Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO: KRS Chapter 13B, 216.2920, 216.2925, 216.2927,
304.14-135
NECESSITY, FUNCTION, AND CONFORMITY:
KRS
216.2925 requires that the Cabinet for Health
and Family Services promulgate administrative regulations requiring specified
health care providers to provide the cabinet with data on cost, quality, and
outcomes of health care services provided in the commonwealth.
KRS
216.2923(3) authorizes the
cabinet to promulgate administrative regulations to impose fines for failure to
report required data. This administrative regulation establishes the required
data elements, forms, and timetables for submission of data to the cabinet and
fines for noncompliance.
Section 1.
Definitions.
(1) "Ambulatory facility" is
defined by
KRS
216.2920(1).
(2) "Cabinet" is defined by
KRS
216.2920(2).
(3) "Coding and transmission specifications",
"Kentucky Inpatient and Outpatient Data Coordinator's Manual for Hospitals", or
"Kentucky Data Coordinator's Manual for Ambulatory Facilities" means the
document containing the technical directives the cabinet issues concerning
technical matters subject to frequent change, including codes and data for
uniform provider entry into particular character positions and fields of the
standard billing form and uniform provider formatting of fields and character
positions for purposes of electronic data transmissions.
(4) "Hospital" is defined by
KRS
216.2920(6).
(5) "Hospitalization" means the inpatient
medical episode identified by a patient's admission date, length of stay, and
discharge date, that is identified by a provider-assigned patient control
number unique to that inpatient episode, except for hospice care.
(6) "National Provider Identifier" or "NPI"
means the unique identifier assigned by the Centers for Medicare and Medicaid
Services to an individual or entity that provides health care services and
supplies.
(7) "Outpatient services"
means services performed on an outpatient basis in a hospital in accordance
with Section 3(2) of this administrative regulation or services performed on an
outpatient basis by an ambulatory facility in accordance with Section 4 of this
administrative regulation.
(8)
"Provider" means a hospital, ambulatory facility, clinic, or other entity of
any nature providing hospitalizations, mammograms, or outpatient services as
defined in the Kentucky In-patient and Outpatient Data Coordinator's Manual for
Hospitals or the Kentucky Data Coordinator's Manual for Ambulatory
Facilities.
(9) "Record" means the
documentation of a hospitalization or outpatient service in the format
prescribed by the Kentucky Inpatient and Outpatient Data Coordinator's Manual
for Hospitals or the Kentucky Data Coordinator's Manual for Ambulatory
Facilities as approved by the Statewide Data Advisory Committee on a computer
readable electronic medium.
(10)
"Standard Billing Form" means the uniform health insurance claim form pursuant
to
KRS
304.14-135, the Professional 837 (ASC X12N
837) format, the Institutional 837 (ASC X12N 837) format, or its successor as
adopted by the Centers for Medicare and Medicaid Services, or the HCFA 1500 for
use by hospitals and other providers in billing for hospitalizations and
outpatient services.
Section
2. Medicare Provider-Based Entity. A licensed outpatient facility
that is a Medicare provider-based entity of a hospital and reports under the
hospital's provider number shall be separately identifiable through a
facility-specific NPI.
Section 3.
Data Collection for Hospitals.
(1) Inpatient
hospitalization records. A hospital shall document every hospitalization it
provides on a Standard Billing Form and shall, for every record, copy and
provide to the cabinet the data specified in Section 12 of this administrative
regulation.
(2) Outpatient services
records.
(a) A hospital shall document on a
Standard Billing Form the outpatient services it provides and shall for every
record, copy and provide to the cabinet the data specified in Section 12 of
this administrative regulation.
(b)
A hospital shall submit records that contain the required outpatient services
procedure codes specified in the Kentucky Inpatient and Outpatient Data
Coordinator's Manual for Hospitals.
(3) Data collection on patients. A hospital
shall submit required data on every patient as provided in Section 12 of this
administrative regulation, regardless of the patient's billing or payment
status.
Section 4. Data
Collection for Ambulatory Facilities.
(1)
Outpatient services records.
(a) An ambulatory
facility shall submit outpatient services records if the ambulatory facility
provides one (1) or more of the following outpatient services:
1. Surgery;
2. Childbirth;
3. Urgent treatment of minor illness or
injury;
4. Emergency;
5. Mammography;
6. X-ray;
7. Ultrasound;
8. Computed tomography;
9. Magnetic resonance imaging;
10. Cardiac catheterization;
11. Positron emission tomography;
and
12. Megavoltage radiation
therapy.
(b) An
ambulatory facility shall document on a Standard Billing Form the outpatient
services it provides and shall, for every record, copy and provide to the
cabinet the data specified in Section 13 of this administrative
regulation.
(c) An ambulatory
facility shall submit records that contain the required outpatient services
procedure codes specified in the Kentucky Data Coordinator's Manual for
Ambulatory Facilities.
(2) Data collection on patients. An
ambulatory facility shall submit required data on every patient as provided in
Section 13 of this administrative regulation, regardless of the patient's
billing or payment status.
Section
5. Data Finalization and Submission by Providers.
(1) Submission of final data.
(a) Data shall be final for purposes of
submission to the cabinet as soon as a record is sufficiently final that the
provider could submit it to a payer for billing purposes, regardless of whether
the record has actually been submitted to a payer.
(b) Finalized data shall not be withheld from
submission to the cabinet on grounds that it remains subject to adjudication by
a payer.
(c) Data on a
hospitalization shall not be submitted to the cabinet before a patient is
discharged and before the record is sufficiently final that it could be used
for billing.
(2) Data
submission responsibility.
(a) If a patient is
served by a mobile health service, specialized medical technology service, or
another situation by which one (1) provider provides services under contract or
other arrangement with another provider, responsibility for providing the
specified data to the cabinet shall reside with the provider that bills for the
service or would do so if a service is unbilled.
(b) Charges for physician services provided
within a hospital shall be reported to the cabinet.
1. Responsibility for reporting the physician
charge data shall rest with the hospital if the physician is an employee of the
hospital.
2. A physician charge
contained within a record generated by a hospital shall be clearly identified
in a separate field within the record so that the cabinet may ensure
comparability when aggregating data with other hospital records that do not
contain physician charges.
(3) Transmission of records.
(a) Records submitted to the cabinet by a
hospital shall be uniformly completed and formatted according to coding and
transmission specifications set forth by the Kentucky Inpatient and Outpatient
Data Coordinator's Manual for Hospitals.
(b) Records submitted to the cabinet by an
ambulatory facility shall be uniformly completed and formatted according to
coding and transmission specifications set forth by the Kentucky Data
Coordinator's Manual for Ambulatory Facilities.
(c) Each provider shall submit data by
electronic transmission as specified by the Kentucky Inpatient and Outpatient
Data Coordinator's Manual for Hospitals and the Kentucky Data Coordinator's
Manual for Ambulatory Facilities.
(d) Each provider shall provide back-up
security against accidental erasure or loss of the data until all incomplete or
inaccurate records identified by the cabinet have been corrected and
resubmitted.
(4)
Verification and audit trail for electronic data submissions.
(a) Each provider shall maintain a date log
of data submissions and the number of records contained in each submission, and
shall make the log available for inspection upon request by the
cabinet.
(b) The cabinet shall,
within twenty-four (24) hours of submission, verify by electronic message to
each provider the receipt of the provider's data transmissions and the number
of records in each transmission.
(c) A provider shall immediately notify the
cabinet of a discrepancy between the provider's data log and a verification
notice.
Section
6. Data Submission Timetable for Providers.
(1) Quarterly submissions. Each provider
shall submit data at least once for each calendar quarter. A quarterly
submission shall:
(a) Contain data that during
that quarter became final as specified in Section 5(1) of this administrative
regulation; and
(b) Be submitted to
the cabinet not later than forty-five (45) days after the last day of the
quarter.
1. If the 45th day falls on a weekend
or holiday, the submission due date shall be the next working day.
2. Calendar quarters shall be January 1
through March 31, April 1 through June 30, July 1 through September 30, and
October 1 through December 31.
(2) Submissions more frequent than quarterly.
A provider may submit data after records become final as specified in Section
5(1) of this administrative regulation and at a reasonable frequency convenient
to a provider for accumulating and submitting batch data.
Section 7. Data Corrections for Providers.
(1) Editing. Data received by the cabinet
shall, upon receipt, be edited to ensure completeness and validity of the data.
Computer editing routines shall identify for correction every record in which
the submitted contents of required fields are not consistent with the cabinet's
coding and transmission specifications contained in the Kentucky Inpatient and
Outpatient Data Coordinator's Manual for Hospitals and the Kentucky Data
Coordinator's Manual for Ambulatory Facilities.
(2) Submission of corrections. The cabinet
shall allow a provider thirty (30) days in which to submit corrected copies of
initially submitted data the cabinet identifies as incomplete or invalid as a
result of edits.
(a) The thirty (30) days
shall begin on the date of the cabinet's notice informing the provider that
corrections are required.
(b) A
provider shall submit to the cabinet corrected data by electronic transmission
within thirty (30) days.
(c)
Corrected data submitted to the cabinet shall be uniformly completed and
formatted according to the cabinet's coding and transmission specifications
contained in the Kentucky Inpatient and Outpatient Data Coordinator's Manual
for Hospitals and the Kentucky Data Coordinator's Manual for Ambulatory
Facilities.
(3)
Percentage error rate.
(a) If editing data
upon its initial submission, the cabinet shall identify and return to the
provider for correction every record in which one (1) or more of the required
data elements fails to pass the edit.
(b) If editing data that a provider has
submitted, the cabinet shall check for an error rate per quarter of no more
than one (1) percent of records or not more than ten (10) records, whichever is
greater.
(c) The cabinet may return
for further correction any submission of allegedly corrected data in which the
provider fails to achieve a corrected error rate per quarter of no more than
one (1) percent of records or not more than ten (10) records, whichever is
greater.
Section
8. Fines for Noncompliance for Providers.
(1) A provider failing to meet quarterly
submission guidelines as established in Sections 6 and 7 of this administrative
regulation shall be assessed a fine of $500 per violation.
(2) The cabinet shall notify a noncompliant
provider by certified mail, return receipt requested, of the documentation of
the reporting deficiency and the assessment of the fine.
(3) A provider shall have thirty (30) days
from the date of receipt of the notification letter to pay the fine, which
shall be made payable to the Kentucky State Treasurer and sent by certified
mail to the Kentucky Cabinet for Health and Family Services, Office of Health
Data and Analytics, 275 East Main Street 4 W-E, Frankfort, Kentucky
40621.
(4) Fines during a calendar
year shall not exceed $1,500 per provider.
Section 9. Extension or Waiver of Data
Submission Timelines.
(1) A provider
experiencing extenuating circumstances or a hardship may request from the
cabinet, in writing, a data submission extension or waiver.
(a) A provider shall request an extension or
waiver from the Office of Health Data and Analytics on or before the last day
of the data reporting period to receive an extension or waiver for that
period.
(b) An extension or waiver
shall not exceed a continuous period of greater than six (6) months.
(2) The cabinet shall consider the
following criteria in determining whether to grant an extension or waiver:
(a) Whether the request was made due to an
event beyond the provider's control, such as a natural disaster, catastrophic
event, or theft of necessary equipment or information;
(b) The severity of the event prompting the
request; and
(c) Whether the
provider continues to gather and submit the information necessary for
billing.
(3) A provider
shall not apply for more than three (3) extensions or waivers during a calendar
year.
Section 10.
Appeals for Providers.
(1) A provider notified
of its noncompliance and assessed a fine pursuant to Section 8(1) of this
administrative regulation shall have the right to appeal within thirty (30)
days of the date of the notification letter.
(a) If the provider believes the action by
the cabinet is unfair, without reason, or unwarranted, and the provider wishes
to appeal, the provider shall appeal in writing to the Secretary of the Cabinet
for Health and Family Services, 5th Floor, 275 East Main Street, Frankfort,
Kentucky 40621.
(b) An appeal shall
be filed in accordance with KRS Chapter 13B.
(2) Upon receipt of the appeal, the secretary
or designee shall issue a notice of hearing no later than twenty (20) days
before the date of the hearing. The notice of the hearing shall comply with
KRS
13B.050. The secretary shall appoint a
hearing officer to conduct the hearing in accordance with KRS Chapter
13B.
(3) The hearing officer shall
issue a recommendation in accordance with
KRS 13B.110.
Upon receipt of the recommended order, following consideration of any
exceptions filed pursuant to
KRS
13B.110(4), the secretary
shall enter a final decision pursuant to
KRS
13B.120.
Section 11. Working Contacts for Providers.
(1) On or before the last day of the data
reporting period, a provider shall report by electronic transmission to the
cabinet the names and telephone numbers of a designated contact person and one
(1) back-up person to facilitate technical follow-up in data reporting and
submission.
(a) A provider's designated
contact and back-up shall not be the chief executive officer unless no other
person employed by the provider has the requisite technical
expertise.
(b) The designated
contact shall be the person responsible for review of the provider's data for
accuracy prior to the publication by the cabinet.
(2) If the chief executive officer,
designated contact person, or back-up person changes during the year, the name
and telephone number of the replacing person shall be reported immediately to
the cabinet.
Section 12.
Required Data Elements for Hospitals. A hospital shall ensure that each record
submitted to the cabinet contains the data elements identified in the Kentucky
Inpatient and Outpatient Data Coordinator's Manual for Hospitals.
Section 13. Required Data Elements for
Ambulatory Facilities. An ambulatory facility shall ensure that each record
submitted to the cabinet contains the data elements identified in the Kentucky
Data Coordinator's Manual for Ambulatory Facilities.
Section 14. Incorporation by Reference.
(1) The following material is incorporated by
reference:
(a) "Kentucky Inpatient and
Outpatient Data Coordinator's Manual for Hospitals", revised January 1, 2019;
and
(b) "Kentucky Data
Coordinator's Manual for Ambulatory Facilities," revised January 1,
2019.
(2) This material
may be inspected, copied, or obtained, subject to applicable copyright law, at
the Cabinet for Health and Family Services, 275 East Main Street 4WE,
Frankfort, Kentucky 40621, Monday through Friday, 8 a.m. to 4:30 p.m.
STATUTORY AUTHORITY:
KRS
216.2923(3),
216.2925