Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part VI - Health Care Cost Containment Council › Chapter 912 - DATA REPORTING REQUIREMENTS › Subchapter D - OTHER REQUIREMENTS › Appendix A

Current through Register Vol. 54, No. 28, July 13, 2024
Pennsylvania
Uniform Claims
and
Billing Form
Reporting Manual
HC-87-101 Volume A-Inpatient Data
					 Reporting
Pennsylvania Health Care Cost
Containment Council
Harrisburg Transportation Center
Suite 208
4th and Chestnut Streets
Harrisburg, Pennsylvania 17101
(717) 232-6787
Purpose
The purpose of this manual is to provide data sources with
					 the technical specifications necessary for data collection and data submissions
					 to the Council. According to Act 89, the collection of health data by the
					 Council will be used to facilitate the continuing provision of quality,
					 cost-effective health services throughout the Commonwealth by providing data
					 and information to the purchasers and consumers of health care on both cost and
					 quality of health care services.
Volume A pertains to data submission formats for hospitals
					 and ambulatory service facilities. The Council will collect the raw data from
					 the various data sources, using some key matching data elements, merge the data
					 to provide records per hospitalization or major ambulatory service
					 visit.
Table of Contents
Index
Hospital and Ambulatory Service Facility Reporting
					 Manual
Header Record Manual
Trailer Record Manual
Hospital and Ambulatory Service Facility Tape Format
Appendices
Index by Data Element Name
Data Element Name
Field #
UB-92 Form Locater
Admission Date
5
6
Admission Hour
40
18
Admission-Type of
26
19
Admission-Source of
27
20
Admitting Diagnosis
36
76
Certification/SSN/ Health Insurance Claim
							 Number
29a-c
60
Discharge Date
6
6
Discharge Hour
41
21
Diagnosis Related Group (DRG)
24
2h
E-Code
37
77
Employer Name
32a-c
65
Employment Status
34a-c
64
Estimated Amount Due
14g
55
Federal Tax ID
39
5
HCPCS/Rates
13a-w6
44
Hispanic/Latino Origin or Descent
35a
2i
Non-Covered Charges
13a-w5
48
Patient Discharge Status
20
22
Patient Date of Birth
2
14
Patient Control Number
23
3
Patient-Uniform Identification
1
2a
Patient Race
35b
2j
Patient Relationship to Insured
28a-c
59
Patient Sex
3
15
Patient Zip Code
4
13
Payor Group Number
19
62
Payor Identification
14b
50
Physician Identification-Attending
11
82
Physician Identification-Operating
12
83
Physician Identification-Referring
38
82
Principal Diagnosis
7a
67
Principal Procedure Code and Date
8a, 8b
80
Prior Payments-Payor and Patient
14f
54
Procedure Coding Method Used
25
79
Provider Quality
21a
2d
Provider Service Effectiveness
21b
2e
Revenue Code
13a-w2
42
Reserve Field
21e
HC4
Secondary Diagnosis
7b-i
68-75
Secondary Procedure Code and Date
9
81
Service Date
13a-w7
45
Total Charges
13a-w4
47
Type of Bill
22
4
Uniform Identifier of Health Care Facility
10
2b
Uniform Identifier of Primary Payor
17
2c
Units of Service
13a-w3
46
Unusual Occurrence-Nosocomial Infection
21c
2f
Unusual Occurrence-Readmission
21d
29
Index by Field Number
Data Element Name
Field #
UB-92 Form Locater
Patient-Uniform Identification
1
2a
Patient Date of Birth
2
14
Patient Sex
3
15
Patient Zip Code
4
13
Admission Date
5
6
Discharge Date
6
6
Principal Diagnosis
7a
67
Secondary Diagnosis
7b-i
68-75
Principal Procedure Code and Date
8a, 8b
80
Secondary Procedure Code and Date
9
81
Uniform Identifier of Health Care Facility
10
2b
Physician Identification-Attending
11
82
Physician Identification-Operating
12
83
Revenue Code
13a-w2
42
Units of Service
13a-w3
46
Total Charges
13a-w4
47
Non-Covered Charges
13a-w5
48
HCPCS/Rates
13a-w6
44
Service Date
13a-w7
45
Payor Identification
14b
50
Prior Payments-Payor and Patient
14f
54
Estimated Amount Due
14g
55
Uniform Identifier of Primary Payor
17
2c
Payor Group Number
19
62
Patient Discharge Status
20
22
Provider Quality
21a
2d
Provider Service Effectiveness
21b
2e
Unusual Occurrence-Nosocomial Infection
21c
2f
Unusual Occurrence-Readmission
21d
29
Reserve Field
21e
Type of Bill
22
4
Patient Control Number
23
3
Diagnosis Related Group (DRG)
24
2h
Procedure Coding Method Used
25
79
Admission-Type of
26
19
Admission-Source of
27
20
Patient Relationship to Insured
28a-c
59
Certification/SSN/Health Insurance Claim
							 Number
29a-c
60
Employer Name
32a-c
65
Employment Status
34a-c
64
Hispanic/Latino Origin or Descent
35a
2i
Patient Race
35b
2j
Admitting Diagnosis
36
76
E-Code
37
77
Physician Identification-Referring
38
82
Federal Tax ID
39
5
Admission Hour
40
18
Discharge Hour
41
21
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