Link to law: http://reports.oah.state.nc.us/ncac/title 10a - health and human services/chapter 14 - director, division of health service regulation/subchapter h/subchapter h rules.html
Published: 2015

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subchapter 14h – certification of statewide data processors

 

SECTION .0100 ‑ CERTIFICATION OF STATEWIDE DATA

PROCESSOR

 

10A NCAC 14H .0101       PURPOSE

This Section sets forth the process and requirements for

obtaining certification as a statewide data processor.

 

History Note:        Filed as a Temporary Adoption effective October 1, 1995 for a period of 180 days or until the permanent rule becomes effective,

whichever is sooner;

Authority G.S. 131E‑214.1(6);

Eff. February 1, 1996.

10A NCAC 14H .0102       DEFINITIONS

(a)  The definitions set forth in G.S. 131E‑214.1

shall apply to this Section.

(b)  As used in this Section:

(1)           "Applicant" means a party

applying to the Division for certification as a statewide data processor.

(2)           "HCFA" means the Health Care

Financing Administration of the U.S. Department of Health and Human Services,

or any successor agency.

(c)  All references in this Section to the "HCFA

1500" and "HCFA 1450" claim forms, include references to their

successor forms that are developed pursuant to federal law under the auspices

of HCFA, the National Uniform Billing Committee, or the North Carolina State

Uniform Billing Committee.

 

History Note:        Filed as a Temporary Adoption effective October 1, 1995 for a period of 180 days or until the permanent rule becomes effective,

whichever is sooner;

Authority G.S. 131E‑214.1(6);

Eff. February 1, 1996.

 

10A NCAC 14H .0103       REQUIREMENTS FOR CERTIFICATION

A party desiring to be certified as a statewide data

processor shall make a written application to the Division that complies with

the following requirements:

(1)           The applicant must make a satisfactory showing that

it is capable of making available annually to the Division, at no charge, a

report which compares the 35 most frequently reported charges of the hospitals

and freestanding ambulatory surgical facilities reporting patient data to the

applicant during the calendar year.  Each annual report shall be due to the

Division within 180 days after the end of the calendar year.

(2)           The applicant must make a satisfactory showing that

it is capable of receiving from hospitals and freestanding ambulatory surgical

facilities throughout the State the patient data elements specified in Items

(3) through (5) of this Rule.

(3)           With regard to patient data concerning inpatients

discharged by hospitals, the applicant must make a satisfactory showing that is

capable of compiling and maintaining a uniform set of data from the patient

data which shall include the following HCFA 1450 (UB‑92) data elements

for every inpatient discharged regardless of payor:

 



 





DATA ELEMENT





DESCRIPTION







(1)





Patient Control Number





Form Locator 3 - As stated in the North Carolina HCFA 1450

Manual







(2)





Bill Type





Form Location 4 - As Stated in the North Carolina HCFA

1450 Manual







(3)





Provider Identification





 







(A)





 

Medicaid Base Provider Number





The number assigned to the provider by Medicaid or as

assigned by the certified statewide data processor (for batching only)







(B)





Federal Tax Number





Form Locator 5 - As stated in the North Carolina HCFA 1450

Manual







(4)





 

Zip Code of Patient Address





Form Locator 13 - Only the zip code portion of this field

is required.  Code as stated in the North Carolina HCFA 1450 Manual







(5)





 

Patient Birth Date





 

Form Locator 14 - As stated in the North Carolina HCFA

1450 Manual







(6)





Patient Sex





Form Locator 15 - As stated in the North Carolina HCFA

1450 Manual







(7)





Admission Date





Form Locator 17 - As stated in the North Carolina HCFA

1450 Manual







(8)





Admission Type





Form Locator 19 - As stated in the North Carolina HCFA

1450 Manual







(9)





Source of Admission





Form Locator 20 - As stated in the North Carolina HCFA

1450 Manual







(10)





Patient Status





Form Locator 22 - As stated in the North Carolina HCFA

1450 Manual







(11)





Discharge Date (Statement Covers Period)





Form Locator 6 - As stated in the North Carolina HCFA 1450

Manual







(12)





All Revenue Codes and Associate Charges





Forms Locators 42 and 47 - As stated in the North Carolina

HCFA 1450 Manual







(13)





 

Payer Identification





Form Locator 50a - Classifications code and specific

carrier identification code for primary payer







(14)





 

Certificate/Social Security/Health





Form Locator 60a - As stated in the Insurance

Claim/Identification Number North Carolina HCFA 1450 Manual







(15)





Insurance Group Number





Form Locator 62a - As stated in the North Carolina HCFA

1450 Manual







(16)





Principal Diagnosis





Form Locator 67 - As stated in the North Carolina HCFA

1450 Manual







(17)





Other Diagnoses 8





Form Locators 68-75 - As stated in the North Carolina HCFA

1450 Manual







(18)





 

External Cause of Injury Code (E Code)





Form Locator 77 - As stated in the North Carolina HCFA

1450 Manual/whenever the principal diagnosis is an injury, poisoning or

adverse effect







(19)





Principal Procedure and Date





Form Locator 80 - As stated in the North Carolina HCFA

1450 Manual







(20)





Other Procedures and Dates





Form Locator 81a-e - As stated in the North Carolina HCFA

1450 Manual







(21)





 

Attending Physician Identification





Form Locator 82 - Only the UPIN is required.  Code as

stated in the North Carolina HCFA 1450 Manual







(22)





 

Other Physician Identification





Form Locator 83 - Only the UPIN is required.  Code as

stated in the North Carolina HCFA 1450 Manual





 

(4)           With regard to patient data concerning ambulatory

surgery patients released from hospitals and freestanding ambulatory surgical

facilities, the applicant must make a satisfactory showing that it is capable

of compiling and maintaining a uniform set of data from the patient data which

shall include the following HCFA 1450 (UB‑92) data elements for every

ambulatory surgical patient released regardless of payor:

 



 





DATA ELEMENT





DESCRIPTION







(1)





Patient Control Number





Form Locator 3 - As stated in the North Carolina HCFA 1450

Manual







(2)





Bill Type





Form Locator 4 - As stated in the North Carolina HCFA 1450

Manual







(3)





Provider Identification





 







(A)





 

Medicaid Base Provider Number





The number assigned to the provider by Medicaid or as

assigned by the certified statewide data processor (for batching only)







(B)





Federal Tax Number





Form Locator 5 - As stated in the North Carolina HCFA 1450

Manual







(4)





 

Zip Code of Patient Address





Form Locator 13 - Only the zip code portion of this field

is required.  Code as stated in the North Carolina HCFA 1450 Manual







(5)





Patient Birth Date





Form Locator 14 - As stated in the North Carolina HCFA

1450 Manual







(6)





Patient Sex





Form Locator 15 - As stated in the North Carolina HCFA

1450 Manual







(7)





Admission Date





Form Locator 17 - As stated in the North Carolina HCFA

1450 Manual







(8)





Admission Type





Form Locator 19 - As stated in the North Carolina HCFA

1450 Manual







(9)





Source of Admission





Form Locator 20 - As stated in the North Carolina HCFA

1450 Manual







(10)





Patient Status





Form Locator 22 - As stated in the North Carolina HCFA

1450 Manual







(11)





Discharge Date (Statement Covers Period)





Form Locator 6 - As stated in the North Carolina HCFA 1450

Manual







(12)





All Revenue Codes and Associated Charges





Form Locators 42 and 47 - As stated in the North Carolina

HCFA 1450 Manual







(13)





Payer Identification





Form Locator 50a - Classification code and specific

carrier identification







(14)





 

Certificate/Social Security/Health





Form Locator 60a - As stated in the Insurance

Claim/Identification Number North Carolina HCFA 1450 Manual







(15)





Insurance Group Number





Form Locator 62a - As stated in the North Carolina HCFA

1450 Manual







(16)





Principal Diagnosis





Form Locator 67 - As stated in the North Carolina HCFA

1450 Manual







(17)





Other Diagnoses





8 Form Locators 68-75 - As stated in the North Carolina

HCFA 1450 Manual







(18)





 

External Cause of Injury Code (E‑Code)





Form Locator 77 - As stated in the North Carolina HCFA

1450 Manual/whenever the principal diagnosis is an injury, poisoning or

adverse effect







(19)





Principal Procedure and Date





Form Locator 80 - As stated in the North Carolina HCFA

1450 Manual







(20)





Other Procedures and Dates





Form Locators 81a-e - As stated in the North Carolina HCFA

1450 Manual







(21)





 

Attending Physician Identification





Form Locator 82 - Only the UPIN is required.  (Code as

stated in the North Carolina HCFA 1450 Manual







(22)





 

Other Physician Identification





Form Locator 83 - Only the UPIN is required.  Code as

stated in the North Carolina HCFA 1450 Manual





 

(5)           With regard to patient data concerning ambulatory

surgery patients released from hospitals and freestanding ambulatory surgical

facilities, the application must make a satisfactory showing that it is capable

of compiling and maintaining a uniform set of data from the patient data which

shall include the following HCFA 1500 data elements for every ambulatory

surgical patient released regardless of payor:

 



(1)





Payer Identification







(2)





Insured's ID Number







(3)





Patient's Date of Birth







(4)





Gender of Patient







(5)





Zip Code of Patient Address







(6)





Diagnosis or Nature of Illness or Injury (1-4)







(7)





Dates of Service







(8)





Place of Service







(9)





Type of Service







(10)





Procedures, Services, and Supplies (including modifiers if

applicable)







(11)





Charges







(12)





Days or Units







(13)





Federal Tax ID







(14)





Patient's Account Number







(15)





Total Charge







(16)





Attending Physician's UPIN Number







(17)





Medicaid Base Provider Number or Number Assigned by

Certified Statewide Data Processor





 

(6)           The applicant must make a satisfactory showing that

it is capable of examining the patient data it receives for accuracy, informing

the hospital or freestanding ambulatory surgical facility submitting the

patient data of all potential errors in the patient data which are discovered

as a result of the examination for accuracy, and correcting the patient data as

directed by the hospital or freestanding ambulatory surgical facility.  An

applicant shall be deemed to have satisfactorily shown that it is capable of

examining patient data for accuracy if the applicant has made a satisfactory

showing that it is capable of designating a record as an error record when:

(a)           A record reported on a HCFA 1450 (UB‑92)

form contains an invalid or all‑blank field for any of the following HCFA

1450 (UB‑92) data elements:  Patient Control Number, Bill Type, Federal

Tax I.D., Zip Code, Date of Birth, Sex, Admission Date, Admission Type, Source

of Admission, Patient Status, Statement Covers Period, Revenue Codes and

Charges, Primary Payer, Principal Diagnosis, Attending Physician

Identification.

(b)           A record reported on a HCFA 1500 form

contains an invalid or all‑blank field for any of the following HCFA 1500

data elements:  Payor Identification, Insured's I.D. Number, Federal Tax I.D.,

Zip Code, Date of Birth, Sex, Dates of Service, Place of Service, Type of

Service, Procedures Defined with CPT‑HCPCS Code with Modifiers, Principal

Diagnosis Codes, Principal and Secondary Surgical Procedure, Patient's Account

Number, Attending Physician Identification.

(c)           The sum indicated by the data element

concerning total charges does not equal the sum of all other charges reported

on the record.

(d)           An inpatient record reported on a HCFA 1450

(UB‑92) contains any of the following data elements which contain an invalid

code:  Other Diagnoses, Principal Procedure Code and Date, Other Procedure

Codes and Dates, External Cause of Injury Code, Other Physician Identification

(if a procedure was performed).

(e)           An ambulatory surgical patient record

reported on a HCFA 1450 (UB‑92) form contains any of the following data

elements which contain an invalid code:  Other Diagnoses, Other Procedure Codes

and Dates, External Cause of Injury Code.

(7)           The applicant shall make satisfactory showing that

it is capable of:

(a)           compiling reports from patient data which

shall further the purposes of the Medical Care Data Act, as set forth in G.S.

131E‑214(b), such as reports enabling a review and comparison of charges,

utilization patterns, and quality of medical services;

(b)           producing such reports at least on a

calendar quarter basis, with reports concerning patients discharged or released

during a specific calendar quarter being published at least within 180 days

after the end of said calendar quarter;

(c)           making such reports available upon request

to all interested persons at a reasonable charge.

(8)           The applicant shall make a satisfactory showing

that it is capable of ensuring that adequate measures will be taken to provide

system security for all data and information received from hospitals and

freestanding ambulatory surgical facilities.

(9)           The applicant shall make a satisfactory showing

that it is capable of protecting the confidentiality of patient records and

complying with applicable laws and regulations concerning patient confidentiality,

including the confidentiality of patient‑identifying information, and

that it shall not disclose patient‑identifying information unless:

(a)           the information was originally submitted by

the party requesting disclosure; or

(b)           the State Health Director requests specific

individual records for the purpose of protecting and promoting the public

health under G.S. 130A, and the disclosure is not otherwise prohibited by

federal law or regulation.

The applicant shall also make a

satisfactory showing that it shall make such records available to the State

Heath Director at a reasonable charge.

 

History Note:        Filed as a Temporary Adoption effective October 1, 1995 for a period of 180 days or until the permanent rule becomes effective,

whichever is sooner;

Authority G.S. 131E‑214.1(6);

Eff. February 1, 1996.

 

10A NCAC 14H .0104       APPLICATION REVIEW

The Division shall notify each applicant of the Division's

decision concerning the applicant's request for certification as a statewide

data processor within 90 days after the Division has received the applicant's written

application unless the Division notifies the applicant that the review has been

extended.  If any portion of an application lacks certain information or is

unclear, the Division may request additional information or clarification from

the applicant during the review period; provided, however, that the Division is

not required to request such additional information or clarification, and the

Division may deny certification on the basis that the application lacks

information or is unclear.

 

History Note:        Filed as a Temporary Adoption effective October 1, 1995 for a period of 180 days or until the permanent rule becomes effective,

whichever is sooner;

Authority G.S. 131E‑214.1(6);

Eff. February 1, 1996.

 

10A NCAC 14H .0105       PERIOD OF CERTIFICATION

An applicant who demonstrates through its application that

it presently is performing each of the requirements specified in 10A NCAC 14H

.0103 (with the exception of the requirement of making annual reports to the

Division found in 10A NCAC 14H .0103(1), and the requirement of disclosing data

to the State Health Director found in 10A NCAC 14H .0103(9), for which

requirements the applicant needs only to make a satisfactory showing that it is

capable of performing the requirements), shall be certified as a statewide data

processor for a period of three years.  An applicant who demonstrates through

its application that it is capable of performing each of the requirements

specified in 10A NCAC 14H .0103 but who presently is not performing each of the

requirements specified in 10A NCAC 14H .0103(2)‑(9) (excluding the

requirement in 10A NCAC 14H .0103(9) to disclose data to the State Health

Director), shall be granted a certificate for a one year period.  If within

that one year period the applicant makes a satisfactory showing to the Division

by written application that it then is performing all of the requirements

specified in 10A NCAC 14H .0103, the applicant shall be granted certification

as a statewide data processor for an additional two year period.

 

History Note:        Filed as a Temporary Adoption effective October 1, 1995 for a period of 180 days or until the permanent rule becomes effective,

whichever is sooner;

Authority G.S. 131E‑214.1(6);

Eff. February 1, 1996.

 

10A NCAC 14H .0106       STANDARDS FOR REFUSAL, SUSPENSION OR

REVOCATION OF CERTIFICATION

A certificate applied for or issued under this Chapter may

be refused, suspended, or revoked by the Division if the Division determines

that the applicant or statewide data processor cannot or does not perform the

requirements specified in 10A NCAC 14H .0103 and G.S. 131E‑214.4.

 

History Note:        Filed as a Temporary Adoption effective October 1, 1995 for a period of 180 days or until the permanent rule becomes effective, whichever

is sooner;

Authority G.S. 131E‑214.1(6);

Eff. February 1, 1996.

 

10A NCAC 14H .0107       FAILURE TO TIMELY RENEW

A certificate issued under this Chapter shall be

automatically suspended by the Division after a failure to renew the

certificate for a period of more than three months after the renewal date.

 

History Note:        Filed as a Temporary Adoption effective October 1, 1995 for a period of 180 days or until the permanent rule becomes effective,

whichever is sooner;

Authority G.S. 131E‑214.1(6);

Eff. February 1, 1996.

 

10A NCAC 14H .0108       PROCEDURE

Except as otherwise provided in this Chapter, the procedure

for revocation, suspension, or refusal of certification shall be in accordance

with the provisions of G.S. 150B.

 

History Note:        Filed as a Temporary Adoption effective October 1, 1995 for a period of 180 days or until the permanent rule becomes effective,

whichever is sooner;

Authority G.S. 131E‑214.1(6);

Eff. February 1, 1996.