Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter A - PRELIMINARY PROVISIONS › Section 127.3 - Definitions

Current through Register Vol. 54, No. 28, July 13, 2024
The following words and terms, when used in this chapter,
					 have the following meanings, unless the context clearly indicates
					 otherwise:
ASC-Ambulatory Surgery Center
-A center
					 that operates exclusively for the purpose of furnishing outpatient surgical
					 services to patients. These facilities are referred to by HCFA as ASCs and by
					 the Department of Health as ASFs. For consistency with the application of
					 Medicare regulations, these facilities are referred to in this chapter as
					 ASCs.
ASF-Ambulatory Surgical Facility
-An
					 ASC.
Accredited speciality board
-A speciality
					 board recognized by the American Board of Medical Specialties, the American
					 Osteopathic Association or by the Chiropractic Council on Education.
Act
-The Workers' Compensation Act
					 (77
					 P. S. §§
											1-1041.4).
Act 44
-The act of July 2, 1993 (P. L. 190,
					 No. 44).
Actual charge
-The provider's usual and
					 customary charge for a specific treatment, accommodation, product or
					 service.
Acute care
-The inpatient and outpatient
					 hospital services provided by a facility licensed by the Department of Health
					 as a general or tertiary care hospital, other than a specialty hospital, such
					 as rehabilitation and psychiatric provider.
Approved teaching program
-A hospital
					 teaching program which is accredited in its field by the appropriate approving
					 body to provide graduate medical education or paramedical education services,
					 or both. Accreditation for medical education programs shall be as recognized by
					 one of the following:
(i) The
				  Accreditation Council for Graduate Medical Education of the American Medical
				  Association.
(ii) The Committee on
				  Hospitals of the Bureau of Professional Education of the American Osteopathic
				  Association.
(iii) The Council on
				  Dental Education of the American Dental Association.
(iv) The Council of Podiatric Medicine
				  Education of the American Podiatric Association.
(v) An appropriate approving body of
				  paramedical educational and training programs.
Audited Medicare cost report
-The Medicare
					 cost report, settled by the Medicare fiscal intermediary through the conduct of
					 either a field audit or desk review resulting in the issuance of the Notice of
					 Program Reimbursement.
Bureau
-The Bureau of Workers' Compensation
					 of the Department.
Burn facility
-A facility which meets the
					 service standards of the American Burn Association.
CCO-Coordinated Care Organization
-An
					 organization certified under Act 44 by the Secretary of Health for the purpose
					 of providing medical services to injured employes.
CDT-1
-The Current Dental Terminology, as
					 defined by the American Dental Association.
CPT-4
-The physician's "Current Procedural
					 Terminology, Fourth Edition," as defined and published by the American Medical
					 Association.
Capital related cost
-The health care
					 provider's expense related to depreciation, interest, insurance and property
					 taxes on fixed assets and moveable equipment.
Charge master
-A provider's listing of
					 current charges for procedures and supplies utilized in the provider's billing
					 process.
Commissioner
-The Insurance Commissioner of
					 the Commonwealth.
DME-Durable medical equipment
-The term
					 includes iron lungs, oxygen tents, hospital beds and wheelchairs (which may
					 include a power-operated vehicle that may be appropriately used as wheelchair)
					 used in the patient's home or in an institution, whether furnished on a rental
					 basis or purchased.
DRG
-Diagnostic related groups.
Department
-The Department of Labor and
					 Industry of the Commonwealth.
Direct medical education cost
-The salaries
					 and other expenses related to the provider's resident and intern graduate
					 medical education approved teaching program. This amount includes the allocable
					 overhead costs associated with the provider's maintenance and administration of
					 the resident and intern programs.
Disproportionate share hospital
-A hospital
					 providing acute care that serves a significantly disproportionate share of
					 low-income patients.
Fully prospective
-Inpatient
					 capital-related cost of an acute care provider included in the DRG payment
					 based on a blend of hospital-specific data and Federal data and excluded from
					 cost report settlements.
HCFA
-The Health Care Financing
					 Administration.
HCPCS-HCFA Common Procedure Coding
					 System
-The procedure codes and associated nomenclature consisting of
					 numeric CPT-4 codes, and alpha-numeric codes, as developed both Nationally by
					 HCFA and on a Statewide basis by local Medicare carriers.
Health care provider
-A person,
					 corporation, facility or institution licensed, or otherwise authorized, by the
					 Commonwealth to provide health care services, including physicians, coordinated
					 care organizations, hospitals, health care facilities, dentists, nurses,
					 optometrists, podiatrists, physical therapists, psychologists, chiropractors,
					 or pharmacists, and officers, employes or agents of the person acting in the
					 course and scope of employment or agency related to health care
					 services.
Hold harmless
-Inpatient capital-related
					 cost of an acute care provider which can either be included fully in the DRG
					 payment or partially included in both the DRG and cost-reimbursed
					 payment.
(i) One hundred percent hold
				  harmless means inpatient capital-related cost included fully in the DRG payment
				  at 100% of the Federal capital rate.
(ii) Blended hold harmless means inpatient
				  capital-related cost included in the DRG payment for assets acquired after
				  December 31, 1990, and cost-reimbursed for assets acquired before December 31,
				  1990.
(iii) Capital-exceptional
				  hospital means a provider receiving payment from Medicare based on cost because
				  payments at either the fully prospective rate or the hold harmless rates are
				  less than or equal to 70% of the provider's payments based on cost.
ICD-9-CM
-(ICD-9) The International
					 Classification of Diseases-Ninth Edition-Clinical Modification
Indirect medical education cost
-The
					 expenses related to the use of additional ancillary services and consumption of
					 provider resources related to the provision of a graduate medical education
					 approved teaching program.
Insurer
-A workers' compensation insurance
					 carrier, including the State Workmen's Insurance Fund, an employer who is
					 authorized by the Department to self-insure its workers' compensation liability
					 under section 305 of the act (77 P. S. §
											501), or a group of employers authorized by
					 the Department to act as a self-insurance fund under section 802 of the act
					 (77
					 P. S. §
											1036.2).
Interim rate notification
-The letter, from
					 the Medicare intermediary to the provider, informing the provider of their
					 interim payment rate and its effective date.
Life-threatening injury
-As defined by the
					 American College of Surgeons' triage guidelines regarding use of trauma centers
					 for the region where the services are provided.
Medicare carrier
-An organization with a
					 contractual relationship with HCFA to process Medicare Part B claims.
Medicare intermediary
-An organization with
					 a contractual relationship with HCFA to process Medicare Part A or Part B
					 claims.
Medicare Part A
-Medicare hospital
					 insurance benefits which pay providers for facility-based care, such as care
					 provided in inpatient general and tertiary hospitals, specialty hospitals, home
					 health agencies and skilled nursing facilities.
Medicare Part B
-Medicare supplementary
					 medical insurance which pays providers for physician services, outpatient
					 hospital services, durable medical equipment, physical therapy and other
					 services.
NPR-Notice of program reimbursement
-The
					 letter of notification from the Medicare intermediary to the provider regarding
					 the final settlement of the Medicare cost report.
New provider
-A provider which began
					 administering patient care after receiving initial licensure on or after August
					 31, 1993.
Notice of biweekly payment rates
-The
					 letter of notification from the Medicare intermediary to the provider,
					 informing the provider of their biweekly payment rate for direct medical
					 education and paramedical education costs.
Notice of per resident amount
-The letter
					 of notification from the Medicare intermediary to the provider, informing the
					 provider of the annual payment amount per resident or intern full-time
					 equivalent.
PRO-Peer Review Organization
-An
					 organization authorized by the Secretary for the purpose of determining the
					 necessity or frequency of medical treatment administered to workers with
					 work-related injuries.
Paramedical education cost
-The education
					 cost related to providers' nongraduate medical education programs including
					 nursing school programs, radiology and laboratory technology training programs
					 and other allied health professional approved teaching programs.
Pass-through costs
-Medicare reimbursed
					 costs to a hospital that "pass through" the prospective payment system and are
					 not included in the DRG payments.
Provider
-A health care provider.
RCC-Ratio of cost-to-charges
-The computed
					 ratio using the Medicare cost report.
Secretary
-The Secretary of the
					 Department.
Specialty hospital
-A health care facility
					 licensed and approved by the Department of Health as a hospital providing
					 either a comprehensive inpatient rehabilitation program or an acute psychiatric
					 inpatient program.
Transition fee schedule
-The Medicare
					 payment amounts as determined by the Medicare carrier, based on the transition
					 rules requiring a blend of the full fee schedule (full implementation of the
					 Resource Based Relative Value Scale, RBRVS) and the original provider fee
					 schedule.
Trauma center
-A facility accredited by the
					 Pennsylvania Trauma Systems Foundation under the Emergency Medical Services Act
					 (35
					 P. S. §§
											6921-6938).
UR
-Utilization Review.
URO-Utilization Review Organization
-An
					 organization authorized by the Secretary for the purpose of determining the
					 reasonableness or necessity of medical treatment administered to workers with
					 work-related injuries.
Unbundling
-The practice of separate
					 billing for multiple service items or procedures instead of grouping the
					 services into one charge item.
Urgent injury
-As defined by the American
					 College of Surgeons' triage guidelines regarding use of trauma centers for the
					 region where the services are provided.
Usual and customary charge
-The charge most
					 often made by providers of similar training, experience and licensure for a
					 specific treatment, accommodation, product or service in the geographic area
					 where the treatment, accommodation, product or service is provided.
Workers' Compensation judge
-As defined by
					 section 401 of the act (77 P. S. §
											701) (definition of "referee") and as
					 appointed by the Secretary.