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.
