Pennsylvania Code
Title 28 - HEALTH AND SAFETY
Part VI - Health Care Cost Containment Council
Chapter 911 - DATA SUBMISSION AND COLLECTION
Subchapter A - STATEMENT OF POLICY
Section 911.4 - Adoption of data elements to be reported to the Council
Universal Citation: 28 PA Code ยง 911.4
Current through Register Vol. 54, No. 44, November 2, 2024
(a) The Council adopted the data elements in Table A and identified fields on the Pennsylvania Uniform Claims and Billing Form format (see Table A).
(b) As required by section 6 of the act (35 P. S. § 449.6), the Council will promulgate rules and regulations establishing technical specifications and schedules, and the identification of data sources required to submit specific data elements to the Council.
(c) The Council will promulgate in the rules and regulations the following data elements:
(1) Field 21c, Unusual Occurrences-Nosocomial
infections.
(2) Field 21d, Unusual
Occurrences-Readmissions.
(3) Field
35, Patient Race.
TABLE A
PENNSYLVANIA UNIFORM CLAIMS AND BILLING FORM DATA ELEMENTS
| Field | Data Element | Definition |
| 1 | Uniform Patient Identifier | Patient's Social Security Number. |
| 2 | Patient Date of Birth | The date of birth of the patient. |
| 3 | Patient Sex | The sex of the patient as recorded at the date of admission, outpatient service, or start of care. |
| 4 | Patient Zip Code | Zip code of patient taken from the patient name and address field. |
| 5 | Date of Admission | The date that the patient was admitted to the provider for inpatient care, outpatient services or start of care. |
| 6 | Date of Discharge | The ending service date of patient care. The date that the patient was discharged from the provider's care. |
| 7a | Principal Diagnosis | The code that identifies the principal diagnosis (i.e., the condition established after study to be chiefly responsible for causing this hospitalization) that exists at the time of admission or develops subsequently that has an effect on the length of stay. |
| 7b, c, d, e | Secondary Diagnosis | The diagnosis code corresponding to additional conditions that co-exist at the time of admission, or develop subsequently, and which have an effect on the treatment received or the length of stay. |
| 8a, b | Principal Procedure Code and Date | The code that identifies the principal procedure performed during the period between admission and discharge and the date on which the principal procedure described was performed. |
| 9a1 through 9c2 | Secondary Procedure | The code identifying the procedures other than the principal procedure, performed during the patient's stay and the dates on which the procedures (identified by the codes) were performed. |
| 10 | Uniform Identifier of Health Care Facility | Number identifying the provider facility as developed and used by Medicaid. |
| 11 | Attending Physician Identifier | The PA state license number of the physician who would normally be expected to certify and recertify the medical necessity of the services rendered and/or who has primary responsibility for the patient's medical care and treatment. |
| 12 | Operating Physician Identifier | The PA state license number of the physician other than the attending physician who performed the principal procedure. |
| 13a1 through 13w1 | Revenue Description | A narrative description of the related revenue categories included for a patient. |
| 13a2 through 13w2 | Revenue Code | A code which identifies a specific accommodation, ancillary service or billing calculation. |
| 13a3 through 13w3 | Units of Service | A quantitative measure of services rendered by revenue category to or for the patient to include items such as number of accommodation days, pints of blood, or renal dialysis treatments, etc. |
| 13a4 through 13w4 | Total Charges | Total charges pertaining to the related revenue code for the current billing period as entered in the statement covers period. |
| 13a5 through 13w5 | Noncovered Charges | Those charges that are not covered by a payor for this patient. |
| 14a | Actual Payments to the Health Care Facility | Payments for services performed by the provider from the payor segregated according to Revenue Code. |
| 14b | Payor Identification | Name and Pennsylvania Insurance Department number identifying each payor organization from which the provider might expect some payment for the bill. |
| 14c | Deductible Amount | The amount assumed by the hospital to be applied to the patient's deductible amount involving the indicated payor. |
| 14d | Co-Insurance Amount | The amount assumed by the hospital to be applied toward the patient's co-insurance amount involving the indicated payor. |
| 14e | Estimated Responsibility | The amount estimated by the hospital to be paid by the indicated payor. |
| 14f | Prior Payments-Payor and Patient | The amount the hospital has received toward payment of this bill prior to the billing date by the indicated payor. |
| 14g | Estimated Amount Due | The amount estimated by the hospital to be due from the indicated payor (estimated responsibility less prior payments). |
| 15a | Physician Identification | License number of the physician who charged the patient for a service related to an episode of illness for the period indicated in Fields 5 and 6. |
| 15b | Type of Physician/ Professional Service | The type of service performed for which payment is expected. |
| 15a3 | Physician/ Professional Services Charge | Amount charged for services rendered to the patient for the procedure indicated in HCFA 1500, item 24d. |
| 16 | Physician/ Professional Services Payment | Payments received for services performed for the procedures indicated in Field 8a. |
| 17 | Uniform Identifier of Primary Payor | Pennsylvania Department of Insurance number. If the number is not available, the Health Care Cost Containment Council will assign a number based on the name in Field 14b. |
| 18 | Zip Code of Facility | XXXXXYYYY. Five character zip code with a four character extension. If the four character extension is unknown, fill with blanks. |
| 19 | Payor Group Number | The identification number, control number, or code assigned by the carrier or plan administrator to identify the group under which the individual is covered. |
| 20 | Patient Discharge Status | The status of the patient at discharge. |
| 21c | Unusual Occurrence | Infections acquired while in the hospital. Nosocomial infections are defined as those infections that are clinically manifested after 72 hours in the hospital, unless: 1. They are evident within 72 hours after admission and are related to a previous hospitalization; 2. They are related to a hospital procedure performed within the first 72 hours. |
| 21d | Unusual Occurrence | Patient readmission to the hospital within 30 days. |
| 22 | Type of Bill | A code indicating the specific type of bill (inpatient, outpatient, adjustments, voids, etc.) |
| 23 | Patient Control Number | Patient's unique alphanumeric number assigned by the provider to facilitate retrieval of individual case records and posting of the payment. |
| 24 | Diagnosis Related Group (DRG) | The condition established after study as being chiefly responsible for the admission of a patient to the hospital for care that exists at the time of admission or develops subsequently that has an effect on the length of stay. |
| 25 | Procedure Coding Method Used | An indicator that identifies the coding method used for procedure coding on this bill. |
| 26 | Type of Admission | A code indicating the priority of this admission. |
| 27 | Source of Admission | A code indicating the source of this admission. |
| 28 | Patient's Relationship to Insured | A code indicating the relationship of the patient to the identified insured. |
| 29 | Certificate/Social Security Number/Health Insurance Claim/ Identification Number | Insured's unique identification number assigned by the payor organization. |
| 30 | Principal and Other Diagnoses Descriptions | Narrative description of the principal diagnosis (i.e., the condition established after study to be chiefly responsible for causing the hospitalization or use of hospital services) and other diagnoses. |
| 31 | Principal and Other Procedure Descriptions | A narrative description of the principal procedure (i.e., the procedure that was performed for definitive treatment rather than the one performed for diagnostic or exploratory purposes or the procedure most related to the principal diagnosis) and other procedures. The principal procedure is to be shown first. |
| 32 | Employer Name | The name of the employer that might or does provide health care coverage for the individual identified in Field 33. |
| 33 | Employment Information | A code that indicates whether the employment information given in the related areas applies to an insured, the patient or the patient's spouse. |
| 34 | Employment Status Code | A code used to define the employment status of the individual identified in Field 33. |
| 35 | Patient Race | This code indicates the patient's racial/ethnic background. |
| 36 | Reserve Field | To be reserved for future use by the Council. |
Disclaimer: These regulations may not be the most recent version. Pennsylvania may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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