health center notified of a non-compliant data submission shall respond
within 30 days of the notification by making the changes necessary to meet the
standards and resubmit the entire data submission.
Source. #9806, eff 11-1-10
APPENDIX I. Source
Codes
(1)
Official UB-04 Data
Specifications Manual
SOURCE: National Uniform Billing Data Element
Specifications
AVAILABLE FROM:
National Uniform
Billing Committee
http://www.nubc.org/
ABSTRACT: A variety of code definitions for many of the
fields included in the healthcare data submission requirements.
(2) Medicare
Claims Process Manual (CMS-1500 Data Set)
SOURCE: CMS-1500 Coding System
AVAILABLE FROM:
www.cms.gov/medicare/hcpcs.htm
Centers for Medicare and Medicaid
Services
Center for Health Plans and Providers
CCPP/DCPC
C5-08-27
(3) Current Procedural Terminology (CPT) Codes
SOURCE: Physicians' Current Procedural Terminology (CPT) Manual
AVAILABLE FROM:
Order Department
American Medical
Association
ABSTRACT: A listing of descriptive terms and
identifying codes for reporting medical services and procedures performed by
physicians.
(4) Healthcare Common Procedural Coding System
SOURCE: Healthcare Common Procedural Coding System
AVAILABLE FROM:
www.cms.gov/medicare/hcpcs.htm
Centers for Medicare and
Medicaid Services
Center for Health Plans and
Providers
CCPP/DCPC
C5-08-27
ABSTRACT: HCPCS is the Centers for Medicare and
Medicaid Services (CMS) coding scheme to group procedures performed for payment
to providers.
(5) Centers for Medicare and Medicaid Services
National Provider Identifier
SOURCE: National Provider System
AVAILABLE FROM:
Centers for Medicare and
Medicaid Services
Office of Information
Services
Security and Standards Group
Director, Division of
Healthcare Information Systems
7500 Security
BoulevardBaltimore, MD 21244-1850
ABSTRACT: The Centers for Medicare and Medicaid Services
is developing the National Provider Identifiers, which is proposed as the
standard unique identifier for each Healthcare provider under the Health
Insurance Portability and Accountability Act of 1996.
(6) International Classification of Diseases Clinical
Mod (ICD-9-CM)(and when available ICD-10-CM)
SOURCE: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
AVAILABLE FROM:
Commission of Professional
and Hospital Activities
ABSTRACT: The International Classification of Diseases,
9th Revision, Clinical Modification, describes the classification of morbidity
and mortality information for statistical purposes and for the indexing of hospital
records by disease and operations.
(7) States and Outlying Areas of the
SOURCE: National Zip Code and Post Office Directory
AVAILABLE FROM:
ABSTRACT: Provides names, abbreviations, and codes for
the 50 states, the
(8) X12 Directories
SOURCE: X12.3 Data Element Directory; X12.22 Segment
Directory
AVAILABLE FROM:
Data Interchange Standards
Association, Inc. (DISA)
ABSTRACT: The data element directory contains the
format and descriptions of data elements used to construct X12 segments. It also contains code lists associated with
these data elements. The segment
director contains the format and definitions of the data segments used to
construct the X12 transaction sets.
(9) ZIP Code
SOURCE: National Zip Code and Post Office Directory,
Publication 65, The USPS Domestic Mail Manual
AVAILABLE FROM:
New Orders
Superintendent of Documents
ABSTRACT: The ZIP Code is a geographic identifier of
areas within the
|
RULE |
STATUTE |
|
|
|
|
Ins 4201.01 |
RSA 400-A:15, |
|
Ins 4201.02 |
RSA 400-A:15, |
|
|
|
|
Ins 4202.01 |
RSA 400-A:15, |
|
Ins 4202.02 |
RSA 400-A:15, |
|
Ins 4202.03 |
RSA 400-A:15, |
|
Ins 4202.04 |
RSA 400-A:15, |
|
Ins 4202.05 |
RSA 400-A;15, |
|
Ins 4202.06 |
RSA 400-A:15, |
|
Ins 4202.07 |
RSA 400-A:15, |
|
Ins 4202.08 |
RSA 400-A:15, |
|
Ins 4202.09 |
RSA 400-A:15, |
|
Ins 4202.10 |
RSA 400-A:15, |
|
|
|
|
Appendix I |
RSA 400-A:15, |
|
|
|